Proximal ligation is generally accepted as the 1st choice of therapy for dissecting vertebral aneurysms. But recently, the problem of rerupture of aneurysm after proximal ligation has been reported. From this view-point, the trapping procedure may be the better choice for the treatment of ruptured dissecting vertebral aneurysms.
We have performed trapping procedures in 6 cases of ruptured dissecting vertebral aneurysms. The presigmoid approach was selected for 3 cases and lateral suboccipital approach for 3 cases. Based on these experiences, we would like to emphasize the advantages of the presigmoid approach. These advantages include on excellent view around the vertebro-basilar junction and less manipulation of the cerebellum and lower cranial nerves. A significant disadvantage of the presigmoid approach is hearing disturbance, which derives from possible intraoperative destruction of either the posterior semicircular canal or endolymphatic duct and sac. Tactics to avoid these complications is important for the better prognosis of these aneurysm patients.
We conclude that trapping might be the treatment of choice for patients of ruptured dissecting vertebral aneurysm, and selection of the surgical approach, presigmoid approach or lateral suboccipital approach, must be chosen by such criteria as location of the aneurysm and angiographic findings including hemodynamic consideration.

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Fifteen patients with ruptured dissecting vertebral aneurysm were treated by intravascular neurosurgery. Twelve of them were treated in the acute stage (within 80 hours after the last rupture) and three were in the chronic stage. They were divided into 3 types according to location of the posterior inferior cerebellar artery (PICA) and the aneurysm: Type A, the PICA originated distal to the aneurysm; Type B, the PICA originated proximal to the aneurysm; Type C, the PICA was absent or uncertain. A parent vertebral artery was occluded as proximal to the aneurysm as possible in Types A and C. A vertebral artery was occluded between the PICA and the aneurysm, if possible, in Type B (Type B-1). Because that procedure is, in practice, difficult, especially if a detachable balloon is used, a parent vertebral artery was occluded at C₄ or C₅ level, proximal to the segmental arteries, in most Type B_s (Type B-2). The parent vertebral artery was occluded with detachable balloons in 14 patients. In all the patients treated with detachable balloon, parent arterial occlusion followed 15 minutes after test occlusion. If the patient's neurological symptoms or conscious conditions were not changed, the balloon was detached just as it was. The most recent case was treated with electrically detachable coils. Three patients developed cranial nerve palsies and three patients developed hemiparesis or sensory disturbance. Those symptoms were thought to be caused by gradual thrombotic formation, since the symptoms appeared not immediately after arterial occlusion but in the next day. Cranial nerve palsies disappeared in a few months in all the patients. Minimal hemiparesis or sensory disturebance remained. Seven patients suffered from symptomatic vasospasm. Transluminal angioplasty was performed on four of them, and one of them soon recovered. The remaining three and another one died of severe vasospasm in spite of angioplasty.
In conclusion, intravascular neurosugery is an effective and less invasive way to treat a ruptured dissecting vertebral aneurysm. Several kinds of platinum coils, including electrically detachable coils are a useful alternative. Attention should be paid to delayed neurological deficits caused by gradual thrombotic formation. Transluminal angioplasty is also an effective way to treat severe vasospasm.

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Twenty-seven cases of dissecting vertebral aneurysm were investigated in this study. These patients were divided into two groups consisting of an SAH group with 17 cases and a non-SAH group with cerebral ischemia and the like with 10 cases.
In the SAH group, four patients had early onset of recurrence of bleeding. Of those four patients, two were inoperable and died.
Surgery was performed on 14 patients. One patient died, but 13 patients had good recovery.
Symptomatically the non-SAH group was diversified, with six cases of cerebral ischemia, two cases suffering only headaches and two cases that were discovered incidentally. Surgery was performed on three patients in whom aneurysmal dilation had been cofirmed on angiograms taken two weeks after onset.
Postoperative courses were good with no exceptions. In other patients obstruction of the vertebral artery and string and pearl signs had subsided on the follow-up angiography.
Surgical techniques comprised proximal clipping in 13 cases, trapping in three cases and coating in one case.

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Recently there have been reports of intracranial dissecting aneurysms. Most authors recommended proximal ligation of the vertebral artery or trapping as the modality of treatment.However, we have had cases in which reconstruction of vertebral arteries with fenestrated clips were performed. Vertebral artery dissecting aneurysms were classified into two groups based on angiograms. One group is the one-side type, which indicates that dissection occurred on one side, and the other is the whole-around type, which points to the progression of the dissection as a whole around the artery. From April 1973 to March 1993 we operated on 1,304 cases of intracranial aneurysms, including 41 vertebral aneurysms. Eleven of the latter were suspected to have dissecting aneurysms based on angiograms and surgery. Six out of 7 cases had one-side type dissecting aneurysms, which were clipped directly and the vertebral arteries were reconstructed. One unsuccessful case had been an aged patient when surgery was done prior to the development of fenestrated clips. Two out of 4 cases had whole-around type aneurysms and underwent proximal clipping and trapping. One case became worse after the second day of trapping because of retrograde thrombosis. Two patients, for whom surgery was contraindicated because of bad neurological condition, died.

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Five autopsied cases of dissecting aneurysms with spontaneous subarachnoid hemorrhage (SAH) of the intracranial vertebro-basilar artery are reported, and the literature is reviewed to investigate the pathological characteristics and pathogenesis of this lesion. The location and pathological features of the aneurysms differed in each presented case. Subadventitial hemorrhage associated with SAH, multiple noncontiguous intramural hemorrhages, and new vessels in and around the arterial wall were noteworthy findings in our series. All 20 reported autopsided cases of the vertebrobasilar artery have a dissection between the media and adventitia with a rupture site in the thin adventitia. Seventeen had disruption of the entire arterial wall, but the remaining three had no apparent luminal connection. The clinico-pathological features of this disease are various. Based on the pathological investigations of these reported cases, the pathogenesis of this lesion is discussed. Intramural hemorrhage associated with dissection without luminal connection should not be disregarded as a causative factor.

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Nine cases of cerebral ischemia and 10 cases of subarachnoid hemorrhage attributed to dissecting aneurysm in the posterior fossa are analyzed for their clinical courses to choose therapeutic modality. Patients with ischemic symptoms had neither clinical deterioration nor reccurence, and most of their outcomes were excellent or good. Angiographic findings of all cases tended to improve 3 months after onset. Considering the high risk of ischemic symptoms associated with occlusion of the parent artery resulting from surgical treatment for dissecting aneurysm, the best initial treatment for dissecting aneurysm of the ischemic type seems to be conservative therapy, including amelioration of circulation, control of blood pressure and serial observation by cerebral angiography.
All 10 patients developing subarachnoid hemorrhage had episodes of unconsciousness before admission. The neurological grades of 6 patients were worst and their vital signs were very unstable. Rebleeding occurred within 24 hours of the onset in the 6 patients. Their outcome was extremely poor except for one who had been treated surgically. He had an excellent outcome in spite of having the worst grade on admission. Therefore, early surgery should be performed in patients with dissecting aneurysm developing subarachnoid hemorrhage.

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A 70-year-old woman visited our hospital with complaints of right hemiparesis and motor aphasia. Neuroradiological studies revealed a giant and partially thrombosed aneurysm at the trifurcation of the left middle cerebral artery (MCA). She was treated by total resection of the aneurysm and arterial transposition following double STA-MCA anastomoses. Perforators originated from the aneurysm were sacrificed, and the inferior devision of the middle cerebral artery was thrombosed in the postoperative period. Unfortunately, she showed a transient deterioration of her neurological status.

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A case of a recurrent and growing giant aneurysm following repeated endovascular treatment is discribed. The patient finally underwent direct clipping of the aneurysm. A surgical specimen of the aneurysm showed marked neovasculization in both the aneurysmal wall and mural thrombus. These findings suggest that this aneurysm grew by repeated bleeding between the aneurysmal wall and the outer layers of the thrombosed sac. Possible explanation of the enlarging aneurysms and risk of endovascular surgery as a treatment for this aneurysm are discussed.

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Interventional neurovascular treatment of giant intracranial aneurysms of the posterior circulation are now being performed in selected cases. Our current indications for therapy include unsuccessful attempt at neurosurgical clipping, surgically inaccessible aneurysms, medically unstable patients who cannot tolerate general anesthesia, and high surgical risk cases. All procedures are performed under local anesthesia, from a transfemoral approach, to monitor the neurological status of the the patient. Fusiform, ectatic aneurysms are treated by test occlusion followed by permanent occlusion of the parent artery utilizing detachable balloons. Aneurysms with a well defined anatomical neck can be approached by placement of silicone balloons, platinum coils with dacron fibers, and/or electrolytic coils into the aneurysm for obliteration.
In our entire series of 321 cases, treated by interventional techniques, 79 patients (24.6%) presented with a posterior circulation aneurysm. In this group, 21/79 patients (26.6%) were diagnosed with a giant aneurysm, measuring greater than 2.5cm in diameter. Patient's ranged in age from 10-73 years, and there were 4 males and 17 females. The location of the aneurysm included the distal vertebral artery in 10 cases, mid-basilar artery in 4 cases, distal basilar artery in 5 cases, and the posterior cerebral artery in 2 cases. The presenting symptoms were mass effect in 16/21 cases (76.2%) and subarachnoid hemorrhage in 5/21 cases (23.8%). In 8/21 cases (38.1%), direct occlusion of the aneurysm was achieved, and in 13/21 cases (61.9%) parent vessel occlusion was performed. Complications related to therapy included 4 deaths (19.0%), 2 strokes (9.5%), and 2 patients (9.5%) with transient posterior fossa ischemia.
Interventional treatment of giant posterior circulation aneurysms is technically feasible, however it is still associated with significant morbidity and mortality.

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Dissection of extracranial and intracranial arteries is now recognized as an important cause of stroke and transient cerebral ischemia. Causes of dissection can be spontaneous, traumatic, associated with amphetamine abuse, hypertension, fibromuscular dysplasia, and collagen vascular disorders. Dissections can also be caused by iatrogenic injuries during diagnostic and endovascular procedures from injury to the intima and media during guidewire and catheter manipulation within intravascular blood vessels.
We report three cases in which acute dissection of the high cervical internal carotid arteries was iatrogenically induced from guiding catheters causing subintimal dissection and near complete occlusion. Treatment by use of balloon angioplasty techniques and guidewire manipulation across the dissection sites were successful in opening up the injury site to complete patency. Long term follow-up demonstrated continued wide patency without evidence of restenosis or severe intimal irregularity.
As more aggressive therapy by endovascular techniques are utilized for definitive management of intracranial aneurysms, malformations, tumors, and preoperative therapy, the incidence of iatrogenic injuries will increase. Balloon angioplasty techniques to treat acute vessel dissections may be a useful therapy to restore patency of the blood vessel for these patients in selected cases.

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In a consecutive series of 207 patients, who were operated on for the ruptured anterior circulation aneurysm in acute stage, 90 patients (43%) of Hunt and Kosnik (H-K) grade III were analyzed to evaluate the grading and to clarify the surgical indication. Those were divided into 3 groups: group A, 54 patients of 59 years or less of age; group B, 22 of 60-69 years; and group C, 14 of 70 years or more. The Glasgow coma scale (GCS) was adopted to assess the preoperative level of consciousness. The outcome was evaluated by the Glasgow outcome scale.
The rate of good recovery was 55% in 44 patients of GCS 13 and 85% in 20 of GCS 14. This difference was statistically significant (ρ<0.02). One-third of the patients, who were of GCS 11, had recovered well in group A, whereas none of GCS 12 recovered in group C. The outcome was significantly poor in the patients with preoperative arterial hypertension (systolic pressure ≥ 160mmHg), and in the patients with subarachnoid thick clot on CT in group A. The incidence of systemic complications was significantly high (ρ<0.05) in group C.
These results indicated that the outcome significantly differs between patients of GCS 13 and 14, and that the aged patients (≥ 70 years) had a poorer outcome despite the same GCS. It is stressed that the GCS score and the age are important prognostic factors in H-K grade III, and that the aged, whose GCS score is 12 or less, would not be indicated for surgery in the acute stage.

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