Aggressive surgical treatment, including intracerebral and/or intraventricular hematoma evacuation, cisternal clot irrigation, external decompression, unilateral temporal lobectomy with resection of herniated uncus and aneurysmal clipping, was carried out on poor-grade aneurysmal SAH patients (Hunt and Kosnik Grade 4 or 5). A protocol consisting of a reversibility test of dilated pupils and light reflex under a rapid infusion of 900-1200ml mannitol was utilized for selection of operative candidates. The patients who showed bilateral negative light reflex with dilated pupils even after the infusion of mannitol were excluded from active treatment and given supportive care only. During the period between April 1992 and December 1994 a total of 207 SAH patients were admitted to our department, with 88 (42.5%) patients arriving in Grade 4 or 5. Urgent operations were performed on all the 41 Grade 4 patients and on 12 of the 47 Grade 5 patients. Preoperative CT scans in Grade 4 patients showed Fisher Group 2 in one case, Group 3 in 23 and Group 4 in 17. Those in Grade 5 surgical group were Fisher Group 3 in 7 cases and Group 4 in 5 cases. The outcome at 3 months of the Grade 4 patients following Glasgow Outcome Scale was GR in 9 (22.0%), MD in 10 (24.4%), SD in 13 (31.7%), V in 1 (2.4%) and D in 8 (19.5%). More favorable outcomes (GR, MD) were obtained in Fisher Group 3 (14/23, 60.9%) than in Fisher Group 4 (5/17, 29.4%). In the 12 Grade 5 patients who were selected for active treatment, 5 patients survived with moderate to severe deficits and 7 died. Mortality in the Fisher Group 3 was 85.7% (6/7) and 20% (1/5) in the Fisher Group 4. In the 4 patients who survived in Grade 5 with Fisher 4, 3 were cases having casting intraventricular hematoma. In the 35 non-surgical group, all patients had died within 2 weeks.
We conclude that Grade 4 aneurysm patients can achieve a better outcome with active treatment based on immediate intracranial pressure decrease and brain stem decompression. Even in Grade 5, patients with Fisher 4, especially the cases with casting intraventricular hematoma, can survive with urgent and aggressive surgical treatment. On the other hand, the result in Grade 5 patients presenting Fisher Group 3 CT findings are poor, and we suggest that hypoxia caused by cardio-pulmonary dysfunction would have a greater effect on brain condition than intracranial hypertension.

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We evaluated CO₂ reactivity of cortical artery on 25 patients with aneurysmal subarachnoid hemorrhage during craniotomy for clipping of their aneurysms. Every case was operated on within 72 hours from onset of subarachnoid hemorrhage. After clipping of aneurysm, we measured cerebral blood flow velocity and resistance index placed on cortical artery of parasylvian region using microvascular Doppler sonography (DWL Elektronische Systeme GmbH, Multi-Dop X) with the PaCO₂ at 30 mmHg, 40 mmHg and 50 mmHg. We controlled PaCO₂ by alteration of respiratory condition and kept systemic mean arterial blood pressure normotensively during measurement. CO₂ reactivity is regarded as one indication of the capacity to tolerate brain ischemia. We evaluated tolerance for brain ischemia according to the increase ratio of cerebral blood flow velocity and the decrease of resistance index as the PaCO₂ was changed from 30 mmHg to 50 mmHg. We recognized 16 cases as patients who had good CO₂ reactivity according to our criterion. Six other cases reacted to hypercapnia poorly and remaining 3 cases showed abnormal CO₂ response. We investigated the relationship between CO₂ reactivity and the outcome at 1 month after the onset of subarachnoid hemorrhage. These 16 cases whose CO₂ reactivity was good resulted in good outcome (GOS 1:11, GOS 2:5).
Six poor CO₂ reactivity patients had worse outcomes (GOS 1:1, GOS 2:3, GOS 3:2). Unfortunately, the remaining 3 patients whose CO₂ reactivity was abnormal resulted in misery state (GOS 4: 2, GOS 5: 1). On the other hand, 8 patients in our series came down with symptomatic vasospasm during the course. While only 2 of 16 patients who had good CO₂ reactivity suffered from symptomatic vasospasm, half of 6 patients whose CO₂ response was poor and all of 3 patients whose CO₂ reactivity was regarded as abnormal developed symptomatic vasospasm. We can conclude that CO₂ reactivity is closely related to the outcome and the appearance of symptomatic vasospasm. And microvascular Doppler sonography is a very useful and noninvasive method for the intraoperative evaluation of CO₂ reactivity in patients of aneurysmal subarachnoid hemorrhage.

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We highlighted 2 cases of radical clipping of large aneurysms that were seen in the vertebrobasilar junction accompanied by a vascular deformity, consisting of fenestration of the split basilar artery at the origin of the basilar artery. Information concerning the inner and outer surface of the aneurysm were obtained pre-operatively from neuroradiographic studies by 3-D CT and 3-D CT endoscopy of the position of the neck, parent vessels of the vertebral arteries on both side, basilar artery and split basilar artery as well as its branches. The neck had a broad base in both cases. The height of the neck extended to the internal acoustic meatus, and it was possible to expose the periphery of the aneurysmal neck with an anterior transpetrosal approach. Based on the size of the aneurysm which was placed on the anterior surface of the brain stem, clipping or arterial reconstruction were performed in the first case under cover of barbiturates and deep hypothermia extracorporeal circulation, and in the second case in a state of circulatory arrest. The following provides a report of these 2 cases along with other cases treated so far.

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This study was aimed to clarify the therapeutic guides for aged patients with ruptured cerebral aneurysms by comparing the clinical features of 81 younger patients between 40 and 64 years (Group A) with those of 38 patients aged over 65 years (Group B). We underwent clipping surgery in our hospital in the past 5 years. Postoperatively, they were managed by the hypervolemic and hyperdynamic therapies against the vasospasm (VS) under the continuous cardiopulmonary monitoring with Swan-Ganz (SG) catheter. The short-term (within 3 months after ictus) outcome was better in the aged patients operated on in the late stage than those in the acute stage. Symptomatic vasospasm (VS) occurred more frequently in Group B, especially in cases of Hunt and Kosnik Grade III and IV with the poor short-term outcome, than in Group A. In Group B, the poor cardiac response to dobutamine result in low cardiac output and pulmonary congestion, which limited the hypervolemic and hyperdynamic therapies. These therapies showed no effect on VS in many cases of Group B. In the cases of Group B with Glasgow Outcome Scale (GOS)>3 within 3 months follow-up, their long-term outcome was poor because of pulmonary and urinary tract infections and social problems. Our conclusions as follows: 1) Late clipping surgery is preferable for the aged patients in Hunt and Kosnik Grade III and IV. 2) Continuous monitoring of cardiopulmonary function with SG catheter is useful for the postoperative management of aged patients. 3) Social factors are an important determinant for the surgical indication in aged patients.

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Casting hematoma and subarachnoid hemorrhage in acute subarachnoid hemorrhage causes serious consciousness disturbance and can be fatal. Severe subarachnoid hemorrhage with Fisher Group 3 or more causes symptomatic cerebral vasospasm, which greatly affects the prognosis in such serious cases. Here we report our procedure to remove intraventricular casting hematoma and subarachnoid clots to improve the prognosis in such serious cases.
Intraventricular casting hematoma: Intraventricular casting hematoma is often found in ruptured anterior communicating artery aneurysm, and anterior interhemispheric approach (AIH) is used to clip the aneurysm. Intraventricular casting hematoma complicated with anterior communicating artery aneurysm, in many cases, ranges from the anterior horn of the lateral ventricle, to the body, posterior horn, inferior horn, and third ventricle. Removal of casting hematoma is possible from the anterior horn of the lateral ventricle by frontal corticotomy after AIH. The contralateral intraventricular casting hematoma can be treated by breaking the septum pellucidum, and the third ventricle can be treated via the foramen of Monro. After removal of the hematoma, drainage tubes are placed in the trigone and third ventricle to control the intracranial pressure.
Subarachnoid clot: For subarachnoid hemorrhage in the acute stage, the irrigation suction system is applied with irrigation water, that is 500ml of saline mixed with 60,000 units of urokinase compressed to 400mmHg, to remove the subarachnoid clots as much as possible. In severe subarachnoid hemorrhage with Fisher Group 3 or more, the sylvian fissure is opened widely from the distal part to remove clots. In addition, clots are removed from the carotid cistern and prechiasmatic cistern, then the liequist membrane is opened, and clots are removed from the ambient cistern, interpeduncular cistern, and prepontine cistern not only in case of internal carotid aneurysm but also in case of middle cerebral aneurysm. Finally, the tip of the drainage tube should be placed in the opposite inlet of the ambient cistern. In case of anterior communicating aneurysm, removal of subarachnoid clots is basically limited to those in the anterior interhemispheric fissure and prechiasmatic cistern because the approach is made by AIH. Therefore, the frontal base should be opened with the bifrontobasal approach first, to allow the sylvian fissure to be easily opened by the frontobasal approach. Subarachnoid clots in the sylvian fissure can be removed by the frontobasal approach, and also from the interpeduncular cistern and prepontine cistern.
By this method, consciousness disturbance was improved in early postoperative stages in intraventricular casting hematoma cases. In addition, extensive removal of subarachnoid clots significantly reduced the occurrences of symptomatic vasospasm.

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To investigate the overall and surgical management results in cases with aneurysmal subarachnoid hemorrhage (SAH), 75 consecutive patients who were admitted to our institute during the last 1 year (1993.11.-1994.10) were retrospectively analyzed compared with the results of the past 20 years (1973.11.-1993.10.). It was revealed that the percentage of the aged patients and the poor-graded patients was increasing. Fifty-seven patients (76.0%) received direct surgery for the ruptured aneurysms and 48 cases (84.2%) were operated on within 3 days after the attack. Overall, 46 (61.3%) patients exhibited a good recovery at discharge and 13 (17.3%) had died, while from the results of the past 20 years the rate of good recovery was 52.9% and dead was 27.4%. From the surgical results of the last 1 year the rates of good recovery and dead were 74.5% and 3.6% respectively, and 66.8% and 10.5% respectively for the past 20 years, showing that have certainly improved, especially in the younger (<70 years old) group. The main causes of poor outcome (severe disability and dead) were the direct effect of initial insults (63.2%), rebleeding (10.5%), high age (21.2%), and technical complications (5.3%). Our therapeutic protocol for vasospasm, including continuous cisternal drainage, intrathecal injection of urokinase, continuous intravenous injection of nicardipine and dobutamine, and rapid volume expansion, has prevented patients from deteriorating neurologically and improved the prognosis. But cases of higher age, poor-grades, and rebleeding remain hard to treat.

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WAIS-R を使用して, 破裂脳動脈瘤手術例のうち, 症例を軽症例に限定しても知能水準の低下が認められるかを検討した. 軽症例を, 1)入院時, WFNS 分類で Grade 1, 2)退院時 GOS (Glasgow Outcome Scale) にて GR(good recovery) の2項目を満たす症例と定義し, クモ膜下出血以外の病変により WAIS-R 評価点に影響を与えうる症例はあらかじめ除外した. このため対象は22例, 動脈瘤の部位は, 左側5例, 右側8例, 正中9例であった. その結果, 1)症例を軽症例に限定しても破裂脳動脈瘤の症例には知能水準の低下が認められ(p<0.01; Table 1), 2) WAIS-R の11項目の下位検査のなかで,「単語」および「理解」の2項目が他の9項目に対し相対的低値をとり(p<0.005; Table2), 3)知能水準の低下に関して動脈瘤の部位による差は認められなかった(Table 3). 動脈瘤の部位による差が認められないことより, 知能水準の低下は手術操作による脳損傷, 血管損傷のような局所的要因に基づくものではなく, クモ膜下出血例に共通した病態生理に基づくものと推定されるとともに, すでに報告されている他の疾患におけるものとは全く異なった, 特殊な WAIS-R subtest profile を呈することが明らかとなった.

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Management outcome in poor-grade patients with ruptured cerebral aneurysms has been unsatisfactory. In the present study, we discuss how to manage patients with Hunt and Hess Grade IV or V, and their surgical indications at the acute stage.
Of the 35 patients with admission Grade N, 25 (71%) were surgically treated for ruptured aneurysms at the acute stage. The clinical grade of 11 of these 25 patients improved spontaneously from IV to III before surgery, and none of them had a vegetative state or died. Ten (40%) of the 25 patients who were surgically treated had good recovery, and only 1 (4%) patient died. Ten patients were not treated surgically, because of deterioration due to rerupture in 5, old age (over 80 years) in 4, and no detection of ruptured aneurysm in 1. Of the 58 patients with admission Grade V, 12 (21%) were operated on at the acute stage. In six of the 12 patients, the clinical grade improved to III or IV before surgery; 2 had a good recovery, and 4 had severe disability. The surgical outcome of the other 6 patients, in whom the clinical grade had not improved preoperatively, was vegetative state or death.
Emergency ventricular drainage was performed in 25 of the 58 patients with admission Grade V. The clinical grade improved in 36% (9) of these patients, which was significantly higher than the 12% (4 out of 33) in patients without ventricular drainage (p=0.033).
In conclusion, in patients with admission Grade IV, acute stage surgery for ruptured aneurysms is indicated for those aged under 80 years. In patients with admission Grade V, if their clinical grade improves spontaneously or in response to emergency ventricular drainage, surgery for ruptured aneurysm is indicated. Surgical outcome in poor-grade patients whose clinical grade improved before surgery was not necessarily unfavorable.

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Spontaneous dissecting aneurysms in the anterior circulation are extremely uncommon. The natural course of this entity is far from being understood, and the treatment is still debated. In this paper, we report a case of cerebral infarction caused by the dissecting aneurysm of the left anterior cerebral artery (ACA). A 45-year-old male developed an acute right hemiparesis with severe headache. CT scan showed a cerebral infarction at the left ACA territory. Consecutive cerebral angiography revealed a double lumen of A2 with an intimal flap immediately distal to the anterior communicating artery (Acom). Under conservative treatment, his motor weakness was gradually improved. However, the second angiography two weeks after admission revealed aneurysmal dilatation of distal A2 with marked stenosis of A3. The rapid growth of the aneurysm during the short period necessitated curative treatment. The patient underwent a left frontal craniotomy. Through an interhemispheric approach, the bilateral distal A3 portion, which seemed intact, was first dissected. Following the A3-A3 side-to-side anastomosis, the proximal left ACA was dissected. In front of genu of corpus callosum, a 1.2cm-sized fusiform aneurysm was observed. Further dissection of A2 to the proximal side revealed an abnormally thin portion of the arterial wall immediately distal to the Acom, which was compatible with the entry point based on the angiographical finding. The outer appearance of the A2, which proved to have a double lumen on the angiogram, seemed relatively thin but almost normal in color. The left AC was trapped from the entry point to the anastomosis. The postoperative course was uneventful, and angiography showed the left peripheral region was supplied from the anastomosis. We believe the best surgical treatment for the dissecting aneurysm is trapping with bypass. Although the dissection causing infarction has scarcely been considered to rupture in the literature, this case suggests the possibility of rupture that might be fatal. Thus, the rapid growth of aneurysm may be a good surgical indication. Surgical treatments for this type of lesion are discussed.

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In this paper, we compare the results of early surgery with those of delayed surgery and discuss the indication of early surgery in 146 cases with ruptured vertebro-basilar aneurysms.
Depending on age, 146 cases were classified into 2 groups: 116 cases under 64 years old (Y-group) and 30 cases over 65 years old (E-group).
Timing of operation (within 3 days after SAH: A, 4-7 days: B, over 8 days: C) and clinical grades by Hunt and Kosnik's classification without attendant were as follows: In Y-group, I-II 17, III 9, IV 5, V 1 in A, I-II 9, III 4 in B, I-II 60, III 9, IV 2 in C. In E-group, I-II 4, 2, IV 3 in A, III 4, IV 1 in B, I-II 10, III 2, IV 4 in C.
Timing of the operation did not differ between the Y-group and E-group, but the number of cases classified into HI and IV was significantly larger in the E-group than in the Y-group.
Favorable results were obtained as follows : In the Y-group, I-II 15/17 (88%), III 8/9 (89%), IV 2/5 (40%), V 0/1 in A, I-II 9/9 (100%), III 4/4 (100%) in B, I-II 54/60 (90%), III 5/9 (56%), IV 1/2 (50%) in C. In the E-group, I-II 2/4 (50%), III 0/2, IV 2/3 (66%) in A, III 0/4, IV 0/1 in B, I-II 8/10 (8%), III 1/2 (50%), IV 0/4 in C.
As a whole, surgical results were better in the Y-group than in the E-group.
Unfavorable outcomes due to surgical procedure in Grade I-II cases and primary brain damage in Grade III-IV cases were significantly frequent in the E-group (3/14: 21%, 9/16: 56%) than in the Y-group (3/86: 3%, 6/30: 20%).
In the Y-group, outcomes of Grade I-II cases and N cases were not significantly different in the timing of the operation, and the outcome of Grade III cases was better in cases operated on within 7 days after SAH than in cases operated on over 8 days after SAH.
In the E-group, the outcome of Grade I-II cases was almost the same irrespective of the timing of the operation except cases over 70 years old with high positioned basilar bifurcation aneurysm.
Two out of 3 favorable cases of Grade III and IV were operated on within 3 days after SAH and those cases showed disturbance of consciousness due to acute hydrocephalus.
From these results and the results of the literature, which has shown a high incidence of deterioration during waiting for the operation in cases with ruptured vertebro-basilar aneurysms, it can be concluded that surgery must be performed as early as possible after SAH in all Grade I-II cases except cases over 70 years old with high positioned basilar aneurysms, and III and IV cases under 64 years old with ruptured vertebro-basilar aneurysms.
Early surgery is also indicated in Grade III and IV cases over 65 years old with disturbance of consciousness due to acute hydrocephalus.

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The surgical indications of severe aneurysmal subarachnoid hemorrhage (SAH) are controversial. We consider that early surgery should be carried out on selected cases.
Therefore we try to estimate SAH not only by the neurological state but also by electrophysiological examination (Brain stem evoked potential or short somatosensory evoked potential) for precise evaluation and determination of the indications.
Either brain stem auditory evoked potential (BAEP) or somatosensory evoked potential (SSEP) were performed in 33 cases (W.F.N.S. Grade N, 13 cases; Grade V 20, cases) of 153 severe aneurysmal subarachnoid hemorrhage within 24 hours after onset.
BAEP were recorded between the vertex (Cz) and the ipsilateral mastoid process. Changes in BAEP were classified into 4 grades as follows: Grade 1 was normal i.e. I-V interpeak latency was 4.1+0.2 msec; in Grade 2, I-V interpeak latency was over 4.5 msec on either side; Grade 3, each wave was obscure except for probably wave V, and in Grade 4, there was no response on either side. SSEP were obtained by median nerve stimulation at the wrist. A recording electrode was placed over the surface of the spine at the C-2 vertebral level and over the areas of the somatosensory cortex bilaterally in the C3'/C4' position in the international 10-20 system. The central conduction time (CCT) was the delay between the N14 peak recorded at the C-2 electrode and the N20 peak recorded at the somatosensory cortex. Changes in the SSEP in SAH were classified into 5 grades as follows: Grade 1 was normal, i.e. CCT was 5.8 ± 0.4 msec; in Grade 2, there was prolongation of CCT on the affected side (CCT>6.6 msec); in Grade 3 there was no response on the affected side and the CCT was normal on the unaffected side; in Grade 4, there was no response on affected side and the CCT was prolonged on the unaffected side; and in Grade 5, there was no response on either side.
The outcome was poor if BAEP were abnormal, but the outcome varied in normal BAEP cases. There was a good positive relationship between the SSEP grade and outcome. When both BAEP and SSEP were measured simultaneously on admission, the SSEP grade and the outcome were variable even if BAEP were normal and SSEP were always abnormal whenever BAEP were abnormal.We speculate that brain damage in severe aneurysmal subarachnoid hemorrhage was not caused by primary brain-stem damage, but mainly caused by cerebral perfusion injury in the basal ganglia or thalamus due to direct injury of hemorrhage or secondary intracranial hypertension. Therefore, the SSEP seems to be superior to the BAEP for evaluation of brain damage in severe aneurysmal subarachnoid hemorrhage.
In conclusion, in the treatment in severe aneurysmal subarachnoid hemorrhage, we consider that early surgery should be performed in cases of SSEP Grade 1 or 2, while conservative therapy is recommended in cases of SSEP Grade 3 or more.

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