The rationale for radical surgery to treat unruptured cerebral aneurysms (uAN) remains unclear. Most investigations of evidence-based medicine (EBM) have focused on prognostic factors such as the natural history, surgical outcome, risk-benefit analysis, and socioeconomic effects, and not on patient factors such as decision-making, anxiety, or satisfaction. However, the number of legal cases focusing on complications caused by examination or surgical intervention has increased in Japan. Further, deterioration of quality of life in patients diagnosed with uAN has also become evident. In this study, we surveyed patient satisfaction (PS) in 197 patients who underwent clipping surgery or coil embolization during the last 7 years, using a mail questionnaire sent by a third party. We review the rationale for the treatment of uAN, and discuss the necessity of a paradigm shift of rationale from treatment based on EBM to treatment that is tailor-made.
The total response rate was 69.5%. A visual analogue scale analyzing PS revealed no significant difference among clip, coil and observation groups. The most striking data was that PS in the patient group who had received clipping surgery for incidentally discovered AN, varied more than we had projected irrespective of no deterioration of neurological and intellectual status evaluated by Wechsler Adult Intelligence Scale-Revised and Wechsler Memory Scale. These results indicate that PS might be highly affected by patients' own personality.
Macroscopic rationale for the treatment of uAN supported by EBM may be insufficient to convince patients of the surgical result because of a lack of evidence. Therefore, collecting better evidence about the natural history, surgical risk, and recurrence of uAN should increase PS. The reaction of individual patients to the potential risks of bleeding and complications caused by surgical intervention varied greatly, so a microscopic, tailor-made treatment rationale should be formulated instead of a macroscopic one in the future.

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Recently patient-based outcomes like quality of life (QOL) have been emphasized in the assessment of several kinds of medical treatments. Little is known about QOL in patients who underwent elective operation for asymptomatic unruptured intracranial aneurysms. The present study aimed to determine how patient QOL changed before and after the elective operation of unruptured aneurysms.
For 39 patients who underwent clipping surgery for asymptomatic unruptured intracranial aneurysms, QOL was assessed using Short Form-36 (SF-36) before, 3 months after, and 1 year after the operation; and results were compared. For 147 patients treated surgically for aneurysms more than 2 years before, QOL was compared with that of Japanese reference population.
Before operation, patient QOL declined for most domains of SF-36. Although daily-life QOL was still low 3 months after the operation, it returned to the level of reference population for most domains 1 year postoperatively. In respect of long-term QOL, scores of SF-36 in 147 patients remained at an average level; however, there were 20 (13.6%) patients with QOL below average. A statistical analysis showed that QOL was affected by history of heart diseases, aneurysm size, and present activity. The present study showed that QOL improved and persisted at the reference level in the majority of patients after operation, supporting the validity of surgical treatment for asymptomatic unruptured intracranial aneurysms.

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Clinical features of vertebral artery dissections presenting with isolated headache or neck pain were investigated, and management was clarified. Forty cases that had only pain at the time of onset, showed neither subarachnoid hemorrhage nor cerebral infarction, and were diagnosed as having vertebral artery dissection by angiography were targeted. In the cases accompanied with aneurysmal dilatation, application of surgical treatment was examined. In other cases, the course was observed by MRA. In the first 18 months, 17 cases were examined. Among them, aneurysmal dilatation was found in 4 cases, and they underwent direct surgery. The other 13 cases were observed: 2 cases showed complete occlusion (at 1.5 months and 5 months, respectively), 3 cases showed no change, and 8 cases showed spontaneous improvement. In the course, neither subarachnoid hemorrhage nor cerebral infarction developed. Therefore, in the last 18 months, observation of the course was attempted as much as possible for the cases, including those of aneurysmal dilatation.
In the period, 23 cases were examined, and aneurysmal dilatation expanded in 2 cases (at 2.5 months and 4 months, respectively). The lesion was obstructed by direct surgery in 1 case and by intravascular treatment in the other. Of the remaining 21 cases, 2 showed no changes in the course by MRA and 19 exhibited spontaneous improvement. In the course, neither subarachnoid hemorrhage nor cerebral infarction developed in any case. For the treatment of vertebral artery dissection presenting with only pain, observation of the course by MRA was effective. Changes occurred in the lesions within several months after onset, and spontaneous improvement occurred in many cases.
Therefore, observation of the course is basically sufficient for management. When aneurysmal dilatation is expanded in the course, direct surgery or intravascular treatment is recommended.

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Intracranial arterial dissection is considered to be not a rare disease recently, but the natural history of this disease is not well known yet. In this study, we analyzed the serial changes of angiographical or MRI/MRA finding and the long-term outcome to clarify the treatment strategy in patients with non-hemorrhagic intracranial arterial dissection.
Among 120 consecutive patients with arterial dissection of the vertebrobasilar system, 44 (37%) presented with ischemia and/or headache. Ages ranged from 27 to 77 years (mean: 49.3+/-11.0 years). Thirty-nine patients were managed conservatively and an antiplatelet agent was given in 10 because of history of myocardial or brain ischemia. Only 5 were treated surgically because the lesion had been enlarged or extended on the follow-up study. The vertebral artery was most commonly affected. On the initial angiographical or MRI/MRA finding, fusiform dilatation (43%) was the most frequent finding, followed by pearl and string sign (32%). In the serial changes of the findings, no change (43%) was most common, followed by improvement (37%).
Among 39 patients who presented with ischemia, 8 (21%) had subsequent symptoms (ischemia in 7, subarachnoid hemorrhage in 1). Recurrence tended to occur more frequently in the antiplatelet group. The follow-up period ranged from 1 to 17 years (mean: 5.8+/-4.1 years). The long-term outcomes were generally favorable. Thirty-three patients (85%) recovered well and 3 died among the 39 conservatively managed patients. Four of 5 patients achieved good recovery and returned to work in the surgically treated group. In addition, the outcomes in the antiplatelet group did not differ significantly from those without the above agents.
These results were quite similar to those in the nationwide study, and suggest that conservative treatment, mainly the control of high blood pressure, is the first choice in the non-hemorrhagic arterial dissection of the vertebrobasilar system and that antiplatelet or anticoagulant therapy might not be indicated in the patient with ischemia. Furthermore, the surgical indication for this disease remains controversial, and the study of a larger number of patients is indispensable to clarify this issue.

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We clinically evaluated the factors influencing the duration of hospitalization in patients with ruptured cerebral aneurysm managed surgically during the acute stage. Statistical analysis demonstrated that the duration of hospital stay was significantly prolonged in aged patients (more than 70 years old), groups with ventriculo-peritoneal shunt replacement, patients who were discharged to rehabilitation or nursing facilities and WFNS Grade IV. Duration of hospital stay in patients with WFNS Grade I or II was stable and did not show scattering of the standard error, with values of 30.2±4.8 days, 42.0±4.4 days, respectively. Therefore, a critical path for such ruptured cerebral aneurysms in WFNS I or II will be introduced in the near future. In such cases, the duration of hospital stay depends on cerebral vasospasm, normal pressure hydrocephalus and meningitis. Measures to prevent such complications are needed.
The duration of hospitalization was shortened in fatal cases mainly because death occurred in a relatively early stage after onset of subarachnoid hemorrhage.
The duration of hospital stay depends on not only clinical factors but also medicosocial and medicoeconomic factors. The evaluation of various factors is necessary to shorten the duration of hospitalization.

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Assessment of the viability of ischemic regions in hyperacute stroke is required for decision-making in thrombolytic therapy. We investigated the efficacy of apparent diffusion coefficient (ADC) in assessing tissue viability of ischemic regions. Subjects comprised 12 patients with middle cerebral artery M1 occlusion. Ten patients underwent intra-arterial thrombolysis and 2 patients received conservative therapies.
On acute diffusion-weighted images, affected regions were classified into 3 groups: hyperintense area (HA), slightly hyperintense area (SHA) or isointense area (IA). ADC ratio (rADC) was calculated and reperfusion was assessed for each area. The rADC values in SHAs (0.80±0.10) were significantly lower than those in IAs (0.99±0.11, p<<0.001) but were significantly higher than those in HAs (0.66±0.09, p<0.001). In recanalized areas, all HAs resulted in infarction, but no IAs resulted in infarction. All SHAs with rADC <0.77 resulted in infarction, and no SHAs with rADC≥0.77 resulted in infarction. Among reperfused areas, an rADC of 0.77 was the cutoff value between reversible and irreversible lesions (sensitivity, 100%; specificity, 100%). Among non-reperfused areas, no apparent rADC threshold was found between areas that became infarcted and that those did not.
In conclusion, the present results suggest that reversibility of ischemic lesions with slight signal hyperintensity on DWI can be quantitatively predicted by measuring rADC. Assessments based on ADC may be useful for determining indications for thrombolytic therapy.

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It has been proved that development of the atheromatous plaque at the carotid bifurcation is related with its variability. We examined a correlation of plaque localization with characteristics of the cervical carotid artery wall. We studied the thickness and length of the atheromatous plaque of the carotid bifurcation and wall characteristics of the carotid artery.
Our results suggest the atheromatous plaque localized at the carotid bifurcation, restricted elastic artery and transitional zone that changed to muscular artery.

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Between October 2002 and September 2003, we treated 5 cases of basal ganglia AVMs manifested by putaminal hemorrhage. The patients were 3 males and 2 females 32 to 65 years of age (mean 52.1). We performed craniotomy and removed hematomas in all cases. AVMs were successfully removed from 4 cases, but only coagulated in the remaining 1 case. Preoperative angiography was performed on 3 cases. AVMs were angiographically occult in 2 cases, while a tiny malformation was revealed in 1 case. The remaining 2 patients were in critical and rapidly deteriorating conditions, so that we had no time to perform preoperative angiography. Thus there was little preoperative information about AVM in our patients, but we did not encounter uncontrollable bleeding during surgery in any of them.
We have concluded that basal ganglia AVMs may be a more common cause of putaminal hemorrhage than we previously suspected. It appears that in patients requiring removal of hematomas, preoperative cerebral angiography should be performed as far as possible. Even if angiography gives no evidence of AVMs, the presence of an occult AVM should be suspected. Nevertheless, because such an occult AVM does not seem to involve a high risk of intraoperative uncontrollable bleeding, its removal at the first surgery may be recommended.

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We assessed clinical outcomes in elderly patients with ruptured intracranial aneurysms treated with selective embolization. Fourteen patients older than 70 years underwent endovascular treatment with Guglielmi detachable coils (GDC). Clinical outcomes were assessed using the Glasgow Outcome Scale (GOS). Preoperative Hunt and Kosnik grading revealed that 3 patients were in Grade II, 6 in Grade III, and 5 in Grade IV. The aneurysms were located in the internal carotid artery in 10 patients, in the anterior communicating artery in 2, and in the middle cerebral artery in 2, respectively.
Outcome was favorable in 65% of patients (GR or MD). One patient (7%) died 1 month after initial bleeding, and the mortality rate was 28.5% after 1 year. Among patients younger than 75 years old, all with Grade II or III had a GR, and 1 patient with Grade IV had a MD at the time of discharge. However, among patients older than 75 years, 1 with Grade III and all with Grade IV had died at the time of final follow-up. No procedural complications were present. Ischemic changes on CT due to vasospasm occurred more frequently in elderly patients (14.3%) than in younger patients (7.1%).
Endovascular treatment using GDC may be successful for selected elderly patients with ruptured intracranial aneurysms. However, among patients older than 75 years with Grade IV conditions, embolization did not result in useful life outcomes, and the mortality rate remains quite high.

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We report 6 patients with rare arteriovenous fistulas of the craniocervical junction: 5 men and 1 woman ranging in age from 54 to 75 years. All manifested associated subarachnoid hemorrhage. Angiography demonstrated that 4 of the 6 fistulas were spinal dural arteriovenous fistulas (SDAVF) fed by the meningeal branch of the vertebral artery, the other 2 were spinal perimedullary arteriovenous fistulas (SPAVF) fed by the anterior spinal artery. Drainage was via the perimedullary vein of the craniocervical junction. Retrograde leptomeningeal venous drainage (RLVD) into the intracranial venous system was recognized in 5 cases; in 3 the draining system contained varices. All 6 patients underwent direct surgery using the transcondylar fossa approach. Before proceeding to surgical coagulation, intraoperative angiography proved useful for the temporary clipping to the feeding artery in our SPAVF cases or the drainer in the SDAVF cases. The postoperative course of 5 patients was good; the other patient remained moderately disabled due to initial damage of the medulla oblongata.
SPAVF and SDAVF in the craniocervical junction led to subarachnoid hemorrhage and the presence of RLVD into the intracranial venous system was related to the hemorrhagic symptoms. By direct surgery a good prognosis can be achieved in patients with arteriovenous fistulas of the craniocervical junction.

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