We treated 27 patients with intracranial aneurysm using Guglielmi detachable coils (GDC) and angiographic results and assessed complications. In 28 aneurysms treated by endosaccular occlusion, 15 (71%), 6 (21%) and 2 (7%) resulted in complete occlusion, neck remnant and dome filling, respectively. Neither haemorrhagic nor thromboembolic complications occurred in 27 patients. Embolization using Guglielmi detachable coils seemed to be a safe and useful procedure without complications, but attention should be given to avoiding complications and incomplete occlusion in particular in a case of (1) wide-necked, (2) small (<3mm) or (3) complex-shaped aneurysms.

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We describe a method of endoscopic evacuation of combined thalamic and intraventricular hemorrhage. We used a steerable endoscope that was inserted into the anterior horn of the lateral ventricle contralateral to the thalamic hemorrhage in 4 cases. Because the volume of the hematoma in the lateral ventricle contralateral to the cerebral hemorrhage was smaller than that of the ipsilateral lateral ventricle, the hematoma in the contralateral lateral ventricle could be easily evacuated and sufficient orientation was obtained in the interior of the lateral ventricle. Hematoma in the third ventricle and the aqueduct of Sylvius could also be evacuated by the endoscope passed through the foramen of Monro. We then performed septostomy, and inserted the endoscope into the lateral ventricle ipsilateral to the cerebral hemorrhage. The hematoma in the ipsilateral lateral ventricle and the cerebral hemorrhage could be adequately evacuated. We conclude that approach to thalamic hemorrhage from the lateral ventricle contralateral to the cerebral hemorrhage through an opening placed in the septum pellucidum is useful for the treatment of combined thalamic and intraventricular hemorrhage.

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We analyzed 68 cases with cerebral AVM 3 years after treatment. Total obliteration rates at 1, 2, and 3 years after treatment were 42.5%, 76.1%, and 82.0%, respectively. Four factors: moya type, small volume, deep location and high marginal dose were found to be correlated with total obliteration. So we scored these factors, and categorized them into a grade 0 to 6 Gamma Knife Score (GKS). The total obliteration rate was high in the low GKS group. Hemorrhage occurred in 6 cases with a yearly risk of 2.9%. These cases were relatively large and had high GKS and high Spetzler-Martin grade. Radiation injury occurred in 2 cases. Both cases had edema spreading to white matter and suffered from hemiparesis. Based on these results and our current grading system, our treatment strategy at present is as follows. AVMs with a low GKS had a high obliteration rate and seemed suitable for radiosurgery. Because total obliteration is difficult to achieve in the high grade group, aggressive surgery or endovascular surgery should be considered.

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脳動脈瘤手術において顕微鏡手術の支援システムとして内視鏡および超音波装置を用いた. 脳動脈瘤に対して開頭手術を行った6例(脳底動脈先端部1例, 内頸動脈後交通動脈分岐部3例, 中大脳動脈2例)を対象とした. 親動脈および分枝や穿通枝と動脈瘤頸部を露出後, ストレート型あるいは当施設の玉木が開発したアングル型硬性内視鏡の先端を動脈瘤頸部や親動脈の背側を観察できるように挿入し, アーム型固定器で固定した. 手術中は顕微鏡と内視鏡の両画面をモニター上に表示し, 観察しながらクリッピングを行った. クリッピング後は親動脈と分枝の血流をマイクロドップラーにて観察した.
アングル型内視鏡は手術操作の支障となることなく術中モニターが可能で, 顕微鏡の死角となる親動脈および分枝や穿通枝などを観察しながらクリッピングを行うことができた. そのため, 動脈瘤周辺での剥離操作を減少できた. クリッピング後にマイクロドップラーにて親動脈や分枝の血流が保たれていることを確認した. 1例では血流障害を認めたためクリップをかけなおした. 全例でネッククリッピングを行い, 合併症は認めなかった.
動脈瘤に対する直達手術の安全性を向上させるために, 内視鏡や超音波を使用したモニタリングは有効であった.

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A 46-year-old female presented with amaurosis fugax. Left vertebral angiography revealed a nonruptured left vertebral artery aneurysm. The aneurysm was located at the level of the cervi-comedullary junction just outside the dura mater. Clipping was done without dural incision. Recently, reports of dissecting aneurysm of extracranial vertebral artery have been increasing. However, nondissecting aneurysms of extracranial vertebral artery are still rare and the majority of extracranial vertebral artery aneurysms are pseudoaneurysms and usually develop secondary to injuries. To our knowledge, six extracranial vertebral artery saccular aneurysms, including our case, without any trauma, inherited disorder or inflammatory lesion have been reported. We report clinical course and discuss the details of the aneurysm at this site.

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Endovascular embolization of the cerebral aneurysms has been established as one strategy of treatment. With the advent of Guglielmi detachable coils (GDC), endovascular embolization has been performed for safety. Some aneurysms, however, are is difficult to treat by either surgical operation or endovascular technique because of wideneck or other reasons. In those cases,“neck plasty”(temporary balloon occlusion) is a useful alternative method.
We present such a case of aneurysm and treatment by neck plasty and review previous cases treated with the same procedure.
A 66-year-old woman had a headache and visited a nearby hospital, where a basilar top unruptured aneurysm was diagnosed by CT scan, MRI and cerebral angiogram. She was referred to our department and admitted. She was treated by endovascular embolization using GDC with temporary balloon occlusion. This treatment was performed uneventfully. She was discharged without neurological deficits. Three months after embolization, a follow up angiogram showed complete occlusion.

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We report a method to expose an aneurysm on the posterior aspect of the internal carotid artery in the operation field with a pterional approach. A 47-year-old woman had an internal carotid artery aneurysm at the junction with the posterior communicating artery. The aneurysm, which was not visualized in the pterional transsylvian route, was successfully exposed by rotating the internal carotid artery by pushing a clip-head of the temporary clip that had been placed at the proximal segment of the parent artery. This method proved to be very effective to expose the aneurysm neck and also to isolate the posterior communicating artery free from the aneurysm.

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Cerebral ischemia has a relatively simple cause: occlusion of supplying blood vessels. The best treatment, therefore, is to remove the cause. If cerebral blood flow is restored within a short time, the brain is not damaged. The recent advent of thrombolytic agents such as t-PA enabled us to attain this therapeutic goal. This mode of treatment, however, is not always possible, because there is a time window during which therapy must be administered. It is well established that ischemic brain damage depends to a great extent on the duration and degree of flow reduction. If flow reduction is mild or ischemic period lasts only a few hours, patients are likely to recover. What happens when flow reduction is not mild or the duration of ischemia is longer? Ischemia, then, causes irreversible brain damage. To counter this problem, the mechanisms of ischemic brain damage have been investigated for many years, yet they still remain unknown. Glutamate has been postulated as one of the major causes of neuronal vulnerability to ischemia. Indeed, extensive evidence has been accumulated that supports this hypothesis, but anti-glutamatergic drugs have been largely unsuccessful. Recent experiments in this field have been done on the hypothesis that at least a part of ischemic brain damage progresses through apoptosis. When apoptosis is used to mean a cell death process that requires gene expression, it is quite possible that this is the case. Downstream to the main cascade of apoptosis, mitochondria are now believed to play a pivotal role. Loss of mitochondrial membrane potential and leakage of pro-apoptotic substances from the mitochondria are essential steps in apoptosis. On the other hand, loss of ATP and breakdown of mitochondrial energy metabolism are well-known characteristics of classic ischemic necrosis. Investigation of mitochondrial alteration will be the most important goal in elucidating ischemic brain damage in the next several years.

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Purpose: We evaluated the efficacy of local intra-arterial fibrinolysis (LIF) in patients with acute ischemic stroke and sought to determine the influence of recanalization time and neuroradiological parameters on outcome.
Methods: We treated 103 patients with local intra-arterial injection of urokinase or recombinant tissue plasminogen activator within several hours after the onset of acute ischemic stroke. Thirty-four patients had occlusions of the internal carotid artery (ICA), 49 of the middle cerebral artery (MCA), and 20 of the vertebrobasilar artery (VBA). Outcome was assessed at the time of discharge and classified as excellent, good, fair, poor, and dead. The site of occlusion, recanalization time (from the onset of stroke to the accomplishment of recirculation), and collateral circulation on the angiogram (good, fair, or poor), and the outcome were evaluated.
Results: Recanalization and good (excellent and good) outcome were achieved in 21 (62%) and 8 (24%) of 34 patients with ICA occlusion, 39 (80%) and 30 (61%) of 49 patients with MCA occlusion, and 20 (100%) and 8 (40%) of 20 patients with VBA occlusion, respectively. The patients were divided into three groups according to the recanalization time of less than 3 hours (Group-I, 8 patients), 3 to 4 hours (Group-II, 31 patients), and more than 4 hours (Group-III, 41 patients). Outcome was good in all the 8 patients in Group-I without regard to the site of occlusion and collateral circulation. In Group-II and III, outcome was also good regardless of collateral circulation in patients with MCA-Mldistal or M2 occlusion, and that of the other patients in these groups was good only when they had a good collateral circulation.
Conclusions: LIF would be most efficacious in any patients with acute stroke when treated within 3 hours of onset and in patients with occlusion of Ml distal and M2 portion when treated after 3 hours. Other patients are good candidates of LIF only when they have good collateral circulation.

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Management strategies of acute ischemic stroke have rapidly evolved since the NINDS rt-PA Stroke Study Group demonstrated the beneficial effect of intravenous recombinant tissue plasminogen activator (rt-PA) therapy within 3 hours of the onset of ischemic stroke. Unfortunately, subsequent clinical trials failed to show beneficial effects of thrombolytic therapy administered later than 3 hours. It has been reported that neuroprotective agents, such as lubeluzole and ebselen, may have beneficial effects for acute ischemic stroke even if the treatment is started between 6 and 24 hours after stroke onset. Other brain protective agents and hypothermia are now being clinically evaluated. To obtain maximal benefits of these promising therapeutic strategies, the education of the public and health workers and the establishment of emergency transfer and management systems will be urgently required.

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Most ischemic strokes are attributable to the obstruction of brain arteries by blood clots. Therefore, antithrombotic therapy is the most essential treatment of acute ischemic stroke. Heparin had long been used for progressing stroke. According to the meta-analysis by the Cochrane Stroke Review Group in 1994, however, heparin was not proven to be beneficial for the treatment of acute ischemic stroke.
Based on this background, the International Stroke Trial (IST) was undertaken. The trial was a large randomized open trial of up to 14 days of antithrombotic therapy to provide evidence on the safety and efficacy of aspirin (300 mg daily) and subcutaneous heparin (5,000 or 12,500 IU twice daily) administered to 19,435 patients with acute ischemic stroke within 48 hours of onset.
Among heparin-allocated patients, there were significantly fewer recurrent ischemic strokes within 14 days but this was offset by a similar-sized increase in hemorrhagic strokes, so the difference in death or non-fatal recurrent stroke was not significant within 14 days. At 6 months the percentage dead or dependent was identical in both the heparin and no-heparin groups. Compared with 5,000 IU bd heparin, 125,000 IU bd heparin was associated with more transfused or fatal bleeds, more hemorrhagic strokes, and more deaths or non-fatal strokes within 14 days. The results suggest that if heparin is given in routine clinical practice, the dose should not exceed 5,000 IU subcutaneously twice daily.
Among aspirin-allocated patients, at 6 months there was a non-significant trend towards a smaller percentage of the aspirin group being dead or dependent. They had significantly fewer recurrent ischemic strokes within 14 days with no significant excess of hemorrhagic strokes, so the reduction in death or non-fatal recurrent stroke with aspirin was significant. The Chinese Acute Stroke Trial (CAST) was a large randomized, placebo-controlled trial of the effects of aspirin (160 mg/day) in 21,106 patients with acute ischemic stroke within 48 hours of onset for up to 4 weeks. There were significant reductions in mortality, recurrent ischemic stroke, and death or non-fatal stroke with no significant increase in hemorrhagic strokes with aspirin. Taking together, CAST and IST show that aspirin started early produces a small but definite net benefit, with about 9 fewer deaths or nonfatal strokes per 1,000 in the first few weeks (p=0.001), and with 13 fewer dead or dependent per 1,000 after some weeks or months of follow-up (p=0.01).
As to the efficacy and safety of low molecular weight heparin or heparinoid, the results were not consistent, necessitating further information, including their differences between subtypes of ischemic stroke. A clinical trial (FISS) showed a lower rate of unfavorable outcomes at 6 months after acute ischemic stroke following the administration of the low molecular weight heparin nadroparin, but no significant differences were noted at 10 days or 3 months. The trial of ORG 10172 in Acute Stroke Treatment (TOAST) was a larger randomized placebo-controlled trial of continuous infusion of the low molecular weight heparinoid danaparoid for 7 days in 1,281 patients with acute ischemic stroke within 24 hours after onset. In total there were no significant differences in percentage favorable or very favorable outcomes at 7 days and 3 months between danaparoid and placebo groups, although the subgroup analysis showed a significant response to treatment at 7 days and 3 months among patients with large-artery atherosclerosis.
In Japan the thrombin inhibitor argatroban and the thromboxane A2 synthetase inhibitor ozagrel are approved for the treatment of acute ischemic stroke. A randomized controlled study is ongoing to compare the efficacy and safety of both agents in patients with atherothrombotic stroke within 48 hours after the onset.

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