We employ the ¹²³I-IMP SPECT dual table ARG method and stereotactic extraction estimation (SEE) analysis 7 or 8 days after subarachnoid hemorrhage (SAH) onset to predict cerebral vasospasm. We report new findings of cerebral vasoparalysis during a period of cerebral vasospasm after SAH.
From January 1, 2005 to April 30, 2008, we encountered 330 cases of aneurysmal SAH, and treated 285 cases. Of these, 65 were excluded as unsuitable for this study, for reasons such as lack of SPECT data, external decompression, admission over 7 days from SAH onset. We studied 220 cases treated by microsurgical clipping (n＝178) or endovascular coil embolization (n＝42). Vasoparalysis was defined as a rise in resting CBF and a loss of vascular reserve on SEE analysis of CBF-SPECT.
Vasoparalysis occurred in 15 cases (6.8%). Of these, 9 cases (60.0%) had cerebral hematoma, temporary clips had been used in the operation for 8 cases (53.3%), 9 cases (60.0%) experienced postoperative cerebral infarction, and 3 cases (20.0%) had postoperative convulsions. Vasoparalysis occurs in relation to perioperative cerebral damage.
In terms of the loss of vascular reserve following SAH, vasoparalysis resembles hemodynamic cerebral ischemia, although the conditions are quite different. Differentiating between these 2 conditions is important, as different forms of management are required. Dual table ARG and SEE analysis are very useful for the evaluating these 2 conditions.

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We assess the usefulness of serial three-dimensional CT angiography (CTA) in the diagnosis of cerebral vasospasm (VS), and evaluate the contribution of VS to symptomatic vasospasm (SVS), cerebral infarction, and modified Rankin scale (mRS) in patients with aneurysmal subarachnoid hemorrhage (SAH). Within 3 hours after the onset of symptoms, CTA was performed in 48 patients with SAH. CTA was repeated on Day 5-8 (median 7) and Day 12-15 (median 14) to assess VS. Vasospasm was defined as ≥25% vascular narrowing, and rated with the following criteria (degree of VS): moderate spasm (25-50% decrease in vessel diameter), and severe spasm (≥50% decrease). Vasospasm was also categorized as follows (CTA grade): no VS, local VS, and diffuse VS. By local VS we mean an area of narrowing of the vessel in continuity with an aneurysm and not extending more than 2 cm to the aneurysm, or limited to the A-1, A-2 portion (≤2 cm). Diffuse VS means any stenosis affecting either a long segment of vessel or distal segments of cerebral arteries.
Aggressive treatments for the VS including triple H therapy were started, when either SVS was revealed or Diffuse VS was detected on CTA. We statistically investigate correlations of Hunt and Kosnik grade, Fisher CT group, degree of VS, and CTA grade, with SVS, cerebral infarction, and mRS. Of the 48 patients, 32 (67%) showed VS and 19 (40%) revealed SVS by the 3rd CTA. Cerebral infarction on CT was detected in 13 (27%) patients. With logistic regression analysis, CTA grade significantly correlated with SVS and infarction, while Hunt and Kosnik grade and age of the patients significantly correlated with mRS.
Prospective evaluation of CTA following SAH might allow early recognition of VS and promote aggressive treatment and improved neurological outcomes.

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We report a case of high-flow arteriovenous malformation with a giant feeder, which was treated by staged therapy without causing retrograde thrombosis. A 24-year-old woman was referred to our hospital with a giant arteriovenous malformation (AVM) in the right frontal lobe. She had experienced a dozen or more epileptic seizures since childhood. The main feeder of the AVM arose from one of the branches of the right middle cerebral artery (MCA). This feeder was thicker than the right internal cerebral artery and was 5 times thicker than the main trunks of the MCA. In addition, the AVM was supplied by the perforating arteries of the MCA and the anterior cerebral artery, and drained into deep veins with venous aneurysms. The main feeder was so thick that it was thought that sudden interruption could produce retrograde thrombosis, which could then cause occlusion of the main trunk of the MCA or total occlusion of the MCA. Therefore, we selected staged therapy.
In the first endovascular treatment session, we embolized one branch of the main feeder with coils and highly concentrated n-butylcyanoacrylate (NBCA), which slightly reduced the flow of the main feeder. The second endovascular treatment session was performed 1 month later via another branch of the main feeder. We inserted a microcatheter into the venous aneurysm through the shunt of the AVM and embolized part of the nidus that involved an aneurysm in the branch of the feeder using coils and a low concentration of NBCA. At that time, flow in the main feeder was reduced and flow in the normal branches of the MCA was moderately improved. One month after the second treatment, right carotid angiogram demonstrated further reduction of the main feeder and normalization of the MCA. Thereafter, we completely removed the AVM without any neurological deficit, and a postoperative angiogram demonstrated extirpation of the AVM without retrograde thrombosis.
There have been some reports of fatal artery occlusion due to retrograde thrombosis after sudden interruption of giant feeders of an AVM. In such cases, it is useful to perform staged therapy by a series of endovascular treatments followed by surgery.

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Between May 2000 and August 2009, we had 5 cases combined with cavernoma and developmental venous anomaly (DVA). In 3 of 5 cases, we removed the cavernoma. Because DVA plays a role in normal venous return, we must preserve the DVA during resection of the cavernoma. We report some surgical considerations to avoid injury of the DVA. In Case 1, a 40-year-old female presented with headache. Magnetic resonance imaging (MRI) showed a cavernoma in the parieto-occipital lobe. We selected a high parietal approach using a navigation system to confirm the location of the cavernoma and DVA. In Case 2, a 70-year-old female presented with cerebellar hemorrhage. MRI showed a cavernoma in the left cerebellopontine angle and DVA at the tentorial surface of the left cerebellar hemisphere. Using the lateral infratentorial supracerebellar approach, the DVA was confirmed and then the cavernoma was removed. In Case 3, a 31-year-old female presented with intracerebral hemorrhage. MRI showed 2 cavernomas in the left frontal lobe. We removed a hemorrhagic lesion by the interhemispheric approach with the horizontal head position. In all 3 cases, the cavernoma was totally removed and the DVA was preserved.

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The treatment goal for cerebral AVMs is mainly to prevent hemorrhage. Bleeding risks of cerebral AVMs depend on several factors such as size/location of the nidus, types of presentation, and angiographical cure does not necessarily mean no risk of hemorrhage. The treatment strategy based on Spetzler-Martin grading is proposed in several guidelines: Grade I, II, and III are a therapeutic target; Grade IV and V should be treated conservatively. According to AHA Scientific Statement, surgical extirpation should be conceded for Spetzler-Martin Grade I and II, and surgical extirpation with preoperative feeder embolization is often effective for Spetzler-Martin Grade III, but single surgical extirpation is not recommended for Spetzler-Martin Grade IV and V. Although low grade AVMs are reported to be amenable to extirpation with low morbidity, patient selection bias seems to reduce estimates of risk.
It is difficult to decide the treatment only by the Spetzler-Martin grading system because of degraded ability of AVM patients to communicate, and wide ranges of risk of hemorrhage and risk of extirpation in each patient. Treatments should be individualized using adequate pre-, and intra-operative assessment of risk.

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Although the introduction of t-PA (tissue plasminogen activator) was considered radical treatment for acute cerebral ischemic disease, the actual number of cases for such administration was limited in Japan for many reasons. One such reason was related to the ability of EMT (emergency medical technician) paramedics to transport patients to the proper hospital for treatment within 2 hours of onset. From this point of view, the Committee of the Prehospital Stroke Life Support (PSLS) of the Japanese Society for Emergency Medicine (JSEM) developed an original standard for prehospital treatment of stroke. In this paper, I provide an overview of PSLS and a half-day practical course, which has been widely disseminated over a short period of time.

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We assess the frequency of periprocedural ischemic complications associated with balloon-assisted coil embolization (BACE) of unruptured cerebral aneurysms and investigate possible risk factors during BACE. Sixty-one aneurysms of 58 patients were included. Thirty-one aneurysms were treated with BACE and 22 aneurysms were treated with conventional coil embolization (CE). No symptomatic ischemic complications were detected in any of the procedures. Asymptomatic ischemic complications were detected in 14 cases of the BACE group (35.5%) and 11 cases of the CE group (50%) on diffusion weighted MRI (DWI), and there was no significant difference.
These results indicate that BACE is a safe and efficient technique for cerebral aneurysms.

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Surgical microscope-integrated near-infrared indocyanine green (ICG) video angiography in cerebrovascular surgery, which has recently made marked advances, has been accepted as a less-invasive, simple, real-time and repeatable technique. Several authors have reported the efficacy of ICG video angiography to evaluate the patency of normal cerebral blood vessels, the perfusion areas of extracranial-intracranial bypass flow and the complete interruption of abnormal blood flow, i.e., arteriovenous shunts. However, its findings have been demonstrated qualitatively in a gray-scale map, and it has been difficult to evaluate decreased vascular blood flow or angiographic circulation time quantitatively. Very recently, the FLOW 800^® system has been developed. This system compiles the information from conventional ICG video angiography into a continuous color-scale map to identify the direction and sequence of vascular blood flow.
In the present study, we assessed the validity of this novel method for cerebrovascular cases including 5-cerebral aneurysm clipping, 3-cerebral arteriovenous malformation (AVM) surgery, 2-carotid endarterectomy (CEA), and 1-moyamoya disease surgery using the Carl Zeiss Surgical Microscope OPMI^® Pentero^® integrated FLOW 800 system (Carl Zeiss Co., Tokyo, Japan). The direction and sequence of ICG fluorescence emitted from vascular blood flow was observed using the INFRARED 800^® system as in the past. Moreover, vascular blood flow dynamics were demonstrated semi-quantitatively in color, using FLOW 800^® system. The variation in blood flow over time was also visualized in each vasculature of interest.
As a result, not only complete obliteration of the aneurysmal sac but the integrity of parent or branching vessels were clearly confirmed in vivid color images in cases of cerebral aneurysm surgery. Furthermore, the time-intensity curve of parent or branching vessels demonstrated a comparative diagram of the blood flow before and after clipping. In a cerebral AVM surgery, ICG video angiography and subsequent analysis of blood flow dynamics demonstrated normalization of the draining venous flow and the complete interruption of arteriovenous shunt in patients undergoing serial injection during AVM resection. In cases of CEA, the extent of carotid plaque and the patent post-sutured carotid artery were vividly demonstrated. In a moyamoya disease surgery, perfusion areas of direct bypass flow from the superficial temporal artery to the middle cerebral artery were clearly demonstrated in color.
Based on these observations, real-time analysis of vascular blood flow dynamics prepared from ICG video angiography may be helpful to perform safe and steady operation in neurovascular cases.

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Cervical carotid artery aneurysms are rare and sometimes induce not only hemorrhage but also ischemic stroke. Various surgical treatments are reported to prevent hemorrhage and stroke. We report the result of endovascular therapies for 4 patients who had large or giant cervical carotid artery aneurysms.
Endovascular therapies were performed for 4 patients and 5 aneurysms, from January 2003 to October 2007. One patient had external carotid artery aneurysm and the other 3 patients had common or internal carotid artery aneurysms. One patient had 2 cervical carotid artery aneurysms.
Case 1 had an external carotid artery aneurysm and underwent parent artery occlusion (PAO); the aneurysm was occluded without any event. Case 2 had an internal carotid artery (ICA) aneurysm and also underwent PAO, but the internal carotid artery showed recanalization 2 days later on magnetic resonance image. Therefore, we added endovascular coil embolization and occluded the aneurysm completely. Case 3 had 1 aneurysm and Case 4 had 2 aneurysms on the common carotid artery (CCA) to ICA. Bare metal stents were deployed, followed by endovascular embolization for 2 aneurysms. One aneurysm in Case 4 on which only stenting was performed completely occluded 1 year after procedure. On 2 aneurysms combined stenting and coil embolization were performed. One was completely occluded, and the other had a tiny flow into the aneurysm, only confirmd by cervical ultrasound examination. No procedural complication or neurological symptoms and signs were recognized during these endovascular procedure.
Endovascular therapy was effective and safe for the cervical carotid artery areurysms. However, the aneurysm sometimes became recanalized, and it is important to treat the recurrent aneurysm.

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Risks of shunt placement during carotid endarterectomy (CEA) include carotid dissection and embolization through the shunt. These rare complications appear to be familiar to neurosurgeons but are infrequently described in the literature. In this report, we describe 2 patients who suffered postoperative carotid stenosis far distal to the operative site. A 68-year-old male with a symptomatic moderate stenosis of the left internal carotid artery (ICA) developed a carotid dissection at the site of shunt placement after CEA. He was successfully treated with carotid artery stenting (CAS). A 77-year-old male with an asymptomatic severe stenosis of the left ICA suffered transient stenosis of the distal ICA due to spasm caused by mechanical stress during shunt placement. As a result of conservative management with clinical and radiologic follow-up, complete resolution of stenosis was observed the day after surgery. In both cases, no apparent neurological deficits were observed soon after CEA. Postoperative angiography can help detect shunt-related complications early.

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We report 2 surgical cases of distal posterior inferior cerebellar artery (PICA) aneurysms and mainly discuss pathological findings. Seventy-one and 61-year-old women experienced a subarachnoid hemorrhage and were found to have fusiform aneurysms showing a pearl-and-string appearance at the distal PICA peripheral to the choroidal point. Both aneurysms were trapped and pathologically examined. The aneurysms show similar pathological findings. The aneurysm walls, which lost both the internal elastic lamina and the vascular smooth muscle layer, had an area of marked fibrous thickening as well as an area of thinning. Infiltration of inflammatory cells, primarily monocytes, was seen localized within the wall of the rupture area. There was no evidence of an acute dissecting aneurysm even though the radiological results are compatible with a dissecting aneurysm. Arteriosclerotic factors can also be excluded because no fat cells or degenerated cells were observed.
In both aneurysms, we speculate, hemodynamic factors in areas where a congenital defect of the internal elastic lamina in the peripheral PICA may have led to aneurysm formation and rupturing.

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