Carotid artery stenting has emerged as an acceptable treatment alternative in patients with carotid artery stenosis. Although early clinical results of carotid artery stenting have shown promise, long, term clinical results remain less certain. We report the frequency, management, and clinical results of in-stent restenosis after carotid artery stenting using a self-expandable stent. Between August 1998 and September 2004, 80 carotid artery stenting procedures in 78 patients were performed. We evaluated 76 of the 80 procedures in 75 of the 78 patients treated during this period who had a minimum 6-month clinical and imaging (ultrasound and/or magnetic resonance angiography) follow-up. Recurrent stenosis (≧50%) after carotid artery stenting occurred in 3 (3.9%) patients. The recurrent stenosis occurred within one year after the procedure in all cases. The low rate of in-stent restenosis using self-expandable stent suggested that carotid artery stenting may be an effective alternative treatment for carotid artery stenosis, but more data of long-term follow-up are required.

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Follow-ups of more than 1 year were carried out in 400 CEAs performed in 372 patients. Perioperative and postoperative clinical features were investigated at 1 month, 1 year and 5 years. Perioperative complications were observed in 6 CEAs (1.5%) whose ADL decreased at 1-5 years. At 1 year, 355 patients maintained preoperative ADL. Poor outcomes were observed in 3 dead patients, 6 patients with surgical complications and an additional 8 patients. The latter 8 patients experienced reduced ADL caused by dementia and poor general condition. Although 223 of 252 patients maintained ADL during the 5-year follow-up, 29 patients experienced reduced ADL mainly due to poor general condition, Parkinsonism or dementia. Ipsilateral stroke was observed in 6 patients. Restenotic changes were detected by ultrasonography in 16 CEAs during 1-3 years and produced TIA in 2 patients.
These results indicate CEA without complications can effectively prevent stroke and allow patients to maintain ADL.

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In recent years, the possibility of treating aged patients of ruptured aneurysm has increased with the progress of surgical technology and the spread of endovascular treatment. But prognosis is still poor. Systemic complications caused by lying on a bed over a long period postoperatively are cited as the cause.
When continuous cerebrospinal fluid (CSF) drainage is used to prevent symptomatic vasospasm, patients are forced to lie on a bed over a long period. In order to start the rehabilitation early, we started to use intermittent CSF drainage from June 2002.
We treated 45 patients of ruptured cerebral aneurysm over 75 years of age from January 2000. We compared 2 groups: a continuous CSF drainage group and an intermittent CSF drainage group. We compared the frequency of symptomatic vasospasm, hydrocephalus and Glasgow outcome scale (GOS) score of 37 patients who underwent intermittent CSF drainage with those of 8 patients who underwent continuous CSF drainage. There was no difference of frequency of symptomatic vasospasm and hydrocephalus between the 2 groups; the GOS score of intermittent CSF drainage group was better than that of the continuous CSF drainage group.
Intermittent CSF drainage prevented the complications of aged patients and was considered to effectively improve prognosis.

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Carotid artery stenting (CAS) is often considered the preferred treatment for severe carotid occlusive disease in patients labelled as “high risk,” including those aged 75 or more. We analyzed 30-day stroke risk and death rates after carotid artery stenting (CAS) for severe symptomatic or asymptomatic carotid stenosis in 55 patients (60 lesions) aged 75 or more and compared the results with those of 119 patients (130 lesions) less than 75 years old.
All procedures were performed with protection devices (balloon protection) and were technically successful. Peri-procedural mortality and morbidity of CAS for elderly patients were 1.7% and 6.7%, respectively, but those for younger patients were 0% and 2.3%, respectively. The elderly patients tended to have a high complication rate, although it was not statistically significant. Therefore there was no significant difference in clinical baseline characteristics between the 2 groups. Randomized data that establish the efficacy of CEA versus medical management are not available for elderly patients, especially for individuals aged 80 years or older. Octogenarians should be considered high-risk patients for CAS. Randomized trial data are needed to compare the CAS versus CEA peri-procedural risk of stroke and death by age.
Pending results from randomized studies, care should be exercised in selecting octogenarians for CAS.

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Cerebral ischemia during clamping of the carotid artery is a procedure-related complication in carotid endarterectomy (CEA). A correlation between the status of the circle of Willis, especially A1-A2 morphology, and the alteration of intraoperative somatosensory evoked potentials (SEP) was evaluated in 68 patients. All carotid endarterectomies were performed under general anesthesia without shunting. Patients were classified into 3 groups based on A1-A2 morphology in preoperative cerebral angiography. The amplitude of intraoperative SEP was decreased in 57.1% of patients with hypoplasia or absence of contralateral A1. On the other hand, amplitude was decreased in 26.7% of patients with hypoplasia or absence of ipsilateral A1 and in 11.4% of patients with patent bilateral A1.
Incompleteness of the anterior part of the circle of Willis, especially hypoplasia or absence of contralateral A1, is a significant risk factor for developing of ischemia during clamping of the carotid artery.

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We investigated whether pretreatment of anticoagulant agents and antiplatelet agents affect the prognosis in patients with intracerebral hemorrhage (ICH).
We retrospectively reviewed the medical records of 451 patients admitted to our center due to intracerebral hemorrhage within 24 hours after onset during an 8-year period from 1998 to 2005. The ICH patients were divided into 4 groups: patients with anticoagulant therapy (AC, 20 patients), with antiplatelet therapy (AP, 47 patients), with combined anticoagulant and antiplatelet therapy (AC+AP, 8 patients), and with no pretreatment (NT, 376 patients). We also selected 345 patients with ICH who had undergone a second CT within 24 hours of initial scan and evaluated the hematoma volume in each scan and the ratio of hematoma enlargement. The AC+AP group showed a worse prognosis and higher in-hospital mortality than the NT group. Meanwhile, the AC and AP group showed no tendency of higher mortality or poor prognosis.
Pretreatment of combination of warfarin and aspirin is associated with poor prognosis and higher mortality in patients with ICH.

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Extensive cerebral hemispheric infarction is a devastating condition leading to early death in nearly 80% of cases due to the rapid rise of intracranial pressure in spite of maximum medical treatment for brain edema and swelling. Recently, decompressive craniectomy has been reevaluated to prevent the brain herniation caused by extensive hemisphelic cerebral infarction. We studied the surgical results after decompressive craniectomy for extensive cerebral infarction. Between December 1997 and August 2006, 13 consecutive patients (7 males and 6 females aged from 39 to 73 with a mean age of 59 years) with massive cerebral infarction of IC (11 patients) and MCA (2 patients) territory were treated with decompressive craniectomy and dural plasty. Five patients had a left-sided stroke with severe aphasia. The cardioembolic source of stroke was seen in 5 patients. Surgery was performed at the point of neurological deterioration, anisocoria, and effacement of perimesencephalic cistern on CT findings. The mean time between stroke onset and surgery was 39.8 hr and ranged from 13 to 102 hr. GOS on discharge was MD 1, SD 8, VS 1, and D 3 (mortality rate 30. 8%). Severe pneumoniae were the causes of death. All survivors underwent cranioplasty and were transferred with the aim of rehabilitation. In this study, we showed that the decompressive craniectomy reduced mortality after extensive cerebral infarction. However, the functional outcome and level of independence are poor. It seems that the early decompressive craniectomy should be aggressively performed for extensive cerebral infarction before neurological deterioration such as worsening of consciousness disturbance or pupil abnormalities. Further investigations will be needed to clarify the surgical indications, timing, and functional outcomes.

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We report 2 patients whose lower ventral pontine cavernous angiomas were removed via the ventral lower pons lateral to the abducens nerve where the angiomas are closest to the surface of the brain stem. A suboccipital transcondylar approach (STC) provided a sufficient operative field to remove the angiomas from the lower pons lateral to the abducens nerve and an adequate operative trajectory along the longitudinal axis of the angiomas.
Successful removal was accomplished without serious complications in both cases. As the cranial nerve nuclei and the reticular formation were displaced dorsally, the corticospinal tract was located medial to the abducens nerve, and the facial nerve fibers were running laterally in our 2 cases. The lower pons lateral to the abducens nerve was a safe entry zone into the brain stem. Bone removal around the condylar emissary vein, the posterior part of occipital condyle, the hypoglossal canal and the jugular tuberculum in STC provided an extensive operative field in ventral aspects of the medulla and lower pons. The patient's position during surgery was important to facilitate bony removal and provide an adequate operative trajectory.
Volume reduction with electrocoagulation and piecemeal resection proved to be essential techniques for safe and complete removal of the brain stem cavernous angiomas.

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We introduce our microsurgical training program for young neurosurgeons. The technological revolution of interventional radiology (IVR) enables us to nonsurgically cure the greater part of cerebral vascular diseases. This recent trend has decreased the number of cases to be treated by open surgery, thus depriving young neurosugeons of opportunities for learning microsurgical techniques in clinical settings.
To teach microsurgical techniques despite the limited clinical case volume, we prepared an easily accessible and practical training program. The program consists of a micro-scissors exercise with gauze (gauze cutting method), which simulates dissection of the sylvian fissure or the interhemispheric fissure, an anastomosis exercise with gauze, prosthetic tubes, chicken wing artery, or cadaver artery, and an operative stand with a small hole, which simulates a variety of surgical fields.
We believe that this protocol is useful for young neurosurgeons to learn and establish steady and skillful microsurgical techniques.

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Whenever we discuss the overall results of surgical treatment for unruptured cerebral aneurysms, especially in aged patients, we tend to consider advanced age or general anesthesia as causes for unfavorable results. There are no reports concerning ischemic stroke events following general anesthesia in aged patients with a prior history of cerebrovascular disease. The purpose of this study is to clarify the influence of general anesthesia on the brain in aged patients with a previous history of ischemic cerebrovascular disease. The subjects were 30 consecutive patients over 70 years of age with previous ischemic cerebrovascular disease who underwent various surgeries except brain and cardiac surgery under general anesthesia. The patients were 70 to 85 years old, with a mean age of 76. Twenty-three were men and 7 were women. Surgical procedures were 12 gastrointestinal, 6 orthopedic and 4 urogenital and others.
The type of cerebrovascular disease evaluated by neuroradiologist and anesthesiologist based on MR imaging was devided as follows: 16 patients had minor stroke, 7 had TIA/RIND and 7 had asymptomatic cerebral infarction. MR angiography was also assessed to evaluate the main artery in the brain. Blood pressure and arterial blood gas (PaCO₂) during general anesthesia were analyzed, and the rate of systemic and neurological complications following general anesthesia were evaluated. MR angiography revealed no occlusion or severe stenosis of the main artery in the brain of any of the patients. The minimum systolic blood pressure showed less than 100 mmHg transiently for 5-20 minutes in 28 of 30 patients during general anesthesia. The minimum value was 65 mmHg maintained for 5 minutes. The minimum PaCO₂ during general anesthesia was as follows: 1 case < 25 mmHg, 7 cases 26-30 mmHg, 10 cases 31-35 mmHg, 9 cases > 36 mmHg. There were no neurological complications following general anesthesia in this study. One of 30 patients (3.3%) had suffered from pneumonia following total gastrectomy.
Except for various surgeries performed under general anesthesia with long-lasting hypotension and hypocapnia, general anesthesia has no effect on the brain in aged patients with previous ischemic cerebrovascular disease without occlusion or severe stenosis of the main artery in the brain.

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We report a case of simultaneously treated extracranial carotid artery stenosis and concomitant ipsilateral intracranial unruptured aneurysm by endovascular approach. Bilateral cervical carotid artery stenosis and a left intracranial unruptured aneurysm were incidently revealed in a 68-year-old male. To minimize the risk of cerebral ischemia and rupture of aneurysm, we simultaneously treated both lesions in the same session.
The patient was given general anesthesia, and left carotid artery stenting was performed with distal embolic protection. Then, a guiding catheter was passed through the stent-strut and endovascular embolization of the lt. IC-PC aneurysm was performed. The postoperative course was uneventful, and the patient underwent contralateral CAS 6 days after the first intervention. The patient discharged 6 days after the second intervention.
Simultaneous treatment for such ipsilateral lesions could be an optimum treatment strategy.

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