To determine the indication for early surgery of aneurysmal subarachnoid hemorrhage (SAH) in the elderly, we retrospectively correlated surgical outcome with Glasgow Coma Scale (GCS) score. Between Jan. 1989 and Dec. 2000, 1,885 of 3,447 patients admitted within 48 hours after SAH underwent clipping of aneurysms between Day 0 and Day 3. The incidence of severe SAH (GCS 3 to 6) on admission inversely correlated with age: 38.2% for patients aged ≥80 years, 27.4% for patients aged 70-79 years, 24.2% for those aged 60-69 years, and 20.6% for those aged <60 years. The rate of early surgery was 87 of 272 patients (32.0%) for those aged ≥80 years, 386 of 738 patients (52.3%) for those aged 70-79 years, 578 of 996 patients (58.0%) for those aged 60-69 years, and 834 of 1441 patients (57.9%) for those aged <60 years.
At the 3-month evaluation, the overall incidence of favorable outcome (Good recovery and moderate disability) was 23.0% for those aged ≥80 years, 43.2% for those aged 70-79 years, 59.4% for those aged 60-69 years, and 74.9% for those aged <60 years. Among patients aged ≥80 years, the incidence of favorable outcome was 47.4% in GCS 15, 31.0% in GCS 13+14, 33.3% in GCS 11+12, and 0% in GCS≤10. For patients aged 70-79 years, the incidence of favorable outcome was 61.9% in GCS 15, 40-50% between GCS 7 and GCS 14, and less than 10% between GCS 4 and 6. Initial bleeding and systemic complications were the major risk factors for poor prognosis in the elderly.
We concluded that lower limitation of GCS score for early surgery was 11 for patients aged ≥80 years, and 7 for those aged 70-79 years.

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We performed embolization of ruptured intracranial aneurysms using Guglielmi detachable coils (GDC) in 20 patients aged over 70 years at the acute stage (<72 hrs) between October 1997 and December 2003.
We treated them without the “remodeling technique.” The most important point of the embolization was the disappearance of contrast material filling into the aneurysmal bleb. Preoperative World Federation of Neurological Surgeons (WFNS) scale revealed that 11 patients were in poor grade (IV or V). The percentage of the coil volume occupying the aneurysm lumen (EVR: embolized volume ratio) and the Glasgow Outcome Scale (GOS) at discharge were evaluated. The embolized volume ratio (EVR) was under 20% in 8 patients. Although good outcome (good recovery or moderate disability) was obtained in only 3 (27%) of the poor-graded patients, there was no evidence of rebleeding irrespective of EVR. One patient received direct surgery for the remnant of aneurysm after embolization at the chronic stage.
We concluded that the embolization using GDC without remodeling technique at the acute stage should be an optional treatment for the elderly patients in poor grade following subarachnoid hemorrhage.

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We performed intraarterial thrombolysis in 36 patients with evolving acute cerebral infarction due to occlusion of the middle cerebral artery (MCA). Angiographic sites of arterial occlusion were divided into 3 types: 1) M1 proximal occlusion type, MCA trunk occlusion proximal to the lenticulostriate arteries (16 patients), 2) M1 middle portion occlusion type, MCA trunk occlusion with partial involvement of the lenticulostriate arteries (9 patients), and 3) M1 distal occlusion type, MCA trunk occlusion distal to the lenticulostriate arteries (11 patients).
The modified Rankin Scale (mRS) was used to assess clinical outcome at discharge. The rate of partial or complete recanalization in the proximal occlusion group was 44%, that in the middle portion occlusion group was 67%, and that in the distal occlusion group was 73%. There were trends toward the better recanalization rate in distal occlusions. Excellent or good outcome (mRS score 0 to 2) was seen in 13% of patients in the proximal occlusion group, 45% of those in the middle portion occlusion group, and 73% of those in the distal occlusion group. There was a significantly higher incidence of functionally independent patients in the distal occlusion group (p<0.05). Symptomatic cerebral hemorrhage occurred in 5 patients (14%).
Intraarterial thrombolysis for acute middle cerebral artery occlusion is a very effective treatment modality for the M1 distal occlusion patients. But in M1 proximal occlusion patients, the recanalization rate is low, and the outcome is significantly poor even in the patients who underwent recanalization. Therefore we should consider intraarterial thrombolysis for the patients with the involvement of the lenticulostriate arteries.

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We report 17 patients with symptomatic giant aneurysms in the cavernous portion of the internal carotid artery (ICA) who were treated by trapping the ICA on either side of the aneurysmal orifice or proximal occlusion using detachable coils.
In all 17 patients, the ICA was sacrificed; 9 patients subsequently underwent bypass surgery (STA-MCA bypass, n=7; high-flow bypass with vein graft, n=1 and median flow bypass with radial artery graft, n=1). The other 8 patients did not. Coil trapping was performed in 10 patients and proximal occlusion in 7 patients. In 16 patients, there were no ischemic complications after treatment; 1 patient who had been treated by proximal occlusion of the ICA developed transient ischemia due to an intra-aneurysmal thrombus. Cranial nerve palsies were improved in 15 patients.
ICA trapping or proximal occlusion using detachable coils was a highly successful treatment method, and we found the detachable coils effective and easy to use in this series of 17 patients.

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The effectiveness of CEA in preventing further stroke of the patient with high grade carotid stenosis is well known. However, controversy still exists as for the choice of CEA or low flow bypass in the cases of near occlusion because of the uncertainty of the patency of distal ICA as well as the risk for postoperative hyperperfusion.
We experienced 7 consecutive cases of near occlusion between May and November 2004 and performed CEA. In all cases, the flexible shunt (Furui shunt) was employed to reduce the risk of hemodynamic ischemia during clamping. To prevent distal embolism during distal shunt tube insertion, great care was taken to secure the “true distal lumen” high enough above the stenotic site. If necessary, arteriotomy was added on the distal wall and then connected toward the proximal. The use of a shunt tube was helpful in gaining a fine view of the distal end during endarterectomy because it held the collapsed lumen round open.
There were no ischemic complications. Good patencies were demonstrated by postoperative DSAs in all cases.
In our experiences, CEA could be safely performed as long as the angiography shows patent ICA distal to stenotic site even in delayed fashion.

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We treated ruptured intracranial aneurysms with endosaccular embolization using Guglielmi Detachable Coils (GDC) in 192 patients treated in Nagoya University and affiliated hospitals over the past 7 years. Hunt & Kosnik grading was I in 18 patients, II in 78, III in 51, IV in 38, and V in 7, respectively. One hundred and seven aneurysms were located in the anterior circulation and 85 in the posterior circulation. Complete obliteration was obtained in 105 (55%), subtotal in 76 (40%), and partial in 11 (5%) aneurysms.
We experienced 27 intraprocedural complications, including 11 intraoperative ruptures and 16 thromboembolisms. Permanent morbidity and mortality related to the procedure were 4.7% and 2.1%, respectively.
An analysis of complication cases based on the aneurysmal configuration and location showed that tiny aneurysms and vertebral aneurysms (VA-PICA) should be carefully treated to avoid possible perioperative hemorrhagic complications. Due attention should also be paid to thromboembolic complications on the treatment of aneurysms located in middle cerebral, basilar-tip and posterior inferior cerebellar artery because of its branching in close relationship to the aneurismal neck.

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Surgical revascularization for moyamoya disease is believed to prevent cerebral ischemic attacks by improving cerebral blood flow (CBF). We investigated how the rapid increase in CBF through the direct bypass affects the ischemic brain.
CBF was measured by N-isopropyl-p-[¹²³I]iodoamphetamine single-photon emission computed tomography (¹²³I-IMP-SPECT) within 1 week after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis performed on 27 sides of 22 consecutive patients (male:female=6:16, 2-62 years old) with moyamoya disease from March 2004 to April 2005. Five patients (male:female=1:4, 26-55 years old) suffered delayed transient focal neurological deficit mimicking ischemic attack at 2 to 7 days after surgery. Postoperative SPECT revealed focal intense increase in CBF at the sites of anastomosis in all 5 patients. Postoperative magnetic resonance imaging showed no ischemic changes, and magnetic resonance angiography showed the apparently patent STA-MCA anastomosis as thick high signal intensity sign in all 5 patients. The anatomical location and the temporal profile of hyperperfusion were completely in accordance with the neurological deficits. Strict blood pressure control and administration of a free radical scavenger were instituted. The symptoms were resolved in all patients.
In conclusion, transient focal neurological deficit following STA-MCA anastomosis can be caused by focal hyperperfusion in patients with moyamoya disease. Routine CBF measurement is recommended to differentiate hyperperfusion and transient ischemic attack, since the treatments for these conditions are contradictory.

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Endovascular therapy, including transarterial or tranvenous embolization, has been standard treatment for intracranial dural arteriovenous fistulae (DAVFs). However, it is not always possible when the dural sinus is isolated from the internal jugular vein, such as type III or IV DAVFs of Cognard's classification. In 23 cases, we performed less invasive surgery or surgery associated with endovascular therapy. We present our surgical procedures and clinical results in this paper.
The location of the DAVF was the cavernous sinus (CS) in 2 patients, transverse-sigmoid sinus (TS-SS) in 12, superior sagittal sinus (SSS) in 2, craniocervical junction (CCJ) in 3, anterior cranial base (ACB) in 2, and tentorium in 2. Twelve patients with DAVFs in TS-SS, 2 in SSS, and 1 in CS were treated with craniotomy/craniectomy and embolization. Surgical exposure of the superior ophthalmic vein and coil embolization were performed for the CS DAVF in 1 case. Three CCJ, 2 ACB, and 2 tentorial DAVFs were treated with surgical coagulation of the draining vein under fluoroscopic guidance. In our series, 22 of 23 patients were cured completely without any new neurological deficit. Transient speech disturbance was recognized in 1 patient, due to subcortical hemorrhage related to manipulation of a guide wire.
Less invasive surgery, including surgery combined with embolization or surgical coagulation of the draining vein, was effective and safe for DAVFs that could not be cured with endovascular treatment alone.

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We explored national and regional characteristics based on age, gender, and prognosis of subarachnoid hemorrhage by using the Japanese Stroke Data Bank, a data bank of acute stroke patients established to provide evidence for standardization of Japanese stroke management. We analyzed data from 1,183 patients with subarachnoid hemorrhage in the Japanese Stroke Data Bank. For regional investigation, we divided the patients into 3 groups according to their place of residence: Hokkaido, Tohoku, and the area west of Kanto. The total male-to-female ratio was 1:1.88. The female proportion was dominant in older patients: 1:2.27 in the 60s, 1:4.48 in the 70s, and 1:4.63 in the 80s. The age distribution of the patients was apparently different between male and female. Female patients (mean age: 64.5) were older than male patients (mean age: 56.1)(p<0.0001). In the regional analysis based on age, the patients of the area west of Kanto were older than those of Hokkaido and Tohoku (p<0.001). Prognosis was evaluated by the modified Rankin scale (mRS).
In total, favorable outcome (mRS of 0-2), extremely poor outcome (mRS of 5-6), and death (mRS of 6) were 58.0%, 28.3%, and 19.8%, respectively. In a regional analysis, the outcome of the patients of the area west of Kanto was poorer than that of Hokkaido and Tohoku (p<0.001). Since the World Federation of Neurological Surgeons scale did not differ among the patients of the 3 groups, we speculate that the higher number of aged patients may be related to the higher number of patients having a poor prognosis in the area west of Kanto.

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We present 3 cases of ruptured aneurysms with circumferential dilatation of the internal carotid artery (IC). Two of the cases presented repeated hemorrhage following neck clipping of the berry aneurysms arising from the anterior wall of IC. In the second surgery, it was confirmed that the newly formed aneurysm extended circumferentially from the primary aneurysm, which had been obliterated completely in the initial surgery.
Case 1 died of rerupture of the aneurysm following the second fundus-wrapping surgery. In Case 2, the aneurysm was obliterated safely using a fenestrated clip in the second surgery. Case 3 with subarachnoid hemorrhage underwent craniotomy because of progressive dilatation of C2 segment. Intraoperatively multiple blister-like bulging spots were identified on the surface of circumferentially dilated IC. It was repaired by so-called clipping on wrapping method. In the surgery, the clip produced mild narrowing of IC in spite of careful application of the clip to avoid kink. This finding suggested that this type of aneurysm was formed by a special mechanism such as arterial dissection.
We stress the necessity of close postoperative observation even if neck obliteration seems to have been complete in the IC anterior wall aneurysm. Furthermore we recommend extraordinary procedures such as a combination of trapping and bypass surgery or the so-called clipping on wrapping method in this type of aneurysm.

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We report the case of a fusiform middle cerebral artery aneurysm at the M1 segment, which was successfully treated with proximal occlusion after a bypass surgery. A 48-year-old-male was admitted with a chief complaint of repeated left hemiparesis. Cerebral angiography showed a fusiform aneurysm at the M1 segment on the right side, corresponding to the ischemic symptom. We performed the occlusion of M1 at its most proximal segment after the high flow bypass from external carotid artery to M2 with a radial artery graft.
The post-operative course was uneventful, and the patient was discharged 10 days after operation. Follow-up imaging studies showed the prominent thrombus formation inside the aneurysm keeping the blood flow from the aneurysmal wall to the M1 perforators intact.
This surgical result supports the hypothesis that the spontaneous fusiform MCA aneurysm might be caused by dissection and the reversing of blood flow inside the dissected artery might make the dissection subside.

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