We present 3 patients with unusual internal carotid artery (ICA) aneurysms who underwent neck clipping with various intraoperative adjuncts.
Case 1. A 64-year-old female underwent surgery of a large intracavernous ICA aneurysm because it enlarged significantly after 4 years of observation. Suction decompression via the catheter for intraoperative angiography was quite effective to dissect and clip the large aneurysm in the cavernous sinus.
Case 2. A 74-year-old male with a re-grown aneurysm on the anterior wall of the ICA. The ruptured aneurysm had initially been clipped 3 years before. The follow-up angiography revealed that a slight neck remnant became prominent. A balloon test occlusion resulted in no neurological deficits. Because of the severe adhesion between the frontal lobe and aneurysm with the previous clips, we dissected the aneurysm and clips subpially from the brain. Then during the temporary trapping of the ICA, clips were applied parallel to the ICA, catching the normal wall of the ICA under the enlarged monitoring view of the endoscope.
Case 3. A 41-year-old female with an angiographically occult ruptured aneurysm at the ICA-posterior communicating artery (PcomA). The aneurysm reruptured during the surgery on the ipsilateral unruptured carotid cave aneurysm that had been supposed as the ruptured aneurysm before surgery. The aneurysm was blind under the microscope because the aneurysm was tiny and located posteriorly. Therefore, the aneurysm was clipped by catching the intact wall of the ICA and PComA beyond the lesion under the simultaneous monitoring of microscope and endoscope.
None of the 3 cases showed postoperative morbidity. In conclusion, we should anticipate all intraoperative problems in treating cerebral aneurysms and prepare all adjuncts for surgery previously.

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Vascular reconstruction of intracranial lesions is sometimes required during various operations. A few examples are: A3-A3 side-to-side anastomosis for anterior communicating aneurysm in order to secure the blood flow to the distal anterior cerebral artery, STA-radial artery graft-A3 hemi-bonnet bypass for bilateral injury of the anterior cerebral artery, and direct stitching for aneurysmal neck laceration, etc. In this paper we describe the various techniques of vascular reconstruction for intracranial lesions and tumors. Some special microsurgical instruments, such as a micro-needle folder for stitching in a deep field, should be sterilized individually, and be ready for use at any time because injury to vessels in a deep operative field occurs suddenly. If the injured vessels are reconstructed quickly and completely, the neurological deficits after surgery can be limited and at times even prevented. Therefore veins or arteries that are or have been damaged should be reconstructed as much as possible.

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A 64-year-old woman underwent clipping surgery on a left unruptured middle cerebral artery aneurysm. A neck remnant was coated with cyanoacrylate glue (Biobond). Six years later, imaging revealed a giant thrombosed aneurysm at the same site. At re-operation, the 2 clips, which were used at the initial operation, were both found to be buried in the thrombosed aneurysmal wall. Aneurysmotomy and re-clipping were performed successfully.
Although recurrence of the aneurysm after surgical obliteration is not uncommon, intraaneurysmal thrombosis and severe granulomatous change are seldom reported in the recurrent cases. These histological changes may be caused by Biobond. A long-term follow-up study is necessary to detect de novo aneurysms and recurrence of clipped aneurysms.

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We have performed CAS for 239 patients with ICA stenosis in our institute using various protection devices since 1997. In this paper, we report our initial results (perioperative complication, morbidity/mortality 30 days after the procedure, change of stenosis ratio), rate of re-stenosis, and midterm results in the cases more than 3 years after CAS. The mean preoperative stenosis ratio, 79.6%, remarkably decreased to 6.2% after CAS. The morbidity/mortality rate at 30 days after CAS was 2.1% (5/239 cases). Five of 179 cases showed restenosis 6 months after CAS (3.2%). In 4 of these cases, in-stent PTA was performed. None of the cases showed new neurological deficits. In 62 cases, followed up more than 3 years after CAS, no ipsilateral ischemic stroke was encountered.
Carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis is an effective and safe treatment to alleviate stenosis and prevent future ischemic stroke as well as carotid endarterectomy (CEA). However, it is necessary to learn several technical methods and optional procedures for successful CAS in all carotid stenoses.

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The outcome for patients with ruptured cerebral aneurysms is improving due to various adjunct treatments, but the prognosis in elderly patients is still poorer than that in younger patients. To evaluate whether surgical results of ruptured cerebral aneurysms were improved in the elderly, we analyzed the outcome of ruptured cerebral aneurysms in patients over 70 years old between 1989 and 2003. Forty-four patients and 66 patients were treated with neck-clipping between 1989 and 1993 (Group A) and between 1999 and 2003 (Group B), respectively. Fifteen patients (Group C) underwent endovascular embolization with Guglielmi detachable coils from 1999 through 2003.
The outcome was favorable in 36% of Group A and 52% of Group B, respectively (P=0.15). Factors for unfavorable outcome, e.g., vasospasm, surgical, and general complications, occurred equally in Group A and B. In Group C, 67% of the patients between Grade I and III in Hunt and Hess grading showed favorable outcomes.
Surgical results of ruptured cerebral aneurysms tend to improve in elderly patients, but the factors contributing to the outcome have not changed. It is supposed that the better outcome results from development of surgical technique, neurointensive care and rehabilitation. Endovascular treatment can be employed more aggressively in elderly patients because of its safety and efficacy.

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The treatment of carotid artery stenosis in elderly patients over 75 years old who present with impending stroke such as progressing or fluctuating stroke are still controversial. To confirm the efficacy of surgical revascularization, we analyzed the treatment outcome of surgical treatment and conservative medical treatment. Seven patients (mean age 78 y/o) were treated by carotid endoarterectomy (CEA: 3 cases) or carotid artery stenting (CAS: 4 cases), and 8 patients (mean age 84 y/o) were treated by anticoagulant or antiplatelet therapy. The outcomes of all surgically treated patients were favorable. But in medical group, 6 patients died and 1 was m-RS Grade 5. The median time between onset and complete stroke was 7 days. Four patients had a complete internal carotid artery occlusion in the medical group.
Even though elderly patients presenting with hemodynamic impending stroke have a treatment high-risk, the emergency revascularization by CEA or CAS after careful evaluation of whole body seems to be a safe and effective strategy.

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We retrospectively analyzed clinical and radiological features in 16 patients with intracranial nonhemorrhagic vertebral artery dissection. Patients were 13 males and 3 females. Ages were 38-67 years old (51 years old on average). Diagnoses were made on angiography in all but 1 case. Presenting symptoms were cerebellomedullary infarction in 10 cases, posterior neck pain in 3 cases, dysphagia and truncal ataxia in 1, vertigo in 1, and asymptomatic in 1. Angiographical features were pearl and string (PS) sign in 5, string sign in 3, fusiform in 4, double lumen in 1, wide neck saccular in 1, and occlusion in 1 case. Treatment methods were proximal VA occlusion in 3, trapping in 1, intra-aneurysmal coil occlusion with stenting in 1, and observation in 11 cases.
Follow-up periods were 10 months-19 years (6 years and 9 months on average). Serial image findings of 5 conservatively treated cases with PS and string sign improved, but those of fusiform and saccular type did not. Outcome: 13 patients showed excellent clinical course without any symptoms. Two patients died of other causes. One patient with an out-pouching aneurysm showing double lumen died of subarachnoid hemorrhage 6 years after initial presentation.
As to surgical indication for intracranial nonhemorrhagic vertebral artery dissection, dilatational lesion may be included for prevention of future rupture.

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We frequently experience grade improvement of poor-grade patients with subarachnoid hemorrhage (SAH) in the acute stage. In this study we evaluated the involvement of the presence or absence of the light reflex in the grade improvement.
We retrospectively analyzed 109 poor-grade patients on admission without massive hematoma or prominent hydrocephalus. All patients were admitted within 6 hours after SAH onset with a poor Hunt & Kosnik grade (IV and V). In Grade IV patients no one revealed bilateral absence of the light reflex. Grade V patients were divided into 2 subgroups. Grade Va patients are assumed to have at least unilateral presence of the light reflex, and Grade Vb patients are assumed to have bilateral absence of the reflex. At the time of admission, 28 patients were Grade IV, 39 were Grade Va and 42 Grade Vb, respectively.
Grade improvement in the acute stage was observed in 22 Grade IV (79%), 25 Grade Va (64%) and 2 Grade Vb (5%) patients. Forty five patients out of these 49 (92%) improved within 24 hours after admission. The grade improvement ratios in Grade IV and Va were statistically insignificant. The improvement ratio in Grade Vb was significantly lower than the other grades. After grade improvement, 22 Grade IV, 25 Grade Va and 2 Grade Vb patients underwent radical surgery, and favorable outcomes were obtained in 28 patients. The remaining 60 patients did not improve and the outcome was unfavorable.
In Grade V patients with presence of the light reflex, grade improvement in the acute stage can be expected to be the same as that for Grade IV patients. The absence of the light reflex in poor-grade patients is a significant predictor of poor outcome.

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Unlike dural arteriovenous fistula (AVF) of the transverse sigmoid and cavernous sinuses that usually have a benign natural history, tentorial dural AVF typically present with hemorrhage or progressive neurological deficit. But relatively few reports are available on tentorial dural AVF accompanied by dementia. We report here 2 cases of dementia caused by a tentorial dural arteriovenous fistula.
The first case is that of a 75-year-old male complaining of dementia and gait disturbance. CT scan showed ventricular dilatation and a high density area in the posterior fossa. Cerebral angiography revealed a dural AVF of the cerebellar tentorium with retrograde drainage into cerebral cortical veins. We performed transarterial embolization and V-P shunt several times, finally adding radiosurgery. Two years later, shunting flow remained but symptoms improved.
The second case is that of a 70-year-old male who presented with dementia and right hemiparesis. CT and MRI revealed venous infarction of the left thalamus. Cerebral angiography revealed a tentorial dural AVF with retrograde leptomeningeal venous drainage. We performed TAE twice and symptoms improved. But dementia recurred and MRI revealed a new venous infarction of the right thalamus. We added TAE but symptoms did not improve. So we performed surgical treatment. Two days postoperation, however, complications developed in the form of intra right occipital lobe hemorrhage. His outcome 3 months later was moderate disability.
Tentorial dural AVF should be performed completely and early because of the high risk of intracranial hemorrhage. Tentorial dural AVF has been successfully treated by endovascular occlusions and/or surgical treatment sometimes in conjunction with radiosurgery. However, in elderly patients, surgical complications may be caused by rapid changes of intracranial pressure and blood flow patterns.

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There are few cases of spinal hemorrhagic disease compared to cerebral stroke. However, progress in diagnostic neuroradiology has shown that it is not such a rare disease. We report on cases of spinal hemorrhagic disease that were diagnosed as cerebral stroke. Subjects are 13 cases of spinal hemorrhagic disease that we treated from September 1998 to November 2003. Among these cases, 6 patients were initially diagnosed as cerebral stroke. These comprised 3 cases of spinal epidural hematoma, 1 case of spinal subdural hematoma and 2 cases of spinal subarachnoid hemorrhage. In most cases, they presented with neck, back or low back pain, but a few cases presented with hemiparesis and were not diagnosed as spinal disease.
These cases are likely to misdiagnosed as cerebral stroke. Hematomas often occur on 1 side of spinal cord and lead to hemiparesis. Now we can easily and correctly diagnose spinal hemorrhagic disease using magnetic resonance imaging (MRI).
Spinal hemorrhagic diseases are rare but a good prognosis can be expected with appropriate diagnosis and treatment.

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