We review advances in treatment of ruptured cerebral aneurysm and cerebral vasospasm following subarachnoid hemorrhage (SAH) over the past 30 years. There have been several potent drugs and irrigation methods for subarachnoid clot removal, which were accompanied by attenuated incidence of symptomatic vasospasm in each study. On the other hand, recent advances such as coil embolization and development of surgical techniques enable us to treat older SAH patients in worse clinical grades. However, these advances have not always improved overall clinical outcomes after SAH. At present, the outcome for as much as 40-50% of SAH patients is dependent (MD+SD+vegetative) or dead. Symptomatic vasospasm is one of the main causes of poor clinical outcome, and about 10% of patients have experienced symptomatic vasospasm that resulted in permanent neurological deficit as a sequel.
The increased number of elderly patients with SAH, who tend to show worse clinical grades and thereby worse clinical outcomes, may be one of main factors leading to unfavorable results of overall clinical outcome after SAH.

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Indications for treatment for poor-grade patients with subarachnoid hemorrhage (SAH) are still controversial. As an emergency center, our hospital admits many poor-grade patients with SAH at ultra-early stage. We have difficulty with the rationale of allowing these patients to have unsecured aneurysms during the peak rebleeding period to see which ones are likely to spontaneously improve. In this study, we report the results of ultra-early treatment for poor-grade patients with SAH. Between August 2003 and March 2005, our hospital admitted 73 patients with SAH. Fifty-two of them (71%) who had WFNS Grade IV (14) and V (38) were analyzed in this study. Patients were not selected based on age (mean age 63.1 years ranging from 27-91). After stable vital parameters were established, the patients underwent radiological examination and surgical treatment for aneurysms in the anterior circulation or endovascular treatment for aneurysms in the posterior circulation as soon as possible.
Outcomes were assessed at 3 months after SAH onset. Forty-six (88%) of 52 poor-grade patients were admitted within 90 minutes after SAH onset. Despite the aggressive management policy, definitive treatment could be given in only 32 patients (62%). The treatment was initiated within 9 hours after SAH onset in 26 patients (81%). Clipping was performed in 19 patients and endovascular coil embolization in 13. Overall mortality was 52%, and overall good outcomes (good recovery+moderate disability) were obtained in 25%. All 17 patients resuscitated after cardiopulmonary arrest (CPA) had Grade V and died with or without treatment. On the other hand, good outcomes were obtained in 37% and mortality was 29% in 35 patients without CPA. However, 4 of the 35 (11%) died because of ultra-early rebleeding. In patients with Grade IV, mortality was 7% and good outcomes were obtained in 50%. In patients with Grade V, mortality was 68% and good outcomes were obtained in 16%.
The outcomes of ultra-early treatment in poor-grade patients with SAH suggest that a non-selective policy of treatment as early as possible provides acceptable results, especially in Grade IV. However, definitive treatment should not be performed for patients with CPA because there is no chance to save them.

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We evaluate clinical results in patients with severe subarachnoid hemorrhage (World Federation Neurological Surgeons: WFNS Grade IV or V) treated with acute aneurysmal surgery (Coil embolization: CE or Neck clipping: NC) subsequent to aggressive ICP control and brain protection therapy (External decompression (ED), mild hypothermia (HT)). We analyzed the relationship between the surgical procedure (CE or NC) applied and the outcome. From 1998 to 2003, 179 consecutive patients with WFNS Grade IV or V were evaluated in this study. CE was the first choice for aneurysmal surgery, and NC was chosen only for the patients with evacuated intra-cerebral hematoma (ICH), too small (less than 2 mm) and unsuitable aneurysmal shape for CE.
Among the 57 Grade IV patients, 26 (45.6%) could be treated with CE and another 31 were treated with NC (21 with ICH, 7 too small, 2 unsuitable shape). Twenty-one of these patients underwent ED and 9 were treated with HT. The 15 (57.6%) patients treated with CE and 8 patients (25.8%) treated with NC obtained favorable outcomes at discharge.
The 122 patients with WFNS Grade V were classified in 3 groups from the Glasgow Coma Scale (GCS 3, 4 or 5, 6). Two (5%) of GCS 3, 28 (62.2%) of GCS 4 or 5, and 26 (70.2%) of GCS 6 patients underwent aneurysmal surgery (CE 25, NC 31). Thirty-seven of these underwent ED and 22 were treated with HT. Although 6 (16.2%) of the GCS 6 patients (42.9% of CE and 15.8% of NC) showed favorable outcomes, none of the GCS 3, 4 or 5 patients obtained favorable outcomes at discharge.

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We analyze 15 cases with giant/large aneurysms of the internal carotid artery that were treated under intraoperative monitoring of motor evoked potential (MEP). Six cases with symptomatic intracavernous aneurysm were treated with proximal occlusion of the internal carotid artery (ICA) along with use of high flow bypass. In these cases, MEP was monitored for 20-30 minutes after temporary occlusion of the ICA, but no changes were observed. There were no postoperative ischemic complications. In 9 cases with giant/large paraclinoid ICA aneurysm, aneurysms were clipped with the suction decompression method or temporary trapping of the ICA. In 8 cases, MEP amplitudes decreased or flattened after trapping of the ICA for about 5 minutes. However, they recovered after immediate release of the ICA clamp. In all cases, MEP remained normal after the final clipping.
We consider that MEP sensitively detected ischemia of the anterior choroidal artery. Thus, intraoperative MEP monitoring is effective in the treatment of giant/large aneurysms of the ICA.

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Intracranial aneurysms are usually treated with either microsurgical clipping or endovascular coiling. However, since neither so-called broad-neck aneurysms nor dog-ear remnants at neck clipping are suitable for such treatment options, a wrapping technique is applied for such cases. The material for aneurysmal wrapping demands both stable adherence and no reactive inflammatory response.
We have developed a newly improved ePTFE by ion beam irradiation technique that is biologically inert and able to firmly adhere to surrounding tissue. Based on the lastest studies, Ar⁺ ion at energy of 150 keV with a fluence of 5×10¹⁴ ions/cm² was chosen to irradiate into ePTFE. Using this ion beam irradiated ePTFE, wrap-clipping was performed in 2 cases and coating was made to dog-ear remnant after clipping in 12 cases. Wrapping technique was easy and ion beam irradiated ePTFE instantly adhered to the aneurysm dome with fibrin glue. After surgery, no aneurysm developed rebleeding. Only 1 case developed subarachnoid hemorrhage due to ruptured dissecting aneurysm at the dominant VA. The patient was treated with wrap-clipping, but died because of serious preoperative SAH grade.
These results indicate that application of this technology may offer one of the best materials for aneurysm wrapping.

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The intracranial internal carotid artery (ICA) is well known to be a muscular artery that lacks an external elastic lamina. Elastic fibers are concentrated inside the internal elastic lamina of the wall of the intracranial ICA. We examined a portion where the external elastic lamina disappeared in the course of the ICA.
We extirpated 32 intracranial ICA specimens from 50 cadavers. We made running specimens of the ICA every 3 mm and stained them using the Elastica van Gieson method and then investigated a portion where the external elastic lamina disappeared in the wall of the ICA. We also examined the intimal thickness of various portions of the ICA.
We identified both the internal elastic lamina and the external elastic lamina in the petrous portion of the ICA in all cases. In the intradural portion of the ICA, the external elastic lamina was not recognized and only the internal elastic lamina was seen in all cases. In 31 of the 32 specimens (98%), the external elastic lamina disappeared in the horizontal portion of the cavernous portion of the ICA. The intimal thickness of the ICA was recognized in 23/32 specimens. The starting point of the intimal thickness approximated the portion where the external elastic lamina disappeared.
The external elastic lamina of the ICA disappeared at the horizontal portion of the cavernous sinus, which was a site where intimal thickness was frequently observed. Changes in the elasticity of the wall of the intracranial ICA may therefore cause atherosclerotic changes in the ICA.

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We describe the utility of three-dimensional (3-D) magnetic resonance (MR) angiography in the detection of small unruptured cerebral aneurysms (SUCA).
Seventy-six patients with suspected or detected unruptured cerebral aneurysms smaller than 10 mm by maximum intensity projection images using 3-D time-of-flight MR angiography were investigated by surface rendered 3-D MR angiography. About 10 minutes were required to reconstruct 3-D display images from source images of MR angiography. A total of 88 SUCA in 76 patients were detected on 3-D MR angiography. A majority of aneurysms were located at the anterior part of the circle of Willis, and the maximum diameter of the aneurysms ranged from 1.7 to 9.8 mm with a mean of 4.0 mm. 3-D MR angiography provided important information regarding the configuration of the aneurysm sac, its size, and its relationship to the surrounding vessels.
These results indicate that 3-D MR angiography will make a contribution as a new supporting method in the detection of patients with SUCA.

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We analyze 2000 cerebral arteriovenous malformations (AVMs) to ascertain the cumulative bleeding-free survival and prognostic factors. All cases in this study had small AVMs (3 cm or less) and were treated with gamma knife (GK) surgery, at 6 institutes located throughout central and eastern. The median age at GK surgery was 37 years, range 4 to 84. There were 1168 men and 843 women. The Speztler-Martin grade was 1 in 488, 2 in 822 and 3 in 701. In 1066 AVMs, clinical symptoms of bleeding were recorded. The annual bleeding rate was 1.46% (overall) and 3.083% with bleeding by the person-year's method. Bleeding was observed more frequently in women than in men, especially in women of reproductive ages. Neither the volume nor the location of AVMs was a significant predictor of bleeding.
This large data-base is expected to provide useful information regarding the natural history of small AVMs that can be effectively treated with GK surgery.

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We report our experience in surgical clipping of 7 patients with a recurrent intracranial aneurysm previously treated by neck clipping. All were treated under deliberate mild hypothermia for protection from ischemia during intraoperative temporary vessel occlusion. Surgical approaches were the same as previous in 5, extended in 1 and different in the 7th, which made it possible to expose the entire length of the previous clip. Intraoperative temporary vessel occlusion was necessary in 5 cases and the maximum occlusion time of each case was 7 to 15 minutes. Clipping was successfully completed without surgical complications in all but 1 case, which suffered transient mild hemiparesis with small infarction in the territory of the perforating artery due to intraoperative temporary vessel occlusion. Adequate selection of surgical approach and sharp dissection around the aneurysm were essential.
We emphasize the usefulness of intraoperative mild hypothermia for protection from ischemic insults during temporary vessel occlusion in territory supplied with the cortical artery.

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We report 2 cases of thrombosed giant aneurysm of peripheral posterior inferior cerebellar artery (PICA) with progressive neurological deterioration due to brain stem and cerebellar compression. The patients underwent aneurysm trapping and revascularization by means of anastomosis between the distal PICA and the occipital artery (OA). In Case 1, which presented with tetraparalysis and lower cranial nerve signs and symptoms, a thrombosed giant aneurysm (4×3 cm) arising from the lateral medullary segment of PICA was treated by clip occlusion of the vertebral artery at 2 points, proximal and distal to PICA origin hidden by the aneurysmal dome, and clipping of PICA distal to the aneurysm. Thus, the aneurysm was trapped, and the PICA territory was revascularized by anastomosis between OA and the distal segment of PICA. In Case 2, which presented with hemiparesis and lateral medullary syndrome, a serpentine aneurysm (2.5×2.5 cm) arising from the lateral medullary segment of PICA was trapped, and the distal PICA was revascularized by anastomosis with OA. Thrombectomy was not done in either case. Both patients showed a very good recovery.
The procedure of choice in aneurysm surgery is the isolation of aneurysm from blood flow with preservation of the parent artery. Trapping of aneurysm with revascularization by bypass is the second-best choice in aneurysms in which direct neck clipping is impossible. Aneurysmal thrombectomy is not necessary as is shown in our cases. It should be avoided in deep and narrow operative fields where the hidden lower cranial nerves or the brain stem can be inadvertently damaged by the maneuver.
Trapping and bypass is the alternative when direct neck clipping or intravascular treatment is not feasible.

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It has been suspected that a zone of perihematomal ischemia analogous to an ischemic penumbra exists in patients with subacute putaminal hemorrhage who showed transient neurological improvement with hyperbaric oxygenation therapy (HBO). A 54-year-old woman, who suffered from left putaminal hemorrhage, was examined for regional hemodynamics in the perihematomal region just before and just after the removal of putaminal hematoma in the subacute period by diffusion and perfusion MRI. The pyramidal tract adjacent to the hematoma was intact in three-dimensional anisotropy contrast (3DAC) MRI, the perihematomal region increased apparent diffusion coefficient (ADC) values and decreased cerebral blood flow (CBF) and cerebral blood volume (CBV) was visualized, but mean transit time (MTT) was slightly increased just before the operation. Just after removal of the hematoma, increasing ADC values, CBF and CBV were demonstrated in the peri-
hematomal region. The increased MTT suggested the vasodilatation of perihematomal region after hematoma removal.
This case revealed that the perihematomal hypoperfusion (penumbra) in the subacute period probably existed as a consequence of reduced metabolic demand and compression of hematoma rather than a sign of ischemia, but after decompression of tissues adjacent to hematoma the hyperperfusion resulted from vasodilatation in the perihematomal region.

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