The internal carotid artery (ICA) is sometimes involved with neck and skull base tumors or aneurysms, requiring elective ICA occlusion. This paper describes our strategy for vascular reconstruction after the ICA occlusion and the long-term follow-up results.
Elective ICA occlusion was performed in 24 patients with unclippable aneurysms or tumors more than 2 years ago. The series comprises 5 males and 19 females, ranging in age from 32 to 75 (a mean age of 54.3). The lesions involved 5 tumors involving the ICA and 19 unclippable ICA aneurysms. Vascular reconstruction was determined by flowchart based on the balloon occlusion test with monitoring by clinical evaluation, EEG and cerebral blood flow (CBF) measurements. High-flow external carotid-internal carotid (EC-IC) bypass (including skull base bypass) was performed in 18 cases, superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis in 4, and replacement using vascular prosthesis in 1. Bypass was not performed in 1 aged patient because adequate CBF was preserved. All bypass grafts have remained patent postoperatively. Two patients have developed mild ischemic complications in the 4.0-year follow-up.
Hemodynamic stroke risk should be examined before elective ICA occlusion when low flow (STA-MCA) bypass or no reconstruction is chosen. Vascular reconstruction is an effective surgical approach in the treatment of tumors involving the ICA and unclippable aneurysms to prevent late ischemic complications.

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Between 1985 and 2000, we treated 117 patients with acute type cerebral dissecting aneurysms (Mizutani's classification in 1999), including 90 patients with SAH and 27 patients without SAH. Ninty dissecting aneurysms presented with SAH included 75 VA aneurysms, 4 ACA aneurysms, 3 MCA aneurysms, 3 PICA aneurysms, 2 IC aneurysms, 1 SCA aneurysm, 1 BA aneurysm and 1 Pcom A aneurysm. Fifty patients with VA dissecting aneurysms underwent 54 surgeries, comprising 28 proximal clippings, 17 trappings, 5 bleb clippings, 2 proximal clipping with PICA clipping and 2 aneurysm body clippings. Two patients with ACA aneurysm and 1 patient with SCA aneurysm underwent trapping and bypass. Every patient with IC, MCA and Pcom A dissecting aneurysm underwent wrap and clip. Twenty-seven dissecting aneurysms without SAH comprised 12 VA aneurysms, 4 BA aneurysms, 4 MCA aneurysms, 3 ACA aneurysms, 2 IC aneurysms, and 2 PCA aneurysms. Two patients with ACA aneurysm underwent trapping with bypass, 1 patient with MCA aneurysm underwent wrapping with clip and 1 patient with PCA aneurysm underwent proximal clipping.
We discuss the indications and methods of surgery for cerebral dissecting aneurysms with and without SAH based on the outcome of 64 surgical experiences.

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Partially thrombosed giant aneurysms are one of the most difficult diseases in neurosurgery. We have had 33 of these cases: 6 in the vertebral artery, 5 in the basilar artery, 8 in the internal carotid artery, 11 in the middle cerebral artery and 3 in the anterior communicating artery. Twenty-three aneurysms were clipped, 2 were removed with anastomosis, the parent artery was clipped in 1 case, 2 cases were treated interventionally and 5 cases were treated conservatively because of serpentine and fusiform types of aneurysms in the internal carotid artery bifurcation, basilar artery or vertebral artery. These conservatively treated patients died due to infarction. When surgery is selected in thrombosed giant aneurysms, an appropriate approach is crucial to secure the neck. Three-dimensional computed tomography angiography was useful to plan the surgical strategy. If the neck is big enough for placement of a clip, arterial reconstruction is the treatment of choice. The reconstruction must include an adequate size of the artery because of the thick wall. If the aneurysm neck is too small to reconstruct, aneurysmectomy with anastomosis is one choice.

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The aim of this prospective multicenter trial was to determine whether bypass surgery can prevent stroke recurrence in patients with major cerebral artery occlusive diseases and hemodynamic cerebral ischemia determined by quantitative measurement of cerebral blood flow, and whether improvement in hemodynamic cerebral ischemia by bypass surgery can prevent the progression of neuropsychological disorders or improve neuropsychological function. The subjects of this study were 196 patients who have been enrolled for 39 months from November 1, 1998 to January 30, 2002. Each patient underwent treatment according to the study program, and the 2-year follow-up survey of the patients is now under way. Of the 196 patients enrolled in the study, 98 each were assigned to the medically treated group and the surgically treated group. Fourteen patients in the medically treated group and 5 in the surgically treated group reached primary endpoint. The incidence of stroke recurrence in the surgically treated group was significantly lower than that in the medically treated group (p=0.046). The final results will become known in 2004.

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We investigated the clinical features of 54 elderly patients aged over 80 years with ruptured intracranial aneurysms admitted to our hospital between May 1968 and December 2001. The changes in patient number, age, male/female ratio, site of cerebral aneurysm and preoperative Hunt & Kosnik grade were studied. The patients were divided into 2 groups (surgically treated group and conservatively treated group). Outcome was evaluated according to the Glasgow Outcome Scale, and the causes of poor results were analyzed.
The number of patients calculated for 5-year periods is rising steadily, and reached 25 patients for the last 5 years (1997-2001), accounting for 46% of all. The mean age of the patients was 82.4 ± 2.5 (range 80-92 years), and 44 patients (81%) were under 84 years. The male/female ratio was 1:5. The location of 50 ruptured cerebral aneurysms (4 cases were excluded because cerebral angiography was not performed) were the internal carotid artery in 24 cases (48%), the middle cerebral artery in 12 cases (24%), the anterior communicating artery in 11 cases (22%), the anterior cerebral artery in 2 cases (4%), and the basilar artery in 1 case (2%). Their preoperative neurological grades, according to the classification of Hunt & Kosnik, were II in 11 cases (20%), III in 17 cases (31%), IV in 14 cases (26%) and V in 12 cases (22%).
Of 54 cases, 26 were treated surgically: neck clipping of cerebral aneurysms was performed in 21 cases, wrapping of cerebral aneurysms in 2 cases, transarterial embolization of cerebral aneurysms in 3 cases and the remaining 28 cases were treated conservatively. The clinical outcome of the surgically treated group was GR in 4 cases (15%), MD in 5 cases (19%), SD in 6 cases (23%), VS in 2 cases (8%) and D in 9 cases (35%). The preoperative Hunt & Kosnik grades of the 4 GR cases were II in 1 case, III in 2 cases, and IV in 1 case. Cerebral infarction caused by cerebral vasospasm was revealed in 10 (38%) of 26 surgically treated cases. The preoperative Hunt & Kosnik grades of these 10 cases were II in 4 cases and III in 6 cases. The clinical outcome was MD in 1 case, SD in 1 case, VS in 1 case and D in 7 cases. Cerebral infarction caused by cerebral vasospasm during the last 5 years (1997-2001) was revealed in 3 (23%) of 13 surgically treated cases, although it was 7 (54%) of 13 cases before 1996. Twenty-two of 28 (79%) conservatively treated cases were serious (Hunt & Kosnik grade IV, V). The clinical outcome was GR in 1 case, SD in 2 cases, VS in 3 cases and D in 22 cases. Causes of death were primary brain damage in 14 cases, re-rupture in 4 cases, cerebral vasospasm in 3 cases and pneumonia in 1 case. It is necessary for determination of surgical indication to evaluate primary brain damage more strictly. And it is indispensable for improvement of operative outcome to take measures for cerebral vasospasm and general complications.

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Stenting is an effective treatment for carotid stenotic lesions. However, there have been no devices for the real-time evaluation of the improvement of cerebral blood flow and the detection of ischemic events. We monitored blood flow velocity of the middle cerebral artery (MCA) and embolic signals using transcranial Doppler (TCD) ultrasonography during the stenting procedure.
We studied 14 patients with carotid stenosis treated with stenting. The lesions were located at the common carotid artery (CCA) in 2, the origin of internal carotid artery (ICA) in 8 and intracranial ICA in 4. TCD was seriously monitored to record mean blood flow velocity (MBFV) and pulsatility index (PI), and to detect hyperintensity transient signals (HITS) in the ipsilateral MCA using a probe fixed to a head frame.
Valuable continuous data have been obtained in all cases except for 1 with the trouble of probe fixation. MBFV elevated from 73.9 ± 5.8 to 91.5 ± 6.2 mmHg on average after stenting, and dramatically elevated in 9 cases without blood pressure change. MBFV showed no decrease even in 5 cases with hypotension induced by baroreflex response. We were able to detect intraoperative distal embolism before presenting neurological signs in 1 case. The serial TCD monitoring also clarified the significance of balloon protection by fewer HITS.
TCD was very useful for monitoring the hemodynamic change and distal embolism on stenting.

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International cooperative studies have almost established carotid endarterectomy (CEA) as the surgical treatment for carotid artery stenosis to prevent cerebral infarction. However, the procedure's success depends on ability of a surgeon's technique and perioperative control with complication under 3% for aymptomatic stenosis. There is little experience with CEA in Japan, so reports of long-term follow-up studies are rare. We have performed CEA with a stable team for the past 17 years, and review surgical outcomes and follow-up results.
The mean age of 203 CEAs was 64. There were 175 men. We have routinely used a shunt system and intraoperative monitoring under general anesthesia. These patients were followed up for 6.5 years on average, and a change of ADL was evaluated with Glasgow Outcome Scale.
Four patients (2.0%) showed neurological deficits such as hemipapresis. The causes were cerebral embolism, wound hemorrhage, cerebral ischaemia by carotid artery hemostasis, and hyperperfusion syndrome. However, all of them were seen in the initial period of more than 10 years before. Mortality was 0%. One hundred and sixty patients were followed up for more than a year. Three patients had re-stenosis and occlusion of the operated internal carotid artery, and 2 of them were operated on again while asymptomatic. Four patients (2.5%) had ischemic attack in the operated side, but all of the lesions were at intracranial sites. Aggravation of ADL was recognized in 28 patients with no carotid lesions. There were 19 deaths, 10 of which were caused by cancers. Twenty-seven patients had ischemic heart diseases, 6 of whom died.
CEA is effective for prevention of cerebral infarction, when practiced surgeons perform with intraoperative monitoring. However, general examination and treatment with cardiologists are necessary, because patients often have cardiovascular diseases.

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The natural history and treatment strategy of intracranial dissecting aneurysm in the vertebrobasilar (V-B) system remains controversial. We report 10 cases of ruptured intracranial dissecting aneurysm in the V-B system and review the literature with focus on the analysis of serial angiographic findings, treatment, and long-term outcome.
All patients were conservatively managed under careful blood pressure control, and angiography was carried out depending on the patient's condition. Surgical or endovascular intervention was chosen when morphological changes leading to rebleeding were recognized by follow-up angiography. Craniotomy in 3 patients and coiling in 3 patients was performed. No rebleeding occurred during the follow-up period in any of the 10 patients, and all cases resulted in favorable outcome.
These results suggested that ruptured intracranial dissecting aneurysms of the V-B system could be treated conservatively, avoiding rebleeding under careful control of blood pressure in the acute stage. Alternatively, surgical or endovascular treatment should be considered if angiographical changes that may lead to risk of rebleeding are noted.

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Only vague guidelines exist for the surgical management of intracerebral hemorrhage (ICH). We investigated the indications for surgical management of intracerebral hemorrhage and compared the outcomes of computed tomography (CT)-guided stereotactic hematoma aspiration with those after hematoma removal under craniotomy.
Our indications for CT-guided stereotactic hematoma aspiration were an age < 80 years old, a hematoma volume ≥ 10 ml, and a Glasgow Coma Scale (GCS) score ≤ 14. Those for hematoma removal under craniotomy were a hematoma that was large enough to be life-threatening and/or lobular, suggesting underlying vascular lesions. Patients with bilateral pupillary dilatation and cases of hematoma extending to the brain stem were excluded. In 131 cases of ICH, hematoma volume, total cost of hospitalization, initial GCS score, age, activity of daily living (ADL) at discharge, and final ADL, were selected for analysis.
In patients with an initial GCS score between 8 and 14, only slight improvement in ADL was found after CT-guided stereotactic hematoma aspiration compared with conservative management. The total cost and the duration of hospitalization were lower and shorter in conservatively managed cases than in cases treated with stereotactic surgery. In patients with an initial GCS score ≤ 9, the total cost was higher for craniotomy cases than for stereotactic cases, however, the ADL at discharge was higher.
CT-guided stereotactic hematoma aspiration has limited benefit for patients with ICH and is contraindicated for patients with an initial GCS score ≤ 9, who should be managed by craniotomy.

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We report 2 cases of dural arteriovenous fistula with brain stem hemorrhage. One patient presented with dysarthric speech and clumsy right hand. A cranial CT revealed pontine hemorrhage. A left external carotid angiogram showed a dural arteriovenous fistula of the isolated sigmoid sinus fed mainly by the occipital artery, and draining into the superior petrosal vein, transverse pontine vein (with a varix), lateral mesencephalic vein and basal vein. The right occipital artery was then catheterized with a microcatheter and the fistula was embolized with a single injection of liquid material. A follow-up angiogram showed complete obliteration of the fistula.
The second patient was referred to our hospital because of chemosis and exophthalmos of the right eye. Gradient echo T2^*-weighted MR images demonstrated a hypointense area in the pons, which suggested hemorrhage. A cerebral angiogram confirmed the diagnosis of a CCF draining into the superior petrosal vein, lateral pontine vein, and cerebellar cortical veins. Subsequently, transvenous coil packing was performed. Ocular symptoms completely disappeared after the embolization, and the patient was discharged without any symptoms of brain stem hemorrhage. However, a follow-up MR with gradient echo T2^*-weighted images still demonstrated hypointense area in the pons. Dural arteriovenous fistulas with cortical venous drainage or with venous ectasia demand urgent treatment due to the risk of hemorrhage or rebleeding.

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We report a rare case of right vertebral artery dissection. A 45-year-old man suffered numbness, vertigo and occipitalgia due to brain stem infarcton. The right vertebral artery angiograms showed pearl and string signs, indicating vertebral artery dissection. He became comatose suddenly 12 days after ischemic attack. CT scans demonstrated subarachnoid hemorrhage. The second angiograms showed right vertebral occlusion and de novo aneurysm in the left vertebral artery. The patient was treated with mild hypothermic therapy. The third angiograms showed a slight recanalization of the right vertebral artery dissection, and an enlargement of the de novo aneurysm.
We embolized the right vertebral artery dissection using GDC and FPC, and then clipped the aneurysm in the left vertebral artery. The patient was discharged without neurological deficit. We discuss the clinical features and the management of this case.

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