The Japanese Health and Welfare Ministry approved Guglielmi detachable coils (GDCs) for clinical use in 1997. This approval makes it possible to compare GDC embolization with surgical clipping from the same standpoint. We review treatment of aneurysms in our hospital in 1997 and focus on the role of embolization in treating aneurysms. We always examined patients with cerebral aneurysms as a possible candidate for neurosurgical clipping. If the patient had any difficulties and/or problems on neurosurgical clipping (surgically difficult location, high age, poor grade, other cerebro-vascular disease, etc.), the patient was treated by intraaneurysmal GDC embolization. The site of the aneurysm was ICA in 23, MCA 6, AcomA 3, ACA 3, VA 2, BA 11, PCA 1.
Eighteen patients with ruptured aneurysm were treated in the acute stage. In this period, another 90 patients with ruptured aneurysm were treated by surgical clipping in the acute stage. The Hunt and Kosnik grade was II in 4, III in 6, IV in 4, V in 4. Spinal drainage was set in 13 patients and tissue type plasminogen activator was administered via the drainage in 7. According to the Glasgow outcome scale, good recovery or moderate disability was obtained in 3 out of 4 Grade II patients, 6 of 6 Grade III, 2 of 4 Grade IV, and 1 of 4 Grade V. Three patients died of distal embolization (technical complication), acute myocardial infarction, and cerebral vasospasm. There were no patients with rebleeding after embolization. In the patients with unruptured aneurysm (23 patients with 27 aneurysms) or a ruptured aneurysm treated in the chronic stage (4 aneurysms), 13 aneurysms were treated by neck plasty technique. Two patients aggravated clinically by complication at discharge. Rupture of the aneurysm occurred in 1 patient who had a very complicated aneurysm, resulting in body filling.
Complications with persistents neurological deficit were aneurysm perforation in 1, distal embolism in 2, and hemorrhagic tendency due to systemic heparinization in 1. In conclusion, intraaneurysmal GDC embolization is a useful and effective treatment, especially for aneurysms located on posterior circulation, high-aged patients, patients with poor grade, and patients with systemic disease. However, there remains some problems such as possibility of technical complications and no information for long-term stability.

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We reviewed 1110 unruptured intracranial aneurysms including asymptomatic, symptomatic and multiple aneurysms presenting with subarachnoid hemorrhage encountered at our institute and 35 affiliated hospitals over the past 8 years. Of these, 737 aneurysms in 701 patients treated with surgical or endovascular approaches were studied to determine factors favoring either surgical or endovascular treatment of unruptured aneurysms, and factors predicting risk of complications. Surgery with clipping or wrapping was conducted in 609 aneurysms, and 128 were treated endovascularly with embolization. As for aneurysm location, 7% of surgically and 45%of endovascularly treated aneurysms were located in the posterior circulation. The frequency of endovascular treatment was 7% in the first half (1990-93) and 24% in the later half of the study (1994-97) when detachable coils were adopted in Japan.
Outcome was excellent or good in 635 patients (90.6%). Among 95 patients with 120 complications, 66 had unfavorable outcomes, including 17 deaths. Thirty-four patients (5.6%) with surgical treatment and 6 (4.7%) with endovascular treatment had unfavorable results because of treatment-related complications. Four patients (0.7%) with surgical treatment had complications related to perioperative management. Unfavorable outcomes in posterior circulation aneurysms were more frequent in the surgical group (27.9%) than the endovascular group (1.8%) (p<0.001). Among causes of unfavorable results or complications vascular occlusive complications were likeliest to occur in surgically treated basilar artery aneurysms (41%) and endovascularly treated middle cerebral artery aneurysms (22%).
Among surgically treated aneurysms the anterior cerebral artery site was relatively associated with brain contusion and the vertebral artery site with cranial nerve injuries, while the complication rate was relatively low with endovascular treatment.
In conclusion, complications of surgery tend to be serious and affect outcome, and endovascular treatment is safer than surgery for posterior circulation aneurysms. Endovascular embolizations using Guglielmi detachable coils are particularly advantageous for patients who are poor surgical risks.

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Aneurysms arising around the carotid siphon, named juxta-dural ring aneurysms, are different from other cerebral aneurysms. These aneurysms are partially or totally covered with the dura mater and surrounded by the bone or the optic nerve. These anatomical specificity makes surgical access and clipping difficult, compared with other aneurysms. In our experience with endovascular treatment of the cerebral aneurysm over the past 4 years, 32 (28.8%) out of 111 patients harbored juxta-dural-ring aneurysms, including 5 males and 27 females whose age ranged between 33 and 76 years (average 57.5 years old). Seven patients suffered from subarachnoid hemorrhage, 3 in Grade 2, 3 in Grade 3 and 1 in Grade 4. Of 25 patients whose aneurysms were intact, 2 patients developed visual disturbance and 23 were asymptomatic. There were 28 small aneurysms and 4 large aneurysms. Giant aneurysms were not included in this study. Eight of them are broad necked. Twelve aneurysms arose distal to the origin of the ophthalmic artery and 20 did proximal, including 5 “carotid cave aneurysms.”“Extradural cavernous aneurysms”were excluded.
Reasons of indication of endovascular treatment were surgically difficult case in 26, surgically unsuccessful case in 2, poor medical condition in 1 and patient's own will in 3. All these 32 aneurysms were occluded with detachable coils with preservation of the carotid artery. Angiographical results were complete occlusion in 12 (37.5%), dome filling in 13 (40.6%) and residual neck in 7 (21.9%). In the follow-up, complete occlusion was seen in 17 (53.1%), dome filling in 11 (34.4%) and residual neck in 4 (12.5%). Clinical results were good recovery in 29 (90.6%), moderately disabled in 2 (6.3%), severely disabled in 1 (3.1%) and dead in 0 (0%). Of 25 non-ruptured aneurysms, all the patients obtained GR, but there was no visual improvement in 2. Only 1 patient developed hemiparesis caused by embolic stroke due to inadequate heparinization in spite of complete occlusion of the aneurysm and intact carotid artery.
Otherwise no serious complications occurred. In the follow-up period from 6 months to 4 years, no bleeding or rebleeding was observed. In our experience over a relatively short period, results are satisfactory. Considering surgical difficulty and results, we conclude that endovascular treatment is useful for carotid aneurysms around the siphon (juxta-dural ring aneurysm). However, special attention should be paid in choosing treatment of intact aneurysms, in which the risk of rupture is not high in the natural course.

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Neither surgery alone nor embolization alone is effective treatment for difficult aneurysms of basilar trunk or proximal intracranial internal carotid artery. Planned combined treatment with both modalities for difficult cerebral aneurysms is not reported. In the present study, we present our experience with the combined treatment with illustrative cases. We have analyzed 1750 cases of cerebral aneurysms treated by surgical clipping, embolization or a combination of both.
Advantage of endovascular treatment is that it does not depend on the site of the aneurysm and its relationship to surrounding vessels or perforators. The disadvantage of embolization in cases with wide neck aneurysms, thin walled aneurysms, aneurysm with arterial branches or perforators on it is that embolization provides no permanent cure. On the other hand, direct surgery has a long history of permanent cure.
3D-CT angiography with endoscopic views were found to be valuable for planning of the therapeutic strategy. We conclude that therapeutic planning for difficult cerebral aneurysms must include clipping and endovascular embolization. Both modalities are complementary options to achieve the goal of cure for the patients without additional morbidity.

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To evaluate an efficacy of hypothermic anesthesia (HTA) in aneurysm surgery, we studied 74 cases who underwent direct surgery under HTA and compared them with a control group comprising 120 consecutive cases who underwent surgery under normothermic anesthesia (NTA). The mean core body temperature in the HTA group was 30.2±1.7°C, which was obtained easily and safely without any trouble during surgical procedure.
Although the HTA group contains a larger number of cases with poor grade and of which surgery is more difficult and complicated (anterior communicating artery aneurysms, vertebro-basilar aneurysms, large or giant aneurysms) than the NTA group (P<0.05), the overall outcome is a bit better in the HTA group (statistically non-significant). As to an intra-operative incidence, use of temporary clip was less frequent and shorter in sum of temporary occlusion time in the HTA group. Bleedings from aneurysms during surgery and ischemic or contused lesions on the postoperative CT scan were less frequently seen in the HTA group than that in the NTA (P<0.05). In summary, a moderate HTA with a core temperature around 30°C is a useful tool in aneurysm surgery especially when the surgical procedure seems to be complicated and/or might cause secondary damage to the brain.

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Omentum transplantation was performed for the treatment of Moyamoya disease on 79 cases. Fifty-four cases of ischemic sign of the frontal lobe and 25 cases of ischemic sign of the occipital lobes underwent grafting.
As a characteristic of cerebral blood flow in Moyamoya disease, abnormal circular distribution is observed frequently. In such a case, reverse CO2 reactivity may be found on occasion.
Restoration of blood circulation by omentum transplantation seems to be effective for treatment of ischemia in the area of anterior or posterior artery in Moyamoya disease. Its outcome largely depends on whether the preoperative symptom is stroke or whether disturbance of cognitive functions is present. Ischemic sign of the anterior cerebral artery did not advance to stroke, but that of the posterior cerebral artery easily advanced to stroke. However, many of the stroke patients with posterior cerebral arterial ischemia were living ordinary life with half of the visual field.

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We describe 3 cases with dissecting aneurysm of middle cerebral artery suffered from subarachnoid hemorrhage. Two cases were male and the other was female. All patients presented with headache and/or deterioration of consciousness without any symptom of cerebral ischemia. Angiography disclosed aneurysmal dilatation of M2 or M3 segment of middle cerebral artery with no branching, and in 1 case, the middle cerebral artery was occluded just distal to the aneurysmal dilatation. All were treated within Day 1, trapping was performed in 2 cases, while proximal clipping was performed in 1. Proximal clipping was followed by STA-MCA anastomosis, because reduction of regional cerebral blood flow was indicated by preoperative ¹³³Xe single photon emisson CT. The postoperative course was excellent in all cases without any ischemic symptom.
Including our 3 patients, 10 cases of dissecting middle cerebral artery aneurysm presenting with subarachnoid hemorrhage were reported previously. Although dissection of middle cerebral artery was thought to occur frequently in the proximal segment of the middle cerebral artery, 7 aneurysms of 10 cases with subarachnoid hemorrhage were located M2 to M3 segment. Rupture of dissecting middle cerebral artery seemed to occur more frequently in the distal segment. Although treatment for dissecting aneurysm of the middle cerebral artery with subarachnoid hemorrhage is controversial, early surgery with trapping or proximal clipping obtained satisfactory results in prevention of rebleeding. The necessity of additional revascularization for distal artery should be decided with findings of angiographical collateral flow, preoperative regional cerebral blood flow and intraoperative flowmetry.

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Patch angioplasty has been used in carotid endarterectomy (CEA) to protect against early occlusion and restenosis of the internal carotid artery (ICA). We evaluated early surgical results of CEA and restenosis using 3 materials for patch angioplasty: Hemashield, expanded polytetrafluoroethylene (PTFE) and saphenous vein, which were used in 5, 12 and 10 CEAs, respectively (randomized control). Irrespective of the material used in CEA, the operative time and blood loss were not significantly different. We found it difficult to pass the needle through the PTFE and the Hemashield; bleeding from the needle hole was seen with the PTFE. The vein patch was easy to handle. There were no perioperative deaths. One patient in the Hemashield group manifested TIA. Two patients in the saphenous vein graft group had a subcutaneous hematoma in the thigh, the location of the vein harvest. There was no permanent or life-threatening complications in any of the patients undergoing CEA, nor were there restenosis or aneurysm formation in the ICA after CEA, irrespective of the material used for patch angioplasty. Consequently, all 3 of the materials appear to be safe for use. Long-term follow-up will identify the material best suited for patch angioplasty.

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To determine what preoperative factors predict surgical outcome, we reviewed the management of 89 patients with ruptured cerebral aneurysm over 70 years old treated at their institutions until 1994. Multivariate logistic analysis of several risk factors revealed that preoperative consciousness, aneurysm location and patient age had an independent correlation with surgical outcome. We propose a simple classification for patients at high risk for unfavorable outcome. The grade of a patient from 0 to 3 obtained by adding the points value for each factor: Risk-Grade=patient over 80 years old (no: 0 or yes: 1)+disturbance of consciousness (no: 0 or yes: 1)+basilar aneurysm (no: 0 or yes: 1). A prospective analysis of this grading scale on 25 surgically treated patients with ruptured cerebral aneurysm over 70 years old after 1995 demonstrated a strong correlation with surgical outcome. The rate of recovery for skills of daily living was 72% in patients of Risk-Grade 0, 46% in patients of Risk-Grade 1, and 0% in patients of Risk-Grade 2. This classification can be used to identify the surgical risk of patients preoperatively, determine the operative indication, and also provides a system that allows for comparison of results from different centers and different techniques.

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We describe the case of a 58-year-old male with hypertensive intracerebral hemorrhage recurrence in the same putaminal region 8 days after CT-guided stereotactic aspiration of the initial hemorrhage. On admission, the patient presented left-sided motor weakness, and CT scan revealed right putaminal hemorrhage 12ml in volume. A repeat CT scan performed 17 hours after the initial CT showed enlargement of the hematoma up to 33ml with ventricular extension. CT-guided stereotactic aspiration of the hematoma was performed 4 days after the onset. Post-operative CT scan showed 85% removal of the hematoma and no postoperative bleeding. Blood pressure of the patient was not well controlled during a week after the operation. Eight days after the operation, the patient complained of headache and his consciousness level deteriorated slightly. CT scan at that time demonstrated recurrent hemorrhage of about 19ml in volume within the same putaminal region. The patient was treated conservatively and with hyperosmolar agents. We discuss possible pathogeneses of the recurrence of the hypertensive intracerebral hemorrhage in the same region.

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We report a surgical case of a ruptured basilar tip aneurysm associated with unilateral moyamoya disease in an acute stage. A 73-year-old man, suffering from a severe headache and vomiting, was transferred to our hospital with a level of consciousness of Grade 2 of Hunt & Kosnik. CT demonstrated high-density areas in bilateral ventricles and subarachnoid space. Angiography revealed a basilar tip aneurysm associated with right unilateral moyamoya disease. No remarkble decrease of CBF was demonstrated on preoperative SPECT. On Day 2, neck clipping of the aneurysm was successfully performed with left pterional approach from the opposite side to moyamoya vessels. On Day 21, hemispheric CBF was preserved at 36.1ml/100g/min on the right and at 36.9ml/100g/min on the left, and Diamox response did not decrease very much.
We discuss stages and approaches of surgical treatment for a basilar aneurysm associated with moyamoya disease by means of CBF measurement using SPECT with a review of the literature.

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