We retrospectively analyzed the hemodynamic status and treatment results of aggressive intracranial dural arteriovenous fistulas (dAVFs) that presented with intracranial hemorrhage, cerebral infarction, status epilepticus, and symptoms of increased intracranial pressure (ICP).
Out of 114 dAVFs we experienced since 1991, 31 were aggressive lesions. Eighteen cases presented with an intracranial hemorrhage, 4 with venous infarction, 3 with status epilepticus, and 6 with symptoms of increased ICP. We retrospectively analyzed the hemodynamic status (focusing on the retrograde leptomeningeal venous, and retrograde sinus drainage) and treatment results of these 31 cases.
[cavernous sinus dAVF] Of 52 cases, retrograde leptomeningeal venous drainage (RLVD) was observed in 8, and 2 of these 8 cases presented with an intracerebral hematoma. One was successfully treated by surgical transvenous embolization, and the other by percutaneous transvenous embolization.
[superior sagittal, transverse-sigmoid, and marginal sinus dAVF] Of 44 cases, RLVD was observed in 24 and retrograde sinus drainage in 3. Nineteen of these 27 cases presented with an aggressive pattern, including intracerebral hematoma in 8, venous infarction in 2, status epilepticus in 3, and increased ICP symptoms in 6. Eight of these 19 cases were treated only by endovascular procedures, 9 by surgical transvenous embolization, 2 by transarterial embolization combined with operation.
[others] The location of dAVF in other cases was the cranial vault in 2 cases, anterior cranial base in 6, craniocervical junction in 7, and tentorium in 3. RLVD was seen in all of these 18 cases, and 10 presented with an aggressive course, including intracerebral hematoma in 8 and venous infarction in 2. Four cases were treated by transarterial embolization, and 6 by operation. Complete angiographic obliteration after treatment was obtained in 24 (77%) cases. The Glasgow Outcome Scale was GR in 18 cases, MD in 4, SD in 4, VS in 4, and D in 1. Procedure-related complications occurred in 2 cases.
Aggressive lesions accounted for 2% of cavernous sinus, 43% of transverse-sigmoid & superior sagittal sinuses, and 55% of the other sinus or cortical dural AVFs. Impaired cerebral venous return due to RLVD was a main cause of the aggressive behaviors. Combined endovascular and surgical treatment was very effective for those lesions.

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Internal carotid (IC) aneurysms arising from the bifurcation of the posterior communicating (Pcom.) and anterior choroidal (Achor.) arteries are common, but carry a risk of intraoperative massive bleeding and ischemia of perforators territory those the patients' outcome worse.
Proximal flow control is important to reduce the risk of rupture aneurysms during dissection and clipping. The internal carotid artery of the supraclinoid portion is sometimes arteriosclerotic and inadequate to place the temporary clip. Therefore we sometimes perform proximal flow control at the cervical carotid artery. Use of the J-shape clip to avoid the origin of the perforating artery to be occluded and anterior temporal approach for the fundus of aneurysms projecting posterior are also useful.
We investigated 135 consecutive aneurysm surgeries for the IC aneurysms arising from the bifurcation of the Pcom. and Achor. arteries as regard to the use of proximal flow control and occurrence of the ischemic complications in the perforators' territory.
Proximal flow control was performed in 62 surgeries for ruptured aneurysms and 13 for un-ruptured aneurysms. In 40 of all 75 surgeries where proximal flow control was performed, the carotid artery was clamped at the extracranial cervical portion. The main reason for this was arteriosclerosis of the intracranial internal carotid artery to be clipped with temporary clips. Each occlusion time was less than 10 minutes in most cases. Infarction of the perforator territory occurred in 4 of 92 surgeries (3.7%) for ruptured aneurysms and in none of 43 surgeries for non-ruptured aneurysms.
Proximal flow control is important for the safe treatment of usual IC aneurysms. Prevention of injury to the Achor. artery is also beneficial to a favorable outcome.

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Recent advances in neuroimaging, including 3-dimensional digital subtraction angiography (3D-DSA), enable the detailed delineation of structural characteristics of aneurysm and the parent artery. We retrospectively reviewed the operative findings and 3D-DSA images of middle cerebral artery bifurcation aneurysm (MCB-An). Morphology of MCB and An, approach to the An, and the operative view in the clipping procedure were considered in 31 MCB-Ans in 29 consecutive cases operated in 2001. In most cases, we used the distal approach, splitting the sylvian fissure from the lateral to medial direction, for clipping the MCB-An. Proximal control of the M1 was achieved in all cases. The proximal approach was performed in a case presenting with the ipsilateral internal carotid artery An. There were 2 patterns of approach angle. One is the medial trans-sylvian (m-TS) approach, in which clipping was attempted after the M1 was ensured beyond the frontal operculum. It was used in 18 cases. The other approach is the lateral trans-sylvian (l-TS) approach, which was used in 13 cases. Proximal control of the M1 was achieved between the superior and inferior trunks. The l-TS approach required an angle of approach more from the lateral and rostral side than the m-TS approach. The l-TS approach was used in cases presenting with the distal M1 running more anteroinferiorly, as compared with the m-TS approach. Morphology of the parent artery, and the relation of An and those vessels were clearly evaluated in 3D-DSA. Preoperative evaluation of 3D structures enables safe aneurysm surgery with minimum surgical procedure.

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We retrospectively analyzed the clinical features, initial managements, and long-term clinical outcomes in 47 young patients with intracranial AVMs. All patients, 24 males and 23 females, were under 15 years of age; their mean age at symptom onset was 9.4±3.8 years. The follow-up period was longer than 2 years; the average was 14.8 years. In 39 (83%) patients, the first symptoms were hemorrhage; 8 (17%) had epileptic seizures.
Of the 47 patients, 25 had AVMs with a small nidus, and 15 had deep venous drainage; 23 (92%) of the former and 14 (93%) of the latter manifested hemorrhage. We posit that the small nidal size and deep venous drainage contribute to the bleeding tendency of pediatric AVMs. Of the 47 patients, 15 (32%) patients had an excellent outcome, 20 (43%) a good outcome, 9 (19%) a fair outcome, and 1 (2%) a poor outcome. Two patients (4%) died. Satisfactory outcomes were obtained in 28 of 39 (72%) patients with hemorrhage and in 7 of 8 (88%) patients with seizures. The remaining 12 patients (26%) had poor outcomes, 11 (92%) of them presenting with hemorrhage. In 10 (83%) patients, the AVMs were in an eloquent area of the brain or drained into the deep venous system. In 9 (82%) patients, the outcomes were poor because of initial irreversible brain damage. Total removal of the AVM was performed initially in 29 patients. Of the 39 patients with hemorrhage, 25 (64%) underwent total removal; 19 (76%) had satisfactory outcomes. In the other 6 patients, the outcomes were poor because initial bleeding was massive or occurred in an eloquent area. Of the 18 patients managed by other methods, 14 had hemorrhagic AVMs, and the outcome was poor in 5 (36%) of them. Furthermore, 6 of the 14 (43%) suffered recurrent bleeding and deterioration of clinical outcome scale for the follow-up period, the average of which was 5.3 years; 3 (50%) of 6 patients had a poor outcome. In the 8 patients with seizure as the initial symptom, the outcomes of both surgical and conservative management were equally satisfactory. However, 2 (50%) of the conservatively treated patients later developed incurable convulsions.
Our data suggest that the initial treatment significantly affects the outcome in young patients, although hemorrhagic onset and severity of the patients' neurological conditions correlate strongly with clinical outcome. Initial curative surgery should be considered—especially in patients with hemorrhagic AVMs—because rebleeding often leads to poor outcomes.

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In patients with unclippable internal carotid (IC) aneurysms, parent artery occlusion combined with bypass surgery is often indicated. To establish a strategy of such surgery, the preoperative IC occlusion test plays a major role.
Recently we experienced 3 cases with EC-IC collateral pathway around the petrous portion of IC, which was evident only on common carotid angiography during balloon occlusion test of IC origin at the neck. Although the significance of this type of collateral pathway is yet to be known, it may be necessary to pay attention to this possible collateral flow into the aneurysm.

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Recently, embolization using the Guglielmi detachable coil (GDC) has been performed as an alternative of direct surgery for cerebral aneurysms. We report clinical results and selection of treatment for cerebral aneurysms after introduction of GDC embolization at Wakayama Medical University and related hospitals. From 1997 to December 2001, 895 patients with intracranial aneurysms were treated either by direct surgery (n=798) or by GDC embolization (n=97). In 239 patients with unruptured aneurysms, 194 patients (81%) underwent direct surgery, while 45 patients (19%) had GDC embolization. In 656 patients with ruptured aneurysms, 604 cases (92%) were treated by direct surgery and 12 cases (8%), by GDC embolization. GDC embolization tended to be selected for paraclinoid IC or posterior fossa aneurysms, especially BA top, BA trunk and VA dissecting aneurysms. Vasospasm after SAH was statistically less in the embolization group than in the surgical group. In unruptured aneurysm series, morbidity and mortality rate of direct surgery was 5.7% and 0.5%, respectively, while those of GDC embolization was 4.4% and 0%, respectively.
These clinical outcomes seemed to be almost the same as the previously published data by other neurosurgeons and interventional neuroradiologists. Therefore, our treatment selection and procedures are likely to be appropriate, especially in the unruptured group, after introduction of GDC embolization.

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The use of self-retaining brain retractors has been considered indispensable for gaining an appropriate operative view during microneurosurgery. But their misuse might cause vital brain damage. We report a pterional approach without brain retractors to an IC-PC or an IC-Ach. unruptured aneurysm.
The surgical techniques for gaining a wide operative view without brain retractors are summarized as follows: 1) Head positioning with chin slightly up (vertex down), allowing the frontal lobe to fall away from the orbital roof. 2) Wide arachnoidal dissection from the Sylvian fissure to the contralateral optic nerve. 3) A long strip of Bemsheets serve as brain retractors. 4) Our “hand-resting” operating style.
A wide operative view without brain retractors contributes to the safe dissection and clipping of an IC-PC or an IC-Ach. aneurysm, preserving the parent arteries and its perforators.

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In a series of 91 patients over 75 years of age with ruptured cerebral aneurysm, 59 patients were operated with clipping. Twenty-seven patients were not operated on because of re-rupture or deterioration of their general condition or refusal, among other reasons. We classified their neurological grade according to World Federation of Neurosurgical Societies and evaluated their outcome at discharge with Glasgow Outcome Scale. Thirty-one were operated on in the acute stage (within 3 days after onset), and 27 were operated on in the delayed stage (at least 10 days after onset). Our conclusions are:
1. Ruptured aneurysms in patients over 75 years old occur about 3 times more often in females than in males.
2. Clipping should be performed in the acute stage for the treatment of ruptured aneurysms and will result in better operative results even among patients over 75 years of Gr IV, V.
3. We treat patients with a more careful operative technique especially, for ruptured aneurysms located in the anterior communicating artery.
4. Symptomatic vasospasm occurred more frequently in elderly patients (20%) than in younger patients (10%), but timing of surgery did not influence the occurrence of symptomatic vasospasm.
5. Aged patients with subarachnoid hemorrhage have various pulmonary and/or cardiovascular complications, so careful postoperative management is essential.

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Management of cerebral hemorrhage in patients with chronic renal failure is very difficult, especially in the acute stage. We evaluated 16 cases of putaminal hemorrhage, thalamic hemorrhage or pontine hemorrhage with chronic renal failure compared with 20 patients of cerebral hemorrhage without chronic renal failure.
There was no significant difference in GCS between patients with chronic renal failure and those without. However, the volume of hematoma was significantly bigger in patients with renal failure than in those without. Moreover, prognosis in patients with chronic renal failure was significantly worse than in patients without. We considered that continuous hemodiafiltration (CHDF) using nafamostat mesilate was superior to hemodialation (HD) in the acute stage of cerebral hemorrhage for controlling intracranial pressure, homeostasis of circulatory dynamics, and preventing enlargement of hematoma.
However, the outcome of patients with chronic renal failure was poor, even if we devised a dialysis method and prevented rebleeding or rising of intracranial pressure.
The management of cerebral hemorrhage in patients with chronic renal failure must be improved.

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Direct clipping for large and giant juxta dural ring internal carotid (IC) aneurysms is a difficult neurosurgical procedure. We describe the importance of skull base surgery techniques and the usefulness of the suction-decompression method for direct clipping of these aneurysms. We have treated 9 large (15-24 mm) and 6 giant (25 mm≤) aneurysms in this region by direct clipping during the past 6 years. The patients presented with subarachnoid hemorrhage in 4 cases, visual disturbance in 7 cases and in 4 cases the aneurysms were incidentally discovered. Preoperative ipsilateral IC balloon test occlusion showed neurological symptoms in 2 cases. Proximal control of IC during surgery was performed either by intravascular balloon catheter or direct exposure in the neck. A conventional pterional craniotomy was performed, the anterior clinoid process and optic canal and strut were drilled off intradurally, and the dural ring was clearly delineated. Mobilization of IC and the optic nerve became easier with these procedures. Before clipping, suction-decompression was commonly used to reduce aneurysmal size enough to facilitate dissection from the surrounding structures. Multiple clips were used: fenestrated clips in 11 cases and straight clips in 4 cases.
Although 1 case had postoperative ischemic complication in the ipsilateral cerebral hemisphere, complete clipping was performed in the other 14 cases without ischemic complication. Postoperative improvement of visual symptoms was observed in 4 cases in which surgery was performed within 3 months of onset.
In conclusion, skull base surgery techniques and the suction-decompression method play important roles in obtaining good surgical outcomes for direct clipping of large and giant juxta dural ring IC aneurysms.

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We evaluated the usefulness of gamma knife radiosurgery (GKS) for patients with arteriovenous malformations (AVMs) associated with arterial aneurysms (AN). Eight AVM cases with AN were treated by GKS. The type of the AN was proximal in 4 cases, distal in 3 cases, and unrelated in 1 case. All proximal AN and unrelated AN cases had received neck clipping before GKS. Among the 3 distal AN cases, GKS was the first treatment in 2 cases.
The mean follow-up period was 40 months (range 6-84 months) after GKS. AVM obliteration with AN disappearance was noted in 2 cases with distal AN 18-24 months after GKS alone. The other 6 AVMs showed obliteration in 2 cases, size decrease in 3 cases, and no change in 1 case 6-51 months after GKS. One case developed minor hemorrhage from the AVM after GKS.
In selected AVM cases associated with distal AN, GKS alone may be indicated.

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