We report the case of a 41-year-old male with a ruptured dissecting aneurysm of the right vertebral artery. He was hospitalized for severe headache and became semicomatose with respiratory arrest after re-bleeding attacks. CT scan demonstrated subarachnoid hemorrhage, especially around the brainstem. Vertebral angiography showed fusiform dilatation and constriction of the right vertebral artery, which suggested the dissecting aneurysm. The right posterior inferior cerebellar artery Was visualized poorly and the left vertebral artery was dominant. The aneurysm was located midline and the right vertebral artery crossed the midline. Therefore the left lateral suboccipital transcondylar approach was performed. The distal vertebral artery was ligated easily, but access to the proximal one was obstructed. The right lateral suboccipital transcondylar approach was quickly carried out, and the proximal vertebral artery was ligated. The patient recovered fully postoperatively. The bilateral transcondylar approach is occasionally advantageous in the midline lesion.

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The transclinoid approach reported by Dolenc for cavernous sinus exposure was used for 30 cases of carotid ophthalmic aneurysms, carotid cavernous sinus portion aneurysms, distal basilar artery aneurysms and some other lesions in 1992 and 1993 and was found useful for several aspects in each lesion. The lesions were internal carotid artery aneurysms in 17 cases (carotid canal portion aneurysm in 1 case, cavernous portion aneurysms in 9 cases, ophthalmic aneurysms in 6 cases), and basilar artery aneurysms in 12 patients (basilar bifurcation aneurysms in 2 cases, basilar superior cerebellar artery aneurysms in 10 cases). The first advantage is that a wide working space can be obtained around the periclinoidal carotid artery, so that the proper clipping can be done with a suitable clip or clips if necessary without obstruction of the field by the clip holder. The second advantage is that it is possible to secure the proximal part of the basilar artery in the early stage of operation for temporary clipping at any time. This advantage would be particularly worthwhile in cases of distal basilar artery aneurysms.

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We review the effects of intra-arterial infusion of papaverine in 5 patients with cerebral vasospasm due to subarachnoid hemorrhage. Angiograms of all patients demonstrated diffuse severe vasospasm. Four of the 5 patients were asymptomatic vasospasm and one was symptomatic. All patients had marked angiographic reversal of the arterial narrowing following papaverine infusion, 1 of whom showed improvement in neurological deficits. One patient developed aphasia during papaverine infusion, which resolved spontaneously over several minutes after cessation of the intraarterial infusion. Intra-arterial infusion of papaverine is an alternative method of prevention and treatment for symptomatic vasospasm after subarachnoid hemorrhage.

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CT-guided stereotactic aspiration of hypertensive intracerebral hemorrhage is now widely used in neurosurgery. However, this method is complicated and takes a long time, so we have developed a simplified stereotactic aspiration of intracerebral hematoma using fluoroscope. 1. After CT is performed, the margin of hematoma is transcribed to the scout view, and the point X that should be the tip of the drainage catheter is decided. 2. In the operation room, the patient's head is fixed perpendicularly to the floor and parallel to the fluoroscope. 3. A burr hole is made and a ventricular puncture needle is punctured to the point X parallel to the sagittal section of the head using a fluoroscope. 4. We trace the needle line on the display using an aquatic felt pen, then remove the needle and insert the drainage catheter with stylet along the line to the point X, and fix it. We have operated on 12 cases of putaminal hemorrhage by this method. We successfully reduced the average distance of the gaps between the tip of the catheter and the ideal point to 5mm, and the time required of the operation to less than half that in with CT-guided stereotactic aspiration of hematoma.

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We report 8 patients with progressing stroke who underwent emergency carotid endarterectomy (CEA) successfully.
There were 7 males and 1 female, with a mean age of 66 years (range 62 to 74 years). The time from the onset of neurological deficit to the CEA ranged from 2 to 36 hours.
Preoperative clinical status included 4 patients with severe deficit, 3 with moderate deficit and 1 with mild deficit according to Walters' grading of 5 categories (intact, mild deficit, moderate deficit, severe deficit, death). Carotid bruit was heard in only 2 patients.
Angiographic findings revealed that all patients had severe stenosis (>93%) of the cervical internal carotid artery (ICA) with delay in flow (one of whom had a residual stenosis after recanalization of ICA-occlusion treated with intra-arterial infusion of urokinase), 5 with occlusion of the intracranial arteries caused by artery-to-artery embolism, 4 with cross-filling from the contralateral carotid artery through the anterior communicating artery and 1 with an intraluminal filling defect of carotid artery due to a floating thrombus.
On the preoperative CT scanning, none of 4 patients admitted within 5 hours of onset had fresh lesions and all of 4 patients admitted after 5 hours of the onset had small fresh infarction, none of which were enhanced after the administration of contrast material.
The postoperative course was excellent in all patients, and the postoperative CT scan did not demonstrate any new lesions in 7 patients but disclosed an asymptomatic small watershed infarction in 1 patient.
We discuss indications for emergency carotid endarterectomy for progressing stroke.

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We report 18 patients with acute thromboembolic occlusion of the middle cerebral artery (MCA) who were treated with superselective urokinase infusion.
The overall recanalization rate of our cases was 78%. The duration of the urokinase infusion from the onset and the decrease of rCBF are significant factors to achieve recanalization. For complete recanalization, treatment should be started within 180 minutes after the onset and more than 60% residual rCBF should be attained compared with an unaffected hemisphere on SPECT.
A characteristic feature was found in the recanalization of the MCA. The recanalization rate of the occluded posterior trunk of the MCA was 90%, but merely 20% of the anterior trunk.
All 3 cases of the proximal occlusion of the MCA revealed an infarction of basal ganglia, and hemorrhagic transformation of infarction occurred in 2 patients.
These results show the efficacy of intra-arterial urokinase infusion for acute thromboembolic occlusion of the MCA and the difficulties of recanalization of the anterior trunk of the MCA.

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Many patients with ruptured saccular aneurysms at the vertebral artery (VA)-posterior inferior cerebellar artery (PICA) junction generally have a good prognosis after surgical intervention. Morbidity, which is mainly due to postoperative cranial nerve dysfunction and cerebral vasospasm, however, is not so favorable, because of VA-PICA aneurysms exist adjacent to cranial nerves and brain stem.
We analyzed the prognostic factors, that is, operative complications and cerebral vasospasm in 23 patients with VA-PICA aneurysms. All patients had suffered from subarachnoid hemorrhage (SAH). Nineteen patients underwent direct aneurysmal surgery. Postoperative cranial nerve dysfunction appeared in 8 patients. Five of them ameliorated within a week. Postoperative cranial dysfunction was observed in patients with an aneurysm over 10 mm from the foramen magnum and was not correlated with distance from the midline in this study. We also analyzed the anatomical types of aneurysmal location. As a result, we concluded that postoperative cranial nerve dysfunction depended on the positional relationships of the cranial nerves and aneurysm, rather than the distance from each landmark to aneurysmal neck. Premature aneurysmal rupture during surgery greatly accelerated prolonged postoperative cranial nerve dysfunction.
Three patients demonstrated symptomatic cerebral vasospasm in the present series. CT scans manifested cerebral infarction in the territory of the middle cerebral artery due to vasospasm in 2 cases.
Only 1 of the 3 cases underwent direct aneurysmal surgery in the acute stage. Patients with ruptured VA-PICA aneurysms should require prophylactic therapy for cerebral vasospasm following surgery during the acute phase as in the anterior circulation aneurysms.

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We surgically treated 5 patients with the Juxta-dural ring aneurysm. Four patients received clipping of the aneurysm after removal of the anterior clinoid process and opening of the dural ring, and 1 patient received coating of the aneurysm. We treated 2 of 4 patients without specific problems at the time of clipping. However, the clip compressed the optic nerve after aneurysm obliteration in 1 patient. In the other patient, we could not apply a fenestrated clip because the shape of the clip did not fit the curvature of the carotid artery. In this patient, we used an L-shaped clip resulting in unstable placement of the clip. In these 2 patients, it was feared the frontal lobe might press the clip after the operation. To prevent further pressure to the optic nerve and slipping of the clip, we split the cortex just facing the clip in these 2 patients. Recently, the approach to the Juxtadural ring aneurysm has been established. However, clipping remains problematical because of the anatomical limitations surrounding the cavernous sinus

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With improved surgical outcome, we need to pay more attention to cosmetic appearance. Major cosmetic problems after the pterional approach, which is routinely used for many aneurysms and tumors, are weakness of the frontalis muscle, asymmetry of the temporalis muscle, and depression of the skin at the bony defect. Patients are very annoyed with these problems even if best surgical results are achieved. Various attempts are made to reduce those deformities. We describe a modification of the muscle incision and use of fibrin bone to reduce postoperative deformity without expense of the surgical field or operating time. We modified the interfascial approach to add transverse incision into the muscle at just below the superior temporal line to leave a small cuff of the muscle and fascia attached to the bone for better reconstruction of the temporalis muscle. A mixture of bony powder, collected at the time of craniotomy, and fibrin glue is used to fill the bone defect.

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Treatment for dissecting vertebral aneurysms is a matter of dispute, because the natural history of the disease is still unclear. Proximal ligation or clipping of the vertebral artery, proximal balloon occlusion or non-surgical conservative therapy are possible treatments of choice. We report two cases of dissecting vertebral aneurysms with subarachnoid hemorrhage who were successfully treated conservatively.
The first case was a 54-year-old male who complained of neck pain and gait disturbance. The angiography demonstrated stenosis of the right vertebral artery and the diagnosis was further confirmed by the MR scan. Wallenberg syndrome developed 12 days after onset. Although proximal clipping was considered, he did not receive surgical treatment, because the stenotic portion of the vertebral artery was found to be occluded on the repeated angiography.
The second case was a 42-year-old male who was admitted because of severe neck pain. No abnormal neurological findings were observed. Distal ends of the bilateral vertebral arteries were obstructed associated with a pearl sign and the basilar artery was not filled on the angiography. The MR scan demonstrated hemorrhage in the vascular wall. Because of fears of ischemic complications, neither surgical nor endovascular treatment was attempted. The neck pain disappeared 1 month after onset. Repeated angiography demonstrated complete filling of the vertebrobasilar system. The follow-up periods of the 2 patients were 19 and 11 months respectively.

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