Surgical treatment for multiple occlusive lesions of the intracranial and extracranial arteries are still controversial. We report 2 patients treated with successful results by multistaged surgical procedures. Case 1, a 65-year-old man, complained of transient ischemic attacks of aphasia and right hemiparesis with vertebrobasilar insufficiency syndrome. He had a past history of hypertrophic cardiomyopathy. His angiograms revealed multiple intra- and extracranial occlusive lesions (the left subclavian artery occlusion and bilateral internal carotid lesions). A subclavian-subclavian bypass following the right carotid endarterectomy (CEA) was performed using external shunt from the subclavian bypass graft end during CEA. However, transient ischemic attacks continued after the first operation and single photon emission tomography still demonstrated the left hemispheric ischemia. The left STA-MCA anastomosis was then performed 7 months later. Postoperative course was uneventful and recurrent episode of TIAs disappeared.
Case 2, a 56-year-old man, suffered from minor stroke of right hemiparesis and acute myocardial infarction simultaneously. Angiogram showed an unruptured aneurysm of the middle cerebral artery and severe stenosis of the right internal carotid artery with contralateral middle cerebral artery stenosis. The aneurysm was clipped prior to CEA of the ipsilateral internal carotid artery stenosis. As the next procedure, CEA on the right side and the left STA-MCA anastomosis was performed simultaneously.
In the cases of extra- and intracranial tandem occlusive lesions, the proximal severe lesion should be treated surgically initially. During the bypass or CEA procedure, extra care should be taken in these cases to protect the brain from ischemia perioperatively. Such patients may often be suffering from various heart diseases. The selection of surgical procedure should be carefully considered in cooperation with a cardiologist.

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Among 15 cases of dural arteriovenous (AV) fistulas, 6 cases were treated with transarterial embolization, 3 with transarterial embolization and surgery, 2 with transarterial embolization and transvenous embolization, and 2 with surgery. The other 2 cases were followed without any therapy because they had asymptomatic low-flow fistulas, and no changes were seen on follow-up angiograms. Among 6 cases treated only with transarterial embolization, recurrences were seen in 4 cases (67%) on the follow-up angiograms.
The other 7 cases who were treated with transvenous embolization or surgery as initial treatments had no recurrence. One recurrent case was treated with transarterial & transvenous embolization, but dural AV fistula did not disappear completely because of incomplete occlusion of the sinus. The other 3 recurrent cases were treated with transarterial embolization followed by surgery, resection or isolation of the affected sinus, and 2 of them were cured completely.
With these clinical experiences, we conclude that transarterial embolization is the first choice of therapy for dural AV fistulas. In cases of high-flow type, incomplete obliteration by embolization, or recurrence after transarterial embolization, transvenous embolization is effective. When it is difficult to treat the lesion by embolization, surgical resection or isolation of the sinus are effective.

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From 1990 to 1993, 56 cases of ruptured anterior communicating artery aneurysms were operated on in an acute stage through the Pterional (PT) approach or the Interhemispheric (IH) approach. In this series, the PT approach was used in 33 cases (PT group), and the IH approach in 23 cases (IH group). We evaluated the surgical complications of these 2 surgical groups retrospectively.
Injury of perforating artery occurred more often in the PT group, and was caused mainly by improper brain retraction or temporary occlusion of the parent artery. In most of these cases, the aneurysms projected laterally or superiorly and the operation was carried out at the side of the A₂ running anteriorly.
On the other hand, symptomatic vasospasm was observed more frequently in the IH group. In these cases, the methods for prevention of symptomatic vasospasm were insufficient.
These results indicate that in the PT approach, it is very important to assess the projection of aneurysm, and the anatomical relationship between the aneurysm and the surrounding vascular structure preoperatively, and to decide the approach side in consideration of the posteriority of the A₂ segment. While, in the IH approach, great care should be taken to prevent vasospasm.

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Lesions located in the middle fossa, prepontine and interpeduncular cisterns are some of the most difficult to approach in case of radical surgery, even with the aid of an operating microscope. To minimize the retraction of the temporal lobe and achieve wide exposure, many operative modalities have been reported.
We describe a zygomatic approach without removal of the lateral orbital rim, which we developed based on a modification of Fujitsu's approach. This approach has been used in 8 patients: 2 with aneurysms in the territory of the basilar artery, 3 with brain stem ischemia, 1 with a hypothalamic hematoma, and 1 with a cavernous angioma in the midbrain. The last patient had an anterior communicating artery aneurysm and a concomitant temporal convexity meningioma.
Complete clip ligation was performed for all 3 aneurysms and gross total removal was achieved in hypothalamic hematoma case and cavernous angioma case. Also, the anastomosis of the superficial temporal artery to superior cerebellar artery was performed for 3 patients with brain stem ischemia. One patient with a large basilar tip aneurysm died due to initial damage of the brain on attack. Another with cavernous angioma developed left hemiparesis and oculomotor palsy but these symptoms markedly improved 6 months after the operation.
The complications we observed in this series, consisted of 2 types. The first comprised temporary third nerve paresis in 2 cases and the second was temporal muscle atrophy. Based on our experience and the operative results obtained, we concluded that this procedure allows a wide operative field and easy access to the interpeduncular fossa with minimal brain retraction.

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We present the cases of 2 surgically treated patients with parasplenial arteriovenous malformations (AVMs). The AVMs fed through the pericallosal artery and posterior cerebral artery (PCA) and drained toward the vein of Galen. We adopted parieto-occipital interhemispheric approach to these AVMs with the patients in a lateral-semiprone position.
Preoperative embolization of the feeding PCA branches was performed in 1 patient, and a contralateral interhemispheric approach to the AVM side was performed in the other patient because of the difficulty in the preservation of the bridging veins of the AVM side. Complete excision was accomplished in these patients without postoperative neurological deficits except transient memory disturbance in one case.
The results of this experience indicate that parasplenial AVMs can be effectively treated by surgical resection via a parieto-occipital interhemispheric approach with, if necessary, preoperative embolization of the feeding PCA branches.

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Subarachnoid hemorrhage (SAH) due to ruptured aneurysm in patients aged 80 years and older has been, until recently, very rare. The number of such cases, however, is growing, and the most appropriate management of cases of elderly patients with SAH is still a matter of controversy.
The cases of 29 patients aged 80 and older with SAH are reported. The outcome was defined according to the Glasgow Outcome Scale at six-months following rupture. Of these, 12 were rated Grade III or better on the Hunt-Kosnik scale, while 17 were rated Grade IV or V. Of the four Grade III or better patients who underwent surgery, two Grade I patients obtained GR and one Grade II patient showed MD, while one Grade III patient is severely disabled due to an intracerebral hemorrhage that developed one week after the operation. The remaining eight Grade III or better patients were treated conservatively. Of the three Grade I patients, one obtained GR but two became D. One Grade II patient showed MD. Of the four Grade III patients, one obtained GR and one became MD, while two showed D.
In our case management policy, surgery is contraindicated for Grade IV and V patients. Accordingly, our 17 patients so rated were treated conservatively. Two deteriorated to a vegetative state, while the remaining 15 died from primary damage or rerupture.
In conclusion because better outcome is obtained with surgery on elderly patients in Grade I cases, and because the outcome of elderly patients with rerupture is very poor, aneurysmal surgery should not be withheld in Grade I patients merely because the patient is 80 years old or older.

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It has been reported that surgical techniques exposing the skull base and skull base tumors are beneficial to various neurosurgical procedures, and should also be applied to the surgical treatment of cerebral aneurysm.
We describe the details of the applications of skull base surgery to cerebral aneurysmal surgery.
A total of 23 cases of aneurysm were treated by this method.
The sites of the aneurysms were around the bifurcation of basilar artery (BA bif, PC-SCA) in 10 cases, VA-PICA in 2 and anterior circulation in 11. Eleven cases showed multiple aneurysms. Subarachnoid hemorrhage (SAH) occured in 18 cases, 12 of which were operated on in the acute stage of SAH.
A orbito-zygomatic, transsylvian approach was indicated in 4 cases. Dolenc's extra-and-intradural approach was employed for 6 cases of multiple anterior circulation aneurysms and for 3 cases of giant carotid aneurysm in the cavernous sinus. A transzygomatic, subtemporal approach was indicated in 8 cases of high-positioned basilar aneurysm. A subtemporal, transpetrosal approach for a case of high-positioned VA-PICA, and a transcondyle approach for a case of low-positioned VA-PICA aneurysm were also carried out. All such approaches required meticulous drilling of cranial base, reconstruction of skull base, and a long operation time, 1 hour longer than in usual approaches. Those procedures permitted us a good operative field, a wide working space and an easy management of aneurysmal neck with no severe retraction of the brain. Neither CSF leakage nor meningitis occurred postoperatively, and the surgical results of the operated cases seemed to be satisfactory. Although skull base surgery required skill for the meticulous removal of the cranial base, understanding the correct anatomy of the skull base, and a long operation time, it should be emphasized that the techniques of skull base surgery are advantageous for aneurysmal surgery.

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The lateral subfrontal approach, i. e. the pterional approach, has some technical problems in dealing with the anterior communicating artery aneurysm that has a highly placed neck or is large enough to disturb dissection of the contralateral A₂. A more anterior approach is desirable in such a case to obtain a better view of the contralateral A₂. The pterional approach, however, needs considerable retraction of the frontal lobe when approaching more anteriorly to the anterior communicating artery complex. The Interhemispheric approach through conventional high frontal craniotomy also has some problems in approaching the anterior communicating artery aneurysm. One of the bridging veins coming off the parasagittal frontal lobes is often sacrified in this approach. When the compromise of the bridging vein is combined with prolonged retraction, contusional hemorrhage often occurs in the frontal lobe. Another problem of the conventional interhemispheric approach is the frequent occurrence of olfactory nerve injury.
To solve these problems in each approach and to realize less invasive surgery for the anterior communicating artery aneurysm, I introduce the orbitobasal approach and the interfalcine approach. The orbitobasal approach is an oblique anterior approach through cranioorbitotomy with detachment of the supraorbital rim and the orbital roof. By retracting the orbital contents downward, the anterior communicating artery aneurysm is approached more anteriorly with minimum retraction of the brain than by the lateral, pterional approach. The basal interfalcine approach is a modified basal interhemispheric approach and preserves the bridging vein and the olfactory nerve. Through a frontal sinusotomy, the basal portion of the falx is split into two leaves, between which the basal interhemispheric approach is conducted. The basal portions of the two leaves of the falx protect the olfactory nerves, and the approach is low enough to spare the frontal bridging vein. The surgical techniques of these modified approaches are described, and surgical indications for these approaches are discussed.

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Dissecting intracranial aneurysms are treated most commonly by proximal ligation of the vertebral artery or trapping. We have, however, treated such patients by reconstruction of the vertebral arteries with fenestrated clips. Patients with vertebral artery dissecting aneurysms were classified into 2 groups based on the results of angiogram. The first group consisted of patients in whom the dissection was confirmed on unilateral side of the artery (one-side type). In the second group, the dissection involved the entire circumference of the artery (whole-around type). From April 1973 to July 1994, 1402 patients with intracranial aneurysms, including 45 vertebral artery aneurysms, underwent operation. Of the 45 patients with vertebral artery aneurysms, 16 had dissecting aneurysms.
They were divided equally between one-side type and whole-around type. Six patients of one-side type underwent clipping and vertebral artery reconstruction. There was 1 unsuccessful outcome. This patient was elderly and was treated prior to the development of fenestrated clips. Of the whole-around type, 2 patients exhibited clinical deterioration on the second day following trapping due to retrograde thrombosis. Two other patients had follow-up angiograms that revealed enlargement of the aneurysm. Daughter clipping and wrapping were performed. There were 3 deaths in patients for whom surgery was contraindicated because poor neurological findings.
Arterial reconstruction should be considered in patients with dissecting intracranial vertebral artery aneurysms confined to one side of the artery. Proximal clipping or trapping should be employed in patients in whom 3 dissections involve the whole circumference of the artery.

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A 2- to 16-years follow-up study was done in a series of 360 patients treated for 386 cerebral aneurysms; by wrapping alone (40 aneurysms), clipping plus wrapping (96 aneurysms), and clipping only (250 aneurysms).
Muslin-gauze was used as a wrapping material in all wrapping cases (136 aneurysms, 35.2%). Recurrent SAH occurred in only 1 case after an incomplete wrapping. The incidence of complications such as meningitis, angiospasm, and hydrocephalus was not different in wrapping group (including clipping plus wrapping cases) compared with clipping alone group. We conclude that muslin-gauze wrapping is a useful armamentarium in the treatment for cerebral aneurysms, particularly, in wrapping residual neck following aneurysmal body clipping.

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Prognostic factors were studied in 31 cases of acute occlusion of the middle cerebral artery (MCA). Sixteen were treated with thrombolysis, 4 with embolectomy, 2 with STA-MCA anastomosis and 9 with conservative therapy. Urokinase up to 48×10⁴ IU was administered intraarterilly or prourokinase 1500 IU was injected through the microcatheter introduced proximal and distal to the occlusion site. MCA was recanalized in 8 patients completely and in 4 partially while no recanalization was occured in 4 patients. Complete patency of the MCA was achieved by embolectomy and STA-MCA anastomosis. Good outcome were obtained in the patients with good collateral circulation. Early recanalization in less than 6 hours from onset of symptoms showed favorable outcome except for 1 severely disabled patient in whom thrombolysis was completed 4 hours after occlusion. Sixty percent of cases of occlusion of the proximal M1 that resulted in ischemia of the territory of the perforating arteries showed poor outcome. Even in cases of good recovery from M1 proximal occlusion CT scan revealed infarction in the basal ganglia indicating rapid irreversible change develops after ischemic insult in this area. These results suggest that in cases without low densities on CT, early and complete recanalization of the MCA by thrombolysis, especially M1 segment including perforators, is the best treatment of occlusion of the MCA before completion of ischemic lesions. Embolectomy and STA-MCA anastomosis are recommended in some cases with incomplete recanalization by thrombolysis.

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