Acute referral and early treatment of ruptured intracranial aneurysms have led to a discussion of the treatment consensus among patients in Hunt Hess grades 4 and 5. The resent possible benefit of Tirilazad among males have been disputed and could not be proven among women in a randomized controlled series.
In a small consecutive series of 14 male patients in H & H grades 4-5, 12 received Tirilazad. 3/12=33% died from MOF and other causes but not from delayed clinical vasospasm, 7/12=58% had a GOS of 3, 2/2=100% not receiving Tirilazad died from vasospasm. Usually 60% of our patients are dying upon admittance with significant infarction and brain shifts due to early referral in our area.The H & H 4-5 group should thus be considered heterogenous and different selective treatment modalities may be advocated including“no treatment.” Early surgery and a strict protocol of 2-H and 3-H treatment consisting of immediate control of ICP and CPP combined with the free radical scavenger Tirilazad resulted in a survival rate of 67% with a good outcome GOS-3 in 58%. It is speculated why early free radical scavengers could be of benefit using the 3-H therapy.

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We present 2 cases of cyst formation after gamma knife radiosurgery for intracerebral arteriovenous malformations (AVM). In both cases complete obliteration of AVM was confirmed by angiography within 2 years after treatment. However, about 5 and 3.5 years after treatment they had a large cyst with neurological signs and symptoms. Operations were performed and the pathology of the cyst wall was investigated in both of cases. The pathological findings showed gliosis without malignant brain change.
These two cases are the first reported in which the pathology of cyst wall was studied after radiosurgery.
To investigate side effects of radiosurgery, a long follow-up will be needed after complete obliteration of AVM.

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This report outlines our pre-and intraoperative decision-making for a unilateral approach in patients with multiple, bilateral intracranial aneurysms. During the last 7 years, 41 patients with 116 bilaterally localized aneurysms were treated in our department by microsurgical clipping. In 18 patients (44%), a unilateral approach enabled a successful clip occlusion of the aneurysms. In 11 patients (27%), a unilateral approach was attempted and the contralateral aneurysm detected. However, intraoperative circumstances suggested not to clip and, consequently, a bilateral approach was chosen for safe and complete clipping. In 12 patients (29%), radiological and clinical features primarily advised a bilateral approach. There was no significant difference in the overall postoperative outcome in patients treated unilaterally versus bilaterally. No complications related to the unilateral surgical management occurred. We conclude on the basis of our experiences, that in selected cases the clipping of contralateral aneurysms via a unilateral approach is possible without additional surgical morbidity.

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To evaluate the effect of temporary clip (TC) and the division of the posterior communicating artery (PComA) on surgical results in cases with ruptured basilar bifurcation aneurysms, we analyzed 57 cases.
Timing of operation (within 3 days after SAH: A, over 4 days: B) and clinical grades by Hunt and Kosnik's classification were as follows: In A-group, grade I-II, 7 cases, and grade III-IV, 8 cases. In group B, grade I-II, 34 cases, and grade 8 cases. Clipping was performed through the pterional approach. We ordinarily used TC for less than 10min. and divided PComA if necessary.
TC was used in 26 cases (T-group). According to the aneurysmal size, TC was used in 12 of 33 small (less than 9mm) and 14 of 24 large (more than 10mm) aneurysms. According to the aneurysmal position, 15 of 37 cases were low position (less than 9mm over the clinoid line) and 11 of 20 cases were high position (more than 10mm). Division of PComA was performed in 16 cases (D-group). Nine of 33 cases were small and 7 of 24 cases were large. According to the position, 11 of 37 were low position and 5 of 20 were high position.
Forty-one (72%) of 57 patients had an overall favorable outcome: In T-group, grade I-II, 87%, grade III-IV, 53% and in non-T-group, grade I-II, 86%, and grade III-IV, 64%. In D-group, grade I-II, 70%, grade III-IV, 50% and in non-D-group, grade I-II, 92%, and grade III-IV, 47%. Sixteen (28%) of 57 patients had an overall unfavorable outcome. In 4 cases who had some risk factors: more than 70 years old, cerebrovascular risk factors (chronic hypertension, atherosclerosis), large aneurysm or high-positioned aneurysm, surgical procedures led to an unfavorable outcome. The causes of deterioration by surgical procedures were injury of the perforating artery or intracerebral hematoma by the brain retraction. Intraoperative hemorrhage did not provoke any deficits.
These results suggest that these operative techniques can be used in cases with ruptured basilar bifurcation aneurysms for safe and easy operations, except for cases with operative risk factors.

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We describe our experiences with surgical clipping of 17 large aneurysms. The location of these aneurysms were 7ICAs (including 2 IC-ophthalamic non-ruptured cases), 7MCAs, 2ACAs, and 1BA. The postoperative outcome was GR, 6; MD, 5; SD, 3; D, 3. Three of 6 poor outcome cases were IC aneurysm. A total of 34 clips were used for clipping (average 2 clips in each case), and fenestrated clips were particularly useful in such cases. The causes of poor outcome were operative procedure in 3, spasm in 2, and primary brain damage in 1. In the preoperative examination, 3DCT virtual endoscopy was useful for a successful clipping.
To improve the postoperative outcome for large aneurysms, prevention of premature rupture and an optimal obliteration of aneurysm with the preservation of afferent and efferent arteries as well as perforating vessels are important.

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Surgical treatment for childhood moyamoya disease has been established in the past 2 decades by an organized nationwide study. However, some controversial problems remain in this surgical treatment that were underestimated in the past study. In this paper, we present set a study focused on the problems associated with the combined surgical treatment of direct and indirect bypass surgery.
During the past 12 years, we performed 66 surgeries on 35 patients of childhood Moyamoya disease (under 15 years of age). A new ischemic lesion was perioperatively observed in 2 surgeries, which were asymptomatic. Of these 35 patients, TIA or RIND was transiently observed in 22% postoperatively, which had disappeared in 1 year (mean). No completed infarction was seen in these patients postoperatively. Quality of life (QOL) was satisfactory in most patients with TIA onset although patients with preoperative completed infarction revealed mental retardation and poor activity of daily life (ADL).
Patients with moyamoya disease can expect a good ADL and QOL with proper treatment before completed infarction takes place. Early screening tests and proper surgery are indispensable to improve the overall outcome of the treatment of childhood moyamoya disease.

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Aneurysms of the cervical internal carotid artery (ICA) are known to present with a mass, fatal hemorrhage or cerebral ischemic attack. The recent advances in skull base surgery and intravascular procedures have provided a wide variety of therapeutic options and are expected to improve results.
We report our experience in 5 patients; 2 patients presented with focal neurological deficit due to embolism, 2 with a growing cervical mass, and 1 was symptom-free. Arterial reconstruction was performed after aneurysmal resection in 2 patients. In 1 patient whose aneurysm was located high at the C2 level, vertical mandibular osteotomy was useful for resecting the aneurysm and primary end-to-end anastomosis. In the other patient who had dilated distal carotid artery and multiple vertebral and basilar aneurysms, an extracranial-intracranial saphenous vein bypass was placed to prevent potential increase of the hemodynamic stress in the posterior circulation. The most recent case with a dissecting aneurysm was treated using a stent with preservation of the ICA flow. For the other 2 patients, trapping and encasement of aneurysms were performed. In our 5 patients, three aneurysms were proved atherosclerotic and 2 were spontaneously dissecting in nature. There was neither mortality nor additional morbidity except for transient lower cranial nerve palsy in 1 case.
We found that minimally invasive diagnostic modalities such as magnetic resonance angiography, Doppler ultrasonography and 3-D-CT angiography were useful in evaluating the change of aneurysmal size. The hemodynamic effect of the intended treatment on the coexisting vascular lesions should be considered before treatment. Technique in skull base surgery is essential in the treatment of distally located aneurysms. Recent advances in intravascular procedures offer less invasive alternatives and include balloon, coiling and stent placement.

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To establish a management strategies for poor-grade patients after aneurysmal subarachnoid hemorrhage (SAH), medical records were analyzed for 166 patients who were in Hunt and Hess Grade IV or V among 588 consecutive cases with ruptured intracranial aneurysm admitted during the past 5 years. Causes of unfavorable outcome (poor or dead) in those 166 patients were evaluated to improve the management outcome.
Overall management results of the 166 poor-grade patients were favorable (good or fair) in 71 (42.8%), unfavorable in 95 (78 dead, 17 poor). Direct clipping was performed in 90 patients, and the results were favorable in 69 (76.7%) and unfavorable in 21(23.3%). Surgery was not done in 76 patients because 41 were moribund on arrival, 15 deterioration due to rebleeding, 7 severe brain swelling, 5 serious medical illness, one severe delayed ischemic deficits (DID), and one cerebral infarction following angiography, and 6 refused surgery. Seven patients survived in non-surgery group (2 fair, 5 poor). Direct effects of aneurysm rupture (34.8%) and early rebleeding (34.8%) were the major causes of unfavorable outcome in Grade IV patients, while it was direct effect of aneurysm rupture (91.8%) in Grade V patients.
As rebleeding is the only preventable cause of unfavorable outcome, urgent management is necessary to prevent rebleeding, especially for grade IV patients. Grade IV patients should be treated aggressively with direct clipping for non-complex aneurysms or for patients with hematoma, and coil embolization for patients with poor surgical indication.

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Numerous operative procedures and percutaneous transluminal angioplasty (PTA) have been proposed for the correction of subclavian syndrome (SSS). We report a case of subclavian steal syndrome with occlusion of the carotid artery that had lateralizing hemispheric focal events.
A 51-year-old male was admitted to our hospital due to right hemiparesis, transcortical sensory aphasia and left arm claudication. Aphasia worsened with right arm physical movement. Blood pressure measured in the right upper limb was 30 mmHg lower than in the opposite side. CT scan and MRI showed infarction in the cortical territory left of the middle cerebral artery. Angiograms revealed complete occlusion of the left carotid artery, and severe stenosis of the right proximal subclavian artery. The left hemisphere was mainly perfused from the vertebral artery via the circle of Willis. STA-MCA anastomosis was performed.
After surgery, the patient was free from any symptoms. SPECT (123I-IMP) performed before and after the operation demonstrated recovery of CBF in the left middle cerebral artery area. The present case suggests that STA-MCA anastomosis should be the first treatment of choice for subclavian steal syndrome with lateralizing hemispheric focal events.

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We describe a case of cavernous dural arteriovenous shunt with ischemic lesion in the brain stem due to venous congestion, which was detected by MRI and SPECT. A significant improvement on MRI and SPECT was observed after embolization. This case suggests that urgent treatment is necessary for cavernous dural arteriovenous shunt with venous congestion on brain parenchyma.

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We report a case of large MCA aneurysm that ruptured during opening of the dura in surgery. A 41-year-old man was brought in to our hospital following sudden onset of coma with right hemiplegia. Computed tomography revealed severe subarachnoid hemorrhage and a hematoma at the left temporal lobe with midline shift. Cerebral angiography also revealed aneurysms both at the left IC bifurcation and at the left MCA bifurcation. An emergency craniotomy for intracranial decompression was carried out, and then sudden rupture of the aneurysm occurred with arterial bleeding when opening the dura. The MCA aneurysm was successfully clipped in spite of extensive bleeding. Intraoperative aneurysmal rupture occuring in the early stage of operation is not common and the control and treatment of bleeding is quite difficult.
We discuss on the management of intraoperative aneurysmal rupture, especially in the early stage.

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