The author summarizes a recent application of neuroendoscopy for cerebrovascular surgery. He describes classification and characteristics of various kinds of endoscopes and the use of an integrated surgical support system, such as image monitor systems and a fixation instrument of an endoscope, which facilitate the actual use of an endoscope for surgical treatment of cerebral stroke. The usefulness and problems of endoscopy at the time of clipping of aneurysms, removal of intracerebral or intraventricular hematomas, and endovascular surgery are discussed.

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The results of surgical treatment in 22 elderly patients aged over 75 years with ruptured intracranial aneurysms were analyzed, especially from the viewpoint of postoperative mental function. The cases corresponded to 7% of all surgical cerebral aneurysms with subarachnoid hemorrhage during 1985 to 1994. Only 32% of the cases showed good outcome at discharge, and morbidity and mortality rates were 54% and 14%. There were more good outcomes in the group with Hunt and Kosnik grades I (including I-a) and II than that with III and IV. At long-term follow-up, 4 cases showed improvement into good recovery, all of which were moderately disabled at discharge due to mental disorder. In 5 cases, long-term follow-up revealed further deterioration, 4 of which had already fixed definitive neurological deficits at discharge. Neuropsychological examination showed that postoperative outcome had closer correlation with Hasegawa dementia scale (HDS) than Kohs block design test (KBD). All cases with higher score rates than 50% in HDS showed good outcome, even if with any score in KBD.

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Dural arteriovenous malformations are estimated to comprise 10 to 15% of all intracranial AVMs. They are predominantly located at the base of the skull, especially in the posterior cranial fossa, and transverse-sigmoid sinuses are usually involved. They also occur in the cavernous sinus. However, dural AVMs involving the anterior cranial fossa are rarely documented and most cases have intracranial hemorrhages, a great majority of which are intracerebral and/or subarachnoid. Cases with seizure attack are very rare. We have recently experienced one such rare case which, was operated on and cured completely.
We report a case of dural arteriovenous malformation in the anterior fossa with seizure attack. A 55-year-old male was hospitalized because of seizure attack. This attack was the first episode for this patient. MRI disclosed the curvilinear flow void in the left frontal pole. Angiography revealed an AVM in the anterior cranial fossa, fed by the left anterior ethmoidal artery and drained by the left olfactory vein. The draining vein without vascular sac finally reached the dural venous sinuses. The diagnosis of dural AVM was made. A left frontal craniotomy was performed. Removal of nidus was abandoned due to its deeply seated location in the olfactory groove, so coagulation of the nidus and resection of the drainer were performed. On postoperative angiography the dural AVM was not visualized any more. The patient showed no neurological deficit.

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During recent three calendar years from 1992 to 1994, we treated 255 consecutive cases of CT-verified subarachnoid hemorrhage (SAH). Among these, 162 patients underwent angiography and in 13 patients the responsible aneurysms were not detected. A second angiography was performed on 10 of the 13 and finally three were diagnosed as idiopathic SAH, which was characterized as perimesencephalic distribution of SAH. Seven patients had aneurysms that were diagnosed at the operation and/or the second angiogram. Three patients showed rebleeding even though they had negative initial angiograms. Acute direct surgery to find and occlude the ruptured aneurysm with negative angiography could be indicated when the patient showed rebleeding, with massive SAH carrying possible risk of vasospasm and with CT findings indicating probable localization of the ruptured aneurysm. Asymmetric distribution of SAH suggesting the hemodynamic stress on the ruptured aneurysm and associated intraparenchymal hemorrhage often accurately occurred where the lesions were. Careful clot removal with frequent irrigation along the main trunk of the arteries was emphasized.

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Recently, the usefulness of three-dimensional CT angiography (3D-CTA) using helical CT has been reported. Although 3D-CTA has been applied for neurosurgical diseases, especially for surgical planning, it has not done for emergency patients because of the long time required for image reconstruction and location of a helical CT scanner. We studied emergency patients with SAH, and compared the 3D-CTA with angiography and surgical findings, using TOSHIBA X vigor.
Twenty-two patients with SAH were evaluated. The helical CT was performed for 55 seconds with a bolus injection of 90 ml non-ionic, iodinated contrast medium at a rate of 3ml/sec with a delay of 20 sec. Angiography was carried out immediately after the helical CT. Eighteen of 22 cases were operated on urgently.
We were able to create the 3D-CTA in about 7 minutes, and diagnose aneurysms by the 3D-CTA before angiography. The 3D-CTA was able to demonstrate 30 of 31 aneurysms including 9 unruptured aneurysms. An unruptured internal carotid-posterior communicating artery aneurysm 1.3mm in diameter and associated with a ruptured aneurysm was not detected by either the 3D-CTA or angiography. On the other hand, an unruptured Acom aneurysm 0.8mm in diameter and associated with a ruptured aneurysm could be detected by the 3D-CTA, but not by angiography. The 3D-CTA gave us useful information concerning the anatomical relationship of the aneurysm, its neck and parent artery, and the surrounding branches. There were no complications or side effects associated with the helical CT scan.
Although the 3D-CTA requires further development of visualization of small arteries less than 1mm in diameter, such as perforating arteries, subtraction technique of bony structure, and a method for checking cervical arteries, it is useful for diagnosis of emergency patients with SAH and urgent operations. We believe that an operation might be performed by only the 3D-CTA without the angiography in the near future.

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We studied the efficacy of cisternal injection of urokinase (UK) and nicardipine for prevention of symptomatic vasospasm (SVS) in patients with ruptured intracranial aneurysms. Two-hundred and fifty-eight patients who were classed into Group 2 to 4 according to Fisher's computed tomographic classification and underwent early surgery with ventricular and cisternal drainage were given UK (6000-12000 I. U.) and nicardipine (1-2mg) via the cisternal catheter twice each day for 6 and 9 days, respectively, after surgery (the treated group). These patients were further subclassified into the 2 groups of the treated Group I, 194 patients treated between 1989 and 1993, and the treated Group II, 64 patients treated in 1994. The rate of SVS and outcome in the treated groups were compared with those in 153 patients who underwent early surgery and were treated with ventricular and cisternal drainage without the cisternal injection of the drugs (the control group).
Permanent neurological deficits due to vasospasm were observed in 6 (3%) patients in the treated Group I, 1 (2%) in the treated Group II, and in 22 (14%) in the control group. The outcome was significantly better in the 2 treated groups than in the control group, and there was no difference between the treated groups in outcome. The amount of hemoglobin in cerebrospinal fluid collected from the cisternal catheter in the treated Group I (n=7) was greater than that in the control group (n=12) in the early period after the surgery. The regional cerebral blood flow measured by SPECT with ¹³³Xe inhalation was increased during the treatment with nicardipine (n=4).
These results suggest that cisternal administration of UK and nicardipine is useful for the prevention of severe SVS in patients with ruptured aneurysms.

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We treated 26 cases of cerebral aneurysms and other intracranial hemorrhagic diseases in patients who needed hemodialysis. Among them, neurosurgical operations were performed in 12 patients and postoperative bleeding or rebleeding occurred in 4 patients. All the bleeding occurred intraparenchymally and rebleeding was not seen in other 14 non-operative patients.
We also analyzed 31 patients with cerebral aneurysms who were under hemodialysis, including 7 of our cases and 24 cases from the literature. It was apparent that final outcome of these patients depended on the initial level of consciousness but not on the mode of dialysis.
From these data we conclude that intracranial hemorrhagic disease can be safely operated on when the manipulation is confined in the extrapial space.

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We describe a case of giant middle cerebral artery aneurysm associated with cyst formation in a 51-year-old woman. She presented with a 2-month history of numbness in her right extremities. Magnetic resonance imaging revealed a large cystic lesion with the oval mixed intensity core in the left parietal lobe, which proved to be a giant aneurysm originating from the anterior parietal artery by left carotid angiogram. She underwent frontotemporal craniotomy with aneurysm resection through the cyst cavity and made a good recovery. Histologically, the aneurysm was almost totally thrombosed and the aneurysmal wall was highly vascularized with capillary channels. The cyst wall consisted of the superficial fibrous layer with hemosiderin deposits and the deep gliotic layer. Cyst fluid was yellowish and slightly turbid and seemed to be exudative. These findings suggest that initial minor bleeding and subsequent serum exudation from the capillary channels in the aneurysmal wall play important roles in pathogenetic mechanism of the cyst.

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We have analyzed the surgical results of ruptured cerebral aneurysms classified into Grade III, IV or V of Hunt and Kosnik's classification, so as to understand the surgical indications and the points of peri-surgical management for these cases at present. We also looked back 12 cases on this criteria experienced in the year of. 1994 and compared these two results. The clinical materials for the study consists of 154 cases in Grade III, 99 in Grade IV and 14 in Grade V. Surgical outcomes at discharge were classified into excellent, good, fair, poor or dead, and the former two were regarded as favorable and later three as unfavorable outcomes. These results were correlated to the aneurysmal location, timing of the operation, patient age, use of temporary clip (TC), premature rupture (PR) or use of continuous cisternal drainage (CCD). There were 52 cases (34%) of unfavorable outcomes in Grade III, 65 (66%) in Grade IV and 14 (100%) in Grade V. Vertebro-basilar aneurysms (VBA) had a tendency to result in a greater rate of unfavorable outcome (43%) compared to the other location of aneurysms in Grade III, but it was not statistically significant. Early surgery (within 72 hours) was somewhat better in VBA in Grade III and the predominance of early surgery was significant (p<0.001) in cases of Grade IV. Patient age (younger or older than 70 years) significantly influenced (p<0.05) the outcome of Grade III patients and early surgery was better especially in the group of younger (<70 years) patients in Grade IV. There was no significant correlation between TC, PR or CCD and the outcome in any group. The main causes for unfavorable outcome were symptomatic vasospasm (VS) in 26 cases (50%), primary brain damage (PBD) in 12 cases (23%), surgical procedure (SP) in 7 cases (13%) and complication (Comp) in 7 cases (13%) out of 52 Grade III unfavorable outcomes, respectively. In Grade IV, PBD occurred in 54 cases (83%), Comp in 6 (9%), and VS in 5 (8%) out of 65 cases. In Grade V, all 14 cases were unfavorable due to PBD. These results indicate that the surgical management for these patients at present should be as follows. Grade V patients basically should not be operated on except for few cases who have special conditions such as acute hydrocephalus or ICH as a cause of poor consciousness. Early surgery is strongly recommended for rest of the cases, especially for the Grade IV cases both younger and advanced aged patients. To reduce the unfavorable outcomes, prevention of the VS is most important in Grade III. It must also be kept in mind that postoperative complications such as pneumonia are important factors of unfavorable outcomes especially for advanced aged patients. Finally the operative results of 12 cases in 1994 were a little better in Grade III but similar problems were still present in Grade IV.

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We report a case of rebleeding after proximal clipping of ruptured vertebral arterydissecting aneurysm.
A 61-year-old-man suffered from severe SAH with coma and dyspnea. VAG showed “pearl & string sign” at the non-dominant right VA distal to the PICA. The left predominant VA demonstrated retrograde filling of the right VA-DA. Through the right suboccipital craniectomy, a Sugita clip was placed across the VA just proximal to the dissection and distal to the PICA.
Just after extubation, 4 hours after surgery, the patient was afflicted with coma and respiratory arrest. Therefore through the left suboccipital approach, the dissecting aneurysm with a small rebleeding point was trapped just distal to the dissection. The patient was discharged under severe disability 1 year after trapping.
We studied 7 cases of rebleeding after proximal clipping of the ruptured VA-DA with our case in a review of the literature.
The following can be concluded:
1) In each case, the evaluation of the preoperative hemodynamics is necessary by balloon occlusion test at cerebral angiography.
2) If a case shows retrograde filling to the VA-DA in the preoperative vertebral angiography, trapping of the VA-DA should be tried.
3) Because rebleeding after proximal clipping of the VA-DA may be encountered not only proximal but also distal to the PICA, the vertebral angiography should be performed within 1 week after surgery.
4) If the angiograms through the contralateral VA demonstrate retrograde filling of the dissecting aneurysm, the patient should be carefully followed up for postoperative rebleeding.

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Hyponatremia is a common complication after subarachnoid hemorrhage. Although the mechanism of hyponatremia is still controversial, cerebral salt wasting syndrome is currently more favored over the the syndrome of inappropriate secretion of antidiuretic hormone. To accurately manage body water and electrolytes in the acute stage of subarachnoid hemorrhage, we prospectively studied the relations among the daily sodium balance, serum sodium, central venous pressure, and body weight.
Ten of 30 patients demonstrated hyponatremia (serum sodium <135mEq/L) during day 7 to 9 after subarachnoid hemorrhage. In these 10 patients hyponatremia was always preceded by a negative sodium balance, a decrease in central venous pressure and a decrease in body weight. Symptomatic vasospasm was coincident with hyponatremia in two patients. In 13 of the 20 patients who did not develop hyponatremia, we found a negative sodium balance; its duration was significantly shorter than with patients with hyponatremia.
These findings indicate that natriuresis develops within the first week after subarachnoid hemorrhage: and when a negative sodium balance due to natriuresis lasts several days, hyponatremia with dehydration develops at the second week. These factors increase the risk of symptomatic vasospasm. We conclude that a greater replacement of water and sodium is required to maintain “normovolemia” within the first week after subarachnoid hemorrhage. This fluid replacement protocol may be helpful for the prevention of vasospasm following subarachnoid hemorrhage

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