Since the ISAT report showed the superiority of coil embolization for aneurysmal rupture over surgical neck clipping, we have selected coil embolization for ruptured aneurysms considered treatable by either modality. We compared our own cases treated by coiling (71 cases; male: 19, female: 52; average age: 64.7 years old) and clipping (129 cases; male: 43, female: 86; average age: 63.4 years old) between April 2000 and December 2008 regarding the early results, complications, and long-term clinical course.
The results within 3 months after coil embolization were superior to those after clipping (Glasgow outcome scale GR plus MD rate among Hunt & Kosnik Grade I through III was 89.8% in the coiling group, and 79.7% in the clipping group), but the differences were not significant. Significant differences between coiling and clipping were the location of aneurysms, and high frequency of hydrocephalus in senile patients treated with clipping. In senile cases, the results of clipping were significantly less favorable than in non-senile cases (GR plus MD rate of 61% in senile cases vs. 85% in non-senile cases). Regarding the long-term clinical course, mRS at the start point was significantly better in the coiling group (0.87±1.30 in coiling vs. 1.93±1.76 in clipping); Subsequently, mRS of the clipping group improved significantly, and, finally, the difference between groups disappeared (0.79±1.51 in coiling vs. 1.16±1.53 in clipping).
Over the long term, the outcomes in both groups in our series were similar except for those in senile cases. As an initial treatment, the optimal treatment should be selected based on factors such as aneurysmal size, location, shape and patient age.

View full abstract

We compared the surgical stress to brain tissue between surgical clipping (SC) and endovascular coil embolization (CE) for unruptured intracranial aneurysm.
We retrospectively analyzed 10 consecutive cases of unruptured intracranial aneurysms and evaluated serum neuron specific enolase (NSE) and S100β protein at postoperative day 1, 2, and 3.
All 10 cases showed good recovery without any neurological sequelae. Mean operation times were 333.6±95.5 min in the SC group and 129.4±30.0 min in the CE group, respectively (p＜0.01, Mann-Whitney test). Peak serum CRP levels were statistically higher in the SC group than in the CE group (p＜0.01, Mann-Whitney test). There was no statistical difference in postoperative serum NSE or S100β between the SC and CE groups.
Serum NSE and S100β are widely used to analyze brain damage, including brain contusion, subarachnoid hemorrhage and cerebral infarction, but these biochemical markers are never used to investigate the surgical stress for the treatment of unruptured intracranial aneurysms. The results of our study are limited, because of the small number of case studies and do not reflect even when the eloquent brain structures are damaged or resected.
Serologically, SC is not more invasive to brain tissue than CE in the treatment of unruptured intracranial aneurysms. However, the postoperative hospital stay in CE is shorter than in SC, because of the surgical stress for the craniotomy, not brain damage.

View full abstract

We retrospectively examined patients with cerebral artery dissection manifesting as simultaneous subarachnoid hemorrhage and cerebral infarction. Fifty-seven of 924 patients admitted to our hospital from January 2000 to October 2008 with a diagnosis of subarachnoid hemorrhage or cerebral infarction were found to have cerebral artery dissection. Five patients presented with subarachnoid hemorrhage and cerebral infarction occurring within 2 days. Dissection was located in the vertebral artery in 2 patients, middle cerebral artery in 2 patients, and anterior cerebral artery in 1 patient. Embolization of the dissected artery was carried out in 1 patient, and conservative treatment was chosen for the others.
The modified Rankin scale at discharge was 1 in 1 patient, 3 in 1 patient, 4 in 2 patients, and dead in 1 patient. These 5 patients were relatively older (55-78 years) than the usual patient with cerebral artery dissection. Wider arterial wall dissection was considered the cause of simultaneous presentation of subarachnoid hemorrhage and cerebral infarction, and the outcome was poor for these 5 patients. To prevent further extension of arterial dissection and to obtain vessel wall healing, hypotension-based conservative treatment might be an acceptable treatment option.
Further case accumulation is necessary to better understand the natural history of cerebral artery dissection, and the risk factors for severe clinical presentation.

View full abstract

Vertebrobasilar artery dissection began to attract attention as a cause of subarachnoid hemorrhage (SAH) in the late 1970s. Although reports on this disease have gradually increased, the natural history of vertebrobasilar artery dissection remains obscure, and long-term follow-up of patients without surgical treatment is necessary to determine appropriate treatment. We describe the long-term clinical course of ruptured vertebrobasilar artery dissection treated non-surgically. Fourteen subjects with ruptured vertebrobasilar artery dissection were treated conservatively in 7 neurosurgical departments. We reviewed their clinical outcomes, image findings and the chronological changes at the dissection site from their charts.
The modified Rankin Scale was Grade 0 in 13 of 14 cases, and Grade 2 in 1 case. The configuration of dissection did not change during the follow-up period in 12 of 14 cases, but occlusion and restoration were recognized in a single case each. Good prognosis was common in the patients with ruptured vertebrobasilar artery dissection who were treated non-surgically. It is essential to accumulate more data on the clinical course and changes in image findings of long-term survival cases to establish a definite strategy for ruptured vertebrobasilar artery dissection.

View full abstract

Endoscopic hematoma evacuation is an established treatment option for patients with intracerebral hemorrhage (ICH). Although it has the advantages of being less invasive than craniotomy and more effective than conservative therapy, its role and indication in ICH treatment are still controversial.
We retrospectively reviewed 34 cases with ICH treated by endoscopic surgery. ICH patients with mild-to-moderate consciousness disturbance were treated by endoscopic surgery. Of 34 patients, 24 (70.6%) exhibited significant improvement in their consciousness level immediately after surgery. Of 29 patients other than those with cerebellar hemorrhage, 12 (41.4%) showed significant functional recovery in their motor weakness on discharge. The extent of improvement in consciousness level was positively correlated to that in motor weakness. The removal rate of hematoma was 68.4±31.7% on average and was not correlated to the extent of functional recovery. Two patients experienced re-bleeding after operation and had poor functional prognoses. Of these, 1 was administered anticoagulants and the other was given antiplatelets before operation.
These data suggest that endoscopic hematoma evacuation may be beneficial for ICH patients with mild-to-moderate consciousness disturbance by promptly improving their consciousness level, leading to the final functional recovery. On the other hand, endoscopic hematoma evacuation has the potential problem of low hemostatic ability.
The operative indication for patients taking an anticoagulant or antiplatelet drugs should be cautiously determined.

View full abstract

The relationship between subarachnoid hemorrhage (SAH) and chronic renal failure (CRF) remains unknown. We retrospectively reviewed 302 cases of SAH. Of these, 6 cases were diagnosed as CRF who needed hemodialysis. In the cases with hemodialysis, SAH of unknown origin was more frequent than in ordinary SAH cases (80.0% vs. 5.5%, P＜0.0001). No SAH occurred during hemodialysis. The frequency of SAH in the patients with hemodialysis seemed to have no relationship with the duration of hemodialysis. These results suggest that further investigation is needed to clarify the effect of hemodialysis on cerebral vessels, which may frequently lead to SAH of unknown origin.

View full abstract

For the treatment of symptomatic large-giant aneurysm in the cavernous portion of the internal carotid artery (ICA), it is often necessary to occlude the ICA with or without extracranial-intracranial (EC-IC) bypass surgery. We report 11 patients with such symptomatic lesions treated between January 2004 and June 2008 by staged endovascular trapping of the aneurysm with detachable coils following selective EC-IC bypass placement. The necessity of the bypass was determined according to neurological conditions and radiological findings during the preoperative balloon test occlusion (BTO) of the ICA. When ischemic symptoms occurred during BTO, high-flow bypass was selected. Otherwise, findings on single-photon emission computed tomography were used for the bypass selection. Following completion of the bypass, dual antiplatelet therapy was induced. Then the confirmative BTO and endovascular ICA occlusion (ICA-O) under local anesthesia were planned several days after the bypass placement.
A total of 4 high-flow bypasses with radial artery graft were placed before ICA-O, while 7 patients underwent endovascular ICA-O without bypass surgery. There were no perioperative complications related to the procedures in 10 cases, but 1 developed cerebral infarction 7 days after bypass placement possibly due to distal embolism from intraaneurysmal thrombus. No patients showed postoperative symptoms according to insufficient ipsilateral cerebral blood flow, and cranial nerve palsies improved in all patients.
Favorable outcomes can be expected for patients with such aneurysms by staged endovascular ICA-O with selective EC-IC bypass. Although endovascular ICA-O can be safe and useful, understanding of adequate antithrombotic therapy and treatment timing are especially important in cases with bypass placement.

View full abstract

Cerebral amyloid angiopathy (CAA) is an important cause of lober intracerebral hemorrhage in the elderly. Although leptomeningeal and cortical arteries with the deposition of the amyloid β-protein (Aβ) have been thought to rupture in CAA, the pathogenesis of CAA-related hemorrhage still remains obscure.
We studied 10 cases of CAA according to the Boston criteria from April 2006 to July 2009 in Omaezaki Municipal Hospital. Based on clinical data, we examined the primary site of hemorrhage and hypothesized the mechanisms of bleeding. Intracerebral hematoma evacuation was performed to alleviate neurological deteriolation in 2 patients and to make diagnosis in 3 patients. The surgical specimens were pathologically examined.
The characteristic MR images of CAA related hemorrhage were characterized by microbleeds, superficial siderosis, subpial or subarachnoid hemorrhage, subcortical hemorrhage and lober intracerebral hemorrhage. Chronological images obtained in 1 patient revealed that lober intracerebral hemorrhage developed from microbleed with subpial hemorrhage without subarachnoid hemorrhage in one side of the cortex in the affected facing cerebral sulci. Operative findings showed subpial and subarachnoid hemorrhages around the cortical veins on the affected cerebral sulci in all cases. Abnormal fragile vessels existed in one side of the cortex of the affected sulci but not in the other side of the cortex. Complete hamatoma evacuation was performed in 4 cases. The surgical specimens of the hematoma and the adjacent brain parenchyma were pathologically examined by tissue staining with hematoxylin-eosin and Congo red. Many vessels in subpial, subcortical and subarachnoid space along the cerebral sulci were deposited with Aβ.
From these findings, we speculated that the primary hemorrhage related to CAA occurred from the cortical arteries with Aβ deposition in the subpial space along the cerebral sulci and formed a lober intracerebral hematoma. Subarachnoid hemorrhage subsequently occurred due to the destruction of the pia matter by the primary hemorrhage.

View full abstract

Three-dimensional CT angiography (3D-CTA) is a useful modality for planning in clipping surgery of cerebral aneurysms. In addition, maximum intensity projection (MIP) technique allows easy visualization of intramural calcification around the aneurysm. In the present study, we compared preoperative findings with intraoperative findings regarding atherosclerosis and encountered 2 cases of unruptured aneurysm with unexpected severe atherosclerosis, which considered potential limitations to the use of MIP image for preoperative planning. We discuss surgical techniques for both cases when the wall of the aneurysm and neighboring arteries are thick and atherosclerotic.

View full abstract

A 57-year-old man was referred to our hospital for detailed investigation and therapy of right exophthalmos and chemosis. Cerebral angiography demonstrated a dural arteriovenous fistula (DAVF) involving an anterior part of the right cavernous sinus (CS). The main feeders of the CS-DAVF consisted of the right inferolateral trunk and right middle meningeal artery. The predominant drainage route was the right superior ophthalmic vein (SOV), extending to the right facial vein. The right inferior petrosal sinus (IPS) was not visualized in the arterial phase, but was visualized in the venous phase, indicating that it contributes normal venous drainage. Transvenous embolization (TVE) was performed under general anesthesia through the right facial vein. We advanced a guiding catheter in the right angular vein and passed a microcatheter system through the tortuous vessel to the shunting point under single plane road mapping. The affected anterior part of the CS was occluded with Micrus coils (UltiPaq and Cashmere) (Micrus Endovascular, San Jose, CA, USA). Post-treatment angiography revealed disappearance of the fistula.
In general, CS-DAVFs are treated with TVE through the IPS. However, in the present case, IPS was not used for the approach based on the angiographic appearance. Large drainage volume of the right facial vein enabled us to advance the guiding catheter to the angular vein with facility, and to pass the microcatheter system through the tortuous vessel with sufficient support of the guiding catheter. Cashmere, which is a 14 system infinity loop-shaped coil and relatively soft as a framing coil, had a tendency to attach to the anterior part of the CS wall.
Because of good packing efficiency, transvenous Micrus coil embolization through the facial vein is an efficient treatment of DAVF involving the anterior part of the CS.

View full abstract

We report a case of ruptured blood blister-like aneurysm of internal carotid artery treated with wrap-clipping followed by endovascular coil embolization.
A 52-year-old woman suffered subarachnoid hemorrhage due to a ruptured blood blister-like aneurysm on the anteromedial wall of the right internal carotid artery (ICA). Since aneurysmal trapping following superficial temporal artery-middle cerebral artery anastomosis was abandoned because of disappearance of intraoperative motor evoked potential, wrap-clipping was performed finally to preserve the right ICA. The postoperative course was uneventful. Digital subtraction angiography (DSA) on the next day showed disappearance of the small bulge and mild stenosis of the right ICA at the site of wrap-clipping. Follow-up DSA 2 weeks after the operation showed reappearance of the aneurysm at the same portion of the right internal carotid artery. Endovascular coil embolization with ultrasoft GDCs was performed at 18 days after wrap-clipping of the aneurysm. The aneurysm disappeared after the procedure. Follow-up DSA after 1 year of coil embolization demonstrated complete obliteration of the aneurysm.
Endovascular coil embolization may be an alternative treatment for blood blister-like aneurysms in late-stage as long as the aneurysms are saccular in shape.

View full abstract