Observance of basic procedures is essential for safe and reliable aneurysm surgeries. At the final steps of aneurysm surgery, dome puncture is a useful procedure for various purposes. For dissection of aneurysms, temporary clipping of the proximal segment of the parent artery is usually used to reduce the tension of the aneurysm. When the tension of the aneurysm is still high despite temporary occlusion of the parent artery, dome puncture under trapping or tentative clipping is very useful to make dissection very easy. Dome puncture after neck clipping is performed to confirm complete obliteration of the neck, to observe behind the dome, and to prevent slipping-in or slipping-out of the clip.

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We evaluated the usefulness of endoscopy, motor evoked potential (MEP) monitoring, and navigation for safe and accurate clipping of cerebral aneurysms.
Of 116 patients (ruptured, 50; unruptured, 66) who underwent surgical procedures from January 2000 to September 2005 at our hospital, endoscope-assisted surgery was performed in 50 operations (ruptured, 17; unruptured, 33), MEP monitoring was done in 6 operations (unruptured, 6), and a navigation system was used in 6 operations (ruptured, 1; unruptured, 5). Endoscope-assisted surgery was performed using a 2.7- or 4-mm-diameter endoscope with a tip angle of 30º or 70º. The Stealth Station was used as the navigation system. MEP monitoring was performed using electrical stimulation of the motor cortex and EMG recording of the face, trunk, and the upper and lower extremities contralateral to the stimulated side.
During endoscope-assisted surgery, the anatomical relationship between the aneurysm neck and the parent artery or perforating artery could be observed before clipping, and the location of the clip tip, occlusion of the perforating artery, or stenosis of the parent artery could be evaluated after clipping. Among the 28 patients whose perforating artery was observed endoscopically, 3 were re-clipped due to suspicion of perforating artery occlusion or stenosis. On postoperative MR and/or CT images, perforating artery infarctions were observed in 4 patients, although none were symptomatic. Although MEP monitoring was expected to predict the postoperative motor function, fortunately, no patients showed abnormal MEP findings after aneurismal neck clipping. Navigation allowed the prediction of the site of aneurysm and parent artery before dissection, resulting in an accurate approach to these structures.
Endoscopy, MEP monitoring, and navigation are considered useful for performing safe and accurate clipping of cerebral aneurysms.

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We previously reported the usefulness of three-dimensional (3D) CT angiography for perioperative evaluation of carotid endarterectomy (CEA). Calcification depicted well in the modality has also been studied pathologically. We have pointed out that the microscopically granular type might be relatively softer than the lump/luminar type and that this factor may affect the result of carotid angioplasty and stenting. The aim of the study was to determine the surgical option by analyzing hardness of calcification with calcium scores obtained by 3DCT angiography.
Seventy carotid arteries were examined with 3DCT angiography and 35 plaques were extracted in CEA. Volume, Hounsfield units and calcium scores of calcified lesions were calculated and analyzed by a 3D workstation.
Calcified lesions were classified into 4 groups according to their volume and Hounsfield units. Though large calcification tended to have a relatively bigger difference between maximum and mean CT values, the calcium score seemed to be plotted in proportion to overall hardness of calcification and to enable comprehensive evaluation, which might affect the choice for surgical treatments.

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After the stroke care unit of Tokushima University hospital was established in November 1999, stroke MRI (diffusion-, perfusion-weighted image, MRA) was performed to initially evaluate stroke patients, except for SAH. Since April 2004, 3 tesla MRI has been used for stroke MRI, and T2* weighted image was added to routine study of stroke MRI. 3 tesla stroke MRI can reduce examination time and also take functional MR images, which yield important information for diagnosis and treatment decisions.
The combination of our stroke center and rehabilitation hospital is a key factor in improving patients' outcomes for acute rehabilitation and improving quality of life.

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We analyzed the outcome of 25 SAH patients who were over 80 years old. We performed early operations on SAH patients between the ages of 80 and 85, and intentionally delayed operations on patients over 85 years of age (7 cases with neck clipping and 3 cases with endovascular coil embolization). Four of 10 patients in the operative group (40%) had favorable outcomes. The risk factors that worsened the outcome were cerebral vasospasm and general complications. All in the non-operative group had a poor outcome.
In elderly SAH patients, an acceptable treatment plan must be made from a social and economic viewpoint.

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We recruited 229 consecutive patients (145 men) aged 29-96 years (mean 70 years). All gave informed consent in this study. Patients were classified into “cardiogenic embolism (cardiogenic),” “atherothrombotic stroke (atheroma),” “lacuna stroke (lacuna)” and “others.” In “atheroma” and “lacuna” groups, significant arterial stenosis as the source was disclosed in 55.6%. The stenotic lesions considerably existed in the extra-cranial region, such as cervical internal carotid artery, foraminal segment of the vertebral artery, or vertebral artery origin. In half of the patients with previous attacks, significant arterial lesions were identified as the source. The symptoms caused by these arterial lesions tended to be slight. Therefore, the source may be overlooked, resulting in relapse.
Determining the source is important as careful neurological assessment may enable a favorable clinical outcome.

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When thalamic hemorrhage is accompanied by severe intraventricular casting, the prognosis is extremely poor. Although the ventricular drainage with thrombolysis agent is effective in some cases, the drainage occlusion and inadequate hematoma removal are often troublesome in actual daily clinical practice. For such severe cases, we performed direct hematoma evacuation through interhemispheric transcallosal route in recent years and compared the results with that of the ventricular drainage, which had been performed before.
We operated on 15 cases (5 men and 10 women) using interhemispheric transcallosal approach (ITA) between June 2002 and May 2005. In all cases, emergent and minimal angiography was performed just to estimate ipsilateral bridging veins to decide the craniotomy site. ITA through the ipsilateral side of thalamic hemorrhage with 2-3 cm callosotomy between bilateral A3 enabled hematoma evacuation of the ipsilateral ventricle, contralateral ventricle through the septum, as well as the thalamus through perforated ventricular wall. The direct hemostasis of bleeding perforators of thalamus was accomplished in all cases.
More than 90% hematoma removal was achieved, and the postoperative serial CT scans demonstrated no rebleeding in any of the cases. Two patients (13.3%) needed VP shunt due to hydrocephalus in the chronic stage. At the time of discharge (average hospital-days 48.1 days), 12 patients were Grade 4 and 2 patients were Grade 5 on the modified Rankin Scale. One sudden death (6.7%) due to pulmonary embolism occurred on the 28th day after surgery. In the previous treatment (ventricular drainage only) of 15 patients between 1997-2002, 1 patient was Grade 3, 8 were Grade 4, 2 were Grade 5 and 4 (26.7%) died.
The direct hematoma removal using ITA might improve the prognosis of thalamic ICH with severe ventricular casting by relieving ventricular irritation and obstructive hydrocephalus quickly as well as by definite hemostasis through direct vision.

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Spinal dural arteriovenous fistula (AVF) is the most common type of spinal vascular malformations. We experienced 3 surgically treated cases of craniocervical junction dural AVF.
Case 1 was a 69-year-old man who suffered from headache and had no neurological deficet. Case 2 was a 65-year-old man who presented subarachnoid hemorrhage. His conciousness was confused but he had no motor weakness. Case 3 was a 38-year-old woman who suffered from headache and had no neurological deficet. MRI, DSA, and 3D-CTA studies were performed for all cases.
The lesions were diagnosed as craniocervical junction dural AVFs with intradural varix and drainage in Case 1 and Case 3, and a C2 level dural AVF with intradural varix and drainage and with an expansive epidural drainage. All cases were successfully treated with surgical drainer clipping.
Pre-operative 3D-CTA study, intra-operative DSA, directional color-flow doppler and the surgical technique of dentate ligament cutting were useful to treat these lesions.

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With a globally aging population, it is imperative to develop specific treatment strategies for subarachnoid hemorrhage (SAH) in the elderly. However, the optimal management of SAH in the elderly remains controversial, especially for patients over 80 years of age. Therefore, we retrospectively evaluated the long-term outcomes measured in 112 consecutive patients aged over 80 years and treated at our single-institution.
We conducted a retrospective review to evaluate the medical records and imaging studies of 112 patients treated with clipping or conservative therapy between January 1992 and August 2006. The neurological status was evaluated according to Hunt & Kosnik (H&K) Grade on admission, the “best” H&K grade during pre-surgical treatment, and Glasgow Outcome Scale (GOS) at discharge. Moreover, the long-term outcome was evaluated by administering a telephone questionnaire to the patients or relatives on October 2006.
Ages of the 112 patients in our study ranged from 80 to 94 (average 84.0 yrs); 20 were men. Thirty-two patients underwent clipping procedures, and 80 patients were under conservative therapy. Overall results evaluated as GOS at discharge were: good recovery (GR), 21 (18.8%); moderate disability (MD), 10 (8.9%); severe disability (SD), 9 (8.0%); vegetative state (V), 4 (3.6%); and death (D), 68 (60.7%). This outcome was in accordance with the “best” H&K grade during pre-surgical treatment, not with H&K grade on admission. The outcome of the “best” H&K Grade 1 and 2 groups was significantly better than that of the “best” H&K Grade 3, 4 and 5 groups. Twenty of 28 patients waiting for chronic operation died due to re-rupture, vasospasm, and pneumonia before the operation. The overall outcome of patients with acute operation (GR12, MD4, SD5, V1 and D2) was significantly better than that of patients waiting for chronic operation (GR4, MD3, SD1, V0 and D20). Long-term follow-up showed the median survival periods after discharge of patients surviving in MD, SD, and V were 10 months, 4 months, and 2 months, respectively. Especially in the case of extremely aged patients, the long-term survival was rare even in MD condition. The leading cause of MD condition at discharge was the induction of dementia by long-term lying in bed.
The “best” H&K Grade during pre-surgical treatment, not that on admission is a useful and practical tool for the selection of elderly patients affected by SAH as surgical candidates. Many patients planned for chronic operation could not survive until the operation period because of deterioration of general condition. Therefore, acute operation was recommended if the patient's “best” H&K Grade comes up to 1 or 2.
All grades of GOS other than GR are a bad prognostic factor for survival after discharge. To prevent the induction of dementia and to achieve good functional condition, rehabilitation soon after surgery should be considered.

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We report 3 patients who developed subarachnoid hemorrhage (SAH) from the vertebral dissecting aneurysm after head-nuchal pain. All 3 patients developed sudden head-nuchal pain, at the onset of which no subarachnoid hemorrhage was observed on CT (n=2) or on CT and MRI (n=1). Subsequently, SAH occurred within 1 or 2 days. All 3 patients were men aged 46 to 55 years, and had a Hunt and Kosnik Grade of III (n=1) or V (n=2) at admission. Vertebral angiography revealed aneurysmal dilatation with narrowing, but no posterior inferior cerebeller artery (PICA) involvement in any of the patients. All patients were treated for proxymal occlusion, including aneurysm, using GDC coils. In 1 patient, decompressive craniectomy was performed due to progression of a thrombosis to the PICA, and cerebeller and brain stem infarction. The Glasgow Outcome Scale (GOS) was good recovery in 2 patients. The patient who underwent decompressive craniectomy presented quadriplegia and had a score of Vegetative State.
Although dissecting vertebral aneurysm presenting with head-nuchal pain and/or ischemic symptoms generally carry a favorable prognosis, we should be careful that it might associated with SAH as shown in the present case.

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Hypertensive intracerebral hemorrhage (HT-ICH) is the most common pathological condition in all intracranial hemorrhages. We report 5 cases of ICH caused by rupture of a small intracerebral AVM, which were all treated surgically. The plain CT scans all demonstrated ICHs looking like hypertensive type, and some 3D-CT scans could not reveal any vascular malformation.
In 42 cases of all surgically treated ICH in 2 consecutive years in our institution, 5 cases were pathologically diagnosed as ruptured AVM. The average age of the 5 patients was 74. The patients comprised 4 males and 1 female. Bleeding points were putamen in 4 cases and subcortex in 1.
Hemorrhages looking like HT-ICH caused by AVM are not rare even in elderly patients. At the time of ICH surgery, caution is needed in case of endoscopic surgery or burr hole surgery, taking vascular malformation into consideration.

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