Long-term follow-up study (more than 5 years) after posterior fossa revascularization was performed. Among 8 patients operated with superficial temporal artery to superior cerebellar artery anastomosis, 6 survived. Clinical improvement during follow-up period was obtained in 4. No recurrent ischemic attack was noted. Among 8 patients treated with extracranial vertebral artery reconstruction, 5 survived. No recurrent attacks of the posterior fossa ischemia was demonstrated. The causes of death were diabetes-associated supratentorial stroke, cardiac failure, pneumonia etc.

抄録全体を表示

Twenty-five lesions of 21 patients with atherosclerotic vertebrobasilar artery stenosis were treated with percutaneous transluminal angioplasty (PTA). These lesions included the vertebral artery ostium (VAO) in 13 lesions, the first portion of vertebral artery (V₁) in 1, second portion (V₂) in 1, forth portion (V₄) in 8, and basilar artery in 2. Patients were followed angiographically at 3-6 and 12 months after PTA. The initial success rate was 92%, but restenosis occurred in 38% (8/21) of lesions successfully treated with first PTA. Six lesions with restenosis (2 VAO and 4 V₄ lesions) were treated with second PTA, and the restenosis was recognized in 1. In total, 86% (18/21) of lesions were free of restenosis after the first or second PTA. Wall dissections were observed in 5 lesions (3 small intimal flaps and 2 pseudolumens). Based on our results, indications of PTA for vertebrobasilar artery stenosis are discussed.

抄録全体を表示

The authors report 4 operative cases of giant or large thrombosed aneurysms in the vertebrobasilar system (VB). The mean age was 53 years, with a range of 31-68 years.
Only 1 giant aneurysm on basilar artery-superior cerebellar artery junction (BA-SCA) was dead 5 months after trapping of BA. Although thrombectomy and neck clipping (NC) was performed successfully in another large aneurysm on BA-SCA, preoperative tetraparesis with cranial nerve palsy remained unchanged.
One case of giant aneurysm on the vertebral artery (VA) PICA junction who underwent NC after incomplete thrombectomy showed transient postoperative deterioration because of PICA occlusion.
One giant aneurysm on distal PICA was excised and showed remarkable improvement.
NC after adequate thrombectomy is thought to be the treatment of choice for thrombosed aneurysm in VB. But it is more difficult than the aneurysm in the carotid system because of the need to prevent injury of neighboring perforators, brainstem and cranial nerves.

抄録全体を表示

Aneurysms of the distal posterior inferior cerebellar artery (PICA) are relatively rare. The authors have encountered 14 aneurysms in 7 cases of distal PICA aneurysms. We discuss the clinical and radiological features, the problems in surgical and other treatment of this aneurysm, with reference to previous literature. In our 7 cases, 5 were discovered from subarachnoid hemorrhage due to rupture of these aneurysms. Two were nonruptured.
The angiographic appearance of 7 cases were identified; 1 congenital saccular, 2 fusiform, 1 giant thrombosed, 1 is assosiated with persistent primitive hypoglossal artery and in other 2 cases aneurysms located on the feeding artery of arteriovenous malformation (both cases had 4 or more aneurysms)
The locations of 14 distal PICA aneurysms were as follows: 2 on the anterior medullary segment, 1 on the lateral medullary segment, 1 on the tonsilomedullary segment, 5 on the telovelotonsillar segment, and 5 on the cortical segment.
Six cases of 7 were treated surgically, another 1 was a nonsurgical case because of the poor risk on admission. One of the surgical cases on the anterior medullary segment aneurysm was extirpated after OA-PICA anastomosis, which was histologically confirmed as a dissecting aneurysm.
Outcome of our cases, 3 died and the remaining 4 cases have followed excellent postoperative courses.

抄録全体を表示

後頭蓋窩の未破裂脳動脈瘤の自然経過と治療成績について検討した. また一部ではテント上のそれらとも対比し後頭蓋窩未破裂脳動脈瘤の特徴を明らかにした. 対象: 昭和54年4月から平成4年10月までに経験した未破裂脳動脈瘤135例 (166個) のうち, 後頭蓋窩の27例 (男16例, 女11例; 8～72歳, 平均54.4歳) 28個を対象とした. 結果: 発生部位は BA top 13個, BA・SCA 8個, VA・PICA 3個, PCA (P_1,2)3個, VA1個であった. 大きさは2～32mm (平均11.4mm) であった. 発見の動機は, SAH の多発性として (1群) 7例7個, 他疾患に合併して (2群) 4例4個, 症候性 (3群) 7例7個, スクリーニングされたもの (4群) 9例10個であった. 非手術例の17例では5例 (29.4%) が経過観察中 (平均36.6か月) 破裂により死亡した. 部位は BA top 2例, BA・SCA 1例, VA・PICA 1例, PCA 1例であり大きさは5mmが2例で, 13, 18, 30mmが各々1例であった. 群別では1群2例, 3群2例, 4群1例であった. テント上の非手術例39例の破裂率は15.4%で後頭蓋窩が高い破裂率であった. 手術は10例10個 (clipping 6例, ligation 1例, coating 1例, 瘤塞栓術2例) に行われた. mortality はなかったが, morbidity は一過性2例 (動眼神経麻痺), 永久的2例 (意識障害, 片麻痺および視力障害) であり, テント上の69例の8.7%に対し高かった. 後者の1例は72歳例で32mmの動脈瘤の neck ligation 後 PCA と穿通枝の閉塞をきたし, 他の1例は8歳女児で経26mmの一部血栓化動脈瘤で超低体温体外循環下に clipping が行われた例であった.

抄録全体を表示

The authors present 33 patients with dissecting aneurysm of the intracranial vertebral artery, of whom subarachnoid hemorrhage developed in 26 patients and cerebral ischemia in 7 patients. Sixteen patients were surgically treated and 17 were conservatively treated. In this series, recurrent hemorrhage occured in 9 (35%) of 26 patients who presented with subarachnoid hemorrhage within 2 weeks after the initial ictus. The outcome of the cases with recurrent hemorrhage was very poor-7 of these 9 patients died. Therefore, surgical intervention during the acute stage is required to avoid the early rerupture. Comparative study with surgical and conservative treatment for dissecting aneurysms of the vertebral artery indicated that the outcome of patients with surgical treatment was much better than with conservative treatment. In surgical procedures, proximal clip-occlusion of the vertebral artery at the site distal to the PICA (DTP) was performed in 5 cases, at proximal to the PICA (PTP) in 4, trapping of the vertebral artery with dissecting aneurysm in 2, coating in 3, and proximal occlusion of the vertebral artery with detachable balloon in 2 patients. Postoperatively, transient lower cranial nerve palsy or cerebellar signs developed in 2 cases with trapping, in 1 with PTP and permanent hemiparesis due to thromboembolism at the top of the basilar artery in 1 with balloon-occlusion of the vertebral artery. In spite of surgical intervention, rerupture occured postoperatively in 1 case with coating and in 1 with DTP. Trapping procedure is most reliable to prevent rerupture of dissecting aneurysm, but it is difficult to expose the distal part of the vertebral artery beyond the aneurysm for trapping. Although proximal clip-occlusion is not completely satisfactory for prevention of rebleeding, it is simple as a method and useful for dissecting aneurysm of the vertebral artery.

抄録全体を表示

Clinical characteristics of 20 patients with arteriovenous malformations of the posterior fossa were investigated. Nineteen of 20 patients presented with intracranial hemorrhage (intra-cerebellar and/or subarachnoid hemorrhage), which was recurrent in 5 cases (26%). One patient demonstrated progressive neurological deficits. AVM located in the cerebellar hemisphere in 10 patients, vermis in 7, tonsil in 1, and brain stem in 2. Four of 20 patients (20%) had concomitant aneurysms relating to the feeding arteries of AVM.
Operative intervention was directed at primary excision in 16 patients, total excision in 14, subtotal excision in 1, and partial excision and feeder clipping in 1. One patient underwent ventricular drainage only. This patient died of recurrent hemorrhage 11 days after the drainage. Three patients did not receive any treatment, and 1 of 3 patients died of pneumonia. Seventeen of 20 patients (85%) had a good result, 1 patient (5%) a poor result, and 2 patients (10%) died. Good results could be expected of surgery in the treatment of AVM localized in the cerebellar hemisphere.

抄録全体を表示

The arachnoidea between the superficial sylvian vein and the temporal lobe is incised, and the bridging veins flowing from the temporal lobe to the superficial sylvian vein and those at the temporal tip are cut. Thus, the temporal lobe is separated from the superficial sylvian vein. The anterior temporal artery is separated from the temporal lobe. These treatments increase the mobility of the temporal lobe. The sylvian fissure is widely opened by compression of the temporal lobe with a spatula placed under the anterior temporal artery. This approach provides good access to the lesions in the interpeduncular cistern.

抄録全体を表示

During 2.5 years after introduction of MRI, we have experienced 9 cases of vertebral dissecting aneurysm (VDA) that initially appeared with the signs and symptoms of subarachnoid hemorrhage. The patients' age ranged from 40 to 70 years (average: 51.8 years), and 6 male and 3 female patients were included in this series. Five of the 9 patients were hypertensive and 1 had an episode of CVA (internal carotid occlusive disease). It was particularly noteworthy that abducens palsy was observed in varying degrees in 8 cases immediately after the SAH symptoms.
Lower cranial nerve palsy was also observed in 2 elderly cases. On MRI, VDA consistently showed high signal intensity around eccentric signal void. However, the intimal flap and double lumen could not be confirmed. Angiography demonstrated a fusiform dilatation of the vertebral artery with irregular surface on it and either narrowing or tapering in vascular diameter was found adjacent to the dilated portion.
VDA with the onset of SAH was characterized by these MRI and angiographic findings.
In 4 cases, VA was surgically ligated following balloon occlusion test. Coating of VDA was performed in 2 cases while conservative treatment was chosen for 2 cases. The outcome in the 9 month to 2 year follow-up study was good or excellent except for 1 case that resulted in death with a complication of early recurrent hemorrhage within 5 days after its onset. Based on our results in this series, it was considered that vertebral dissection tends to extend to the basilar artery particularly in aged patients with atherosclerosis, and so conservative treatment seems to be preferred for these elderly cases. For relatively younger cases, proximal ligation should be chosen in stable chronic stage, for spontaneous occlusion is not rare in these cases.

抄録全体を表示