Ruptured blister-like aneurysms (BBA) originating from the internal carotid artery (ICA) are known to present several challenges in treatment such as difficulties of clipping, intraoperative rupture, and postoperative rebleeding. We experienced 7 cases of ruptured BBA originating from the ICA treated with a definite strategy in the past 3 years at our institution. In this paper, we report our treatment strategy and surgical results.
We treated 7 cases between the ages of 35 and 60 years, including 3 males treated in the acute stage. Our treatment strategy is basically trapping of aneurysms with STA-proximal MCA anastomosis or high-flow bypass, a strategy that depends on the cross-flow through the anterior communicating artery. Following EC/IC bypass, we confirmed whether trapping of the aneurysm was possible or not. If intraoperative motor evoked potential (MEP) decreased or disappeared during tentative occlusion of ICA, we treated aneurysms with wrap-clipping.
Six cases were successfully treated with trapping of BBA following STA-proximal MCA anastomosis. Wrap-clipping was performed in 1 case due to reduction of MEP after occlusion of the ICA at the proximal portion of BBA. Although there were no surgical complications, 2 cases suffered symptomatic vasospasm. The outcome at 3 months after the onset was 5 mRS0, 1 mRS1, 1 mRS3.
Our treatment strategy achieved favorable clinical outcomes: 6 of 7 cases were able to be treated with trapping with STA-proximal MCA anastomosis without clipping difficulties, intraoperative rupture or postoperative rebleeding. On the other hand, 2 of 6 cases treated with trapping with STA-proximal MCA anastomosis suffered symptomatic vasospasm. Therefore, more attention must be paid to vasospasm.

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While the radicality of resection for cerebral arteriovenous malformation (AVM) is superb, it is regarded as a difficult type of neurosurgical operation. One reason for this is the risk of uncontrollable intraoperative hemorrhage. Preoperative embolization or staged operations are conducted to avoid this. We examined recent cases at our hospital.
Among 124 cases of AVM treated at our hospital between January 2005 and June 2010, complete resection was conducted in 90 cases. We examined the operative procedures and outcomes of these 90 cases retrospectively. The Spetzler-Martin grade (S-M grade) in the 90 cases was 1-2 in 45 cases, 3 in 35 cases and 4 in 10 cases, with no cases of Grade 5. Preoperative embolization was conducted in 33 of the 90 cases (37%), while a staged operation was conducted in 12 cases (13%). In the cases with S-M Grade 3-4 (45 cases), preoperative embolization was conducted in 25 cases (56%) and a staged operation was conducted in 12 cases (27%). The outcome was undesirable in 0% of S-M Grade 1, 4% of S-M Grade 2, 11% of S-M Grade 3 and 30% of S-M Grade 4. Uncontrollable intraoperative hemorrhage did not occur in any of the cases.
Although examination of the individual cases is necessary, the recent outcomes at our hospital demonstrate the utility of preoperative embolization and staged operations for high-grade AVM.

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Carotid endarterectomy (CEA) is a standard treatment for the internal carotid artery stenosis, but the routine use of internal shunt tube during CEA is controversial. The carotid bifurcation of Japanese is reported to be higher than that of Europeans. Therefore, it is somewhat difficult to insert the internal shunt into the internal carotid artery. The purpose of this study is to clarify the usefulness and feasibility of using a guide-wire to insert an internal shunt tube into internal carotid artery.
Between 2007 and 2009, 24 CEAs for 24 consecutive patients with internal carotid artery stenosis were performed in our institute. We routinely used an internal shunt tube. Twenty-two CEAs were performed using the internal shunt tube. Internal shunt tubes were not used for 2 near-occlusion CEA cases. For 11 of the CEAs, we used a 3.5-inch guide-wire to insert the internal shunt tube. We compared the time required to insert the tube in the guide-wire group and the without guide-wire group. The average time required for the guide-wire group was 6.8 minutes, and the without guide-wire group required 9.5 minutes. The guide-wire group required significantly (P<0.05) less time than the without guide-wire group.
We consider using a guide-wire during the insertion of the internal shunt tube for CEA to be useful.

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Carotid endarterectomy remains an effective procedure despite the introduction of carotid artery stenting. We have established a simple but sophisticated protocol for surgery, management of patients, and education of surgeons to prevent perioperative complications. Using our treatment strategy and education system, we performed 422 CEAs on 372 patients as the first-line choice for carotid artery stenosis between 2002 and 2009. Four experienced surgeons performed 121 procedures, and 15 inexperienced surgeons performed 301 procedures. Surgical morbidity and mortality rates within 1 month were 1.6% and 0%, respectively, for the experienced surgeons, and 1.4% and 0.2%, respectively, for the inexperienced surgeons. Our results are acceptable compared with other clinical studies.
The defined procedural protocol, including thorough systemic control, especially prevention of ischemic heart disease, and an education system reduce surgical morbidity and mortality rates, even for inexperienced surgeons.

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We evaluated the prognosis of patients 6 months after a brain-stem hemorrhage, based on clinical findings obtained at admission and 1 month after commencement of rehabilitation.
Seventeen patients who were admitted to our hospital during the past 2 years with a brain-stem hemorrhage were evaluated at admission and 1 month later, based on the National Institute of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM), modified Rankin Scale (mRS), motor paralysis, sensory disturbance, ataxia, blood pressure, and swallowing. To retrospectively examine these evaluation items, the patients were divided into 2 groups: patients who became ambulatory within 6 months (Group A) and patients who did not become ambulatory (Group B).
Significant differences were confirmed between groups regarding NIHSS, FIM points, motor paralysis, sensory disturbance, and ataxia at admission and regarding motion capability and mRS at 1 month. At admission, Group A had NIHSS of ≤8.5 (lower limit: 16), FIM of ≥60.7 points (24 points), motor paralysis of Stage IV or higher, and normal to mild sensory disturbance. Moreover, they could retain the sitting position within 1 month, with mRS of Grade 3 or higher (Grade 4 or higher), which indicates their motion capability. Many patients with severe ataxia became ambulatory.
Based on these findings, 6-month recovery of patients with brain-stem hemorrhage could be determined based on their achievements at 1 month.

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In many cases of anterior choroidal artery aneurysms (IC-AChA An), anterior choroidal arteries (AChA) arise from the aneurysmal neck or dome. This is an important reason for a higher rate of surgical complications. We treated 29 cases of IC-AChA An between January 2006 and May 2010, and classified them based on the origin of AChA by retrospective investigation of preoperative 3D-DSA. Cases in which AChA mainly arose from internal carotid arteries were classified as Group 1, those from the aneurysmal neck were classified as Group 2, and those from the aneurysmal dome were classified as Group 3. Thare were 3 cases (10.3%) in Group 1, 21 cases (72.4%) in Group 2 and 5 cases (17.2%) in Group 3. The average of dome /neck ratio was 1.22. Clipping was performed with indocyanine green (ICG) videoangiography in 27 cases and motor evoked potential monitoring (MEP) in 18 cases. There were no ischemic lesions in MRI or neurological dysfunction after surgeries in any of the groups. In 3 of 18 cases with MEP—1 in Group 2 and 2 in Group 3—the amplitudes decreased. In 2 of the 3 cases, ICG videoangiography showed good blood flow. We should keep in mind that ICG videoangiography is not quantitative. ICG videoangiography is very useful, but MEP is routinely needed. Group 1 and Group 2 cases about 90% of all cases, require careful modification of the origin of AChA in clipping.
Understanding the origin of AChA using 3D-DSA before surgery is very important to realize good surgical results.

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The natural history of intracranial arterial dissection (ICAD) is not known precisely, so that treatment strategy is hard to determine in some cases. We examined the clinical features, treatment and long-term outcomes in the ICAD of ischemic onset.
Among 214 consecutive patients with ICAD [199 in the vertebrobasilar system (VBs) and 15 in the internal carotid system (ICs)], 76 presented with brain ischemia. Those were classified into 2 groups: 63 in the VBs and 13 in the ICs. We analyzed age, site of dissection, progression or recurrence of ischemia, medical and surgical treatment, and long-term outcomes. The outcomes were evaluated by modified Rankin disability scale (mRS). Good outcome was defined as mRS 0 to 2.
Results: 1) The patients were younger in the ICs (mean: 44.8 years) than in the VBs (mean: 53.0 years). 2) The vertebral artery was mostly affected in both arterial systems. 3) The acute stage progression or recurrence of ischemia was observed in 37% of the VBs and 54% of the ICs. The progression or recurrence is more frequent in the patients of the VBs with antithrombotic therapy (p=0.0224). 4) Treatment: Medical treatment was performed in 94% of the VBs and in all of the ICs. In addition, antithrombotic agents were prescribed in 38% of the VBs and in 85% of the ICs. Four patients (6%) of the VBs were surgically treated because of enlargement of the aneurysmal dilatation on follow-up study of MRI/MRA or 3D-CT angiography. 5) Long-term outcomes: In the medical group, good outcomes were achieved in 77% of the VBs and all of the ICs. In the VBs, the patients with antithrombotic therapy had poorer outcomes than those without the therapy (P=0.0399). All the patients in the surgical group had good outcomes in the VBs.
These results suggest that antithrombotic therapy might lead to the progression or recurrence of ICAD and a poorer outcome. This therapy should be selected prudently in the ICAD of ischemic onset, especially in the VBs.

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We analyzed the outcome of 62 consecutive patients with unruptured intracranial aneurysm treated by surgical clipping. Thirty-one cases were operated without intraoperative monitoring, 17 cases with indocyanine green videoangiography (ICGA), and 14 cases with electrophysiological monitoring (EPM) in addition to ICGA. Complete obliteration of the aneurysm was confirmed in all 62 cases. Diffusion-weighted imaging of MRI disclosed no ischemic lesions after surgery in any of the cases. Asymptomatic venous infarction was detected by CT study in 2 cases. Cranial nerve palsy occurred in 4 cases but EPM could not detect it. There was no difference among the group without monitoring, the group with ICGA and the group with ICGA and EPM. The mortality and morbidity of all cases was calculated as 0% and 6.5%, respectively.
ICGA appeared to be useful in surgery for aneurysms encasing perforators or for repair of problems such as premature rupture. EPA seemed effective in surgery for anterior choroidal artery aneurysms or aneurysms requiring trapping before clipping. However, monitoring would not have been effective without extensive dissection of aneurysms, suggesting that basic microsurgical techniques are crucial for successful surgery.

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We planned carotid artery stenting (CAS) with “seat belt and air bag” technique for a patient of symptomatic post-radiation pseudo-occlusion of the right cervical internal carotid artery (ICA) in the chronic stage because of an artery-to-artery embolic episode in the sub-acute phase. During the CAS procedure, the right ICA was found to be totally occluded. Neither the left ICAG nor the left vertebral angiogram (VAG) could demonstrate the retrograde opacification of the right ICA below the C2 portion. A 4Fr. catheter was navigated to the cervical C1 vertebral level beyond the occlusion point, where arterial blood was aspirated. However, contrast injection from the catheter seemed risky because a large thrombus may have existed in the ICA above the C1 vertebral level. Left VAG with simultaneous aspiration from the catheter placed in the right ICA under flow reverse condition (named “retrograde injection and suction method”) retrogradely depicted a clean right ICA from its cavernous to cervical portion. This information confirmed us to pass the guidewire across the long occluded lesion safely, leading to a successful CAS of a totally occluded ICA.

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We report a case of cerebral infarction in the internal capsule following a resection of AVM in the trigone of the left lateral ventricle fed by the anterior choroidal artery. A 61-year-old man presented with mild right hemiparesis and seizure. He had had an AVM in the trigone of the left lateral ventricle since 37 years before, and had experienced a seizure and cerebral hemorrhage. Cerebral angiography showed an AVM of Spetzler-Martin’s Grade 2 fed by the anterior choroidal artery in the trigone of the left lateral ventricle. An operation was performed by the transcortical approach using a former hemorrhagic cavity. The left anterior choroidal artery feeding the nidus was cut in the left lateral ventricle, and AVM was removed together with a choroid plexus.
Right hemiparesis worsened postoperatively, and MRI revealed cerebral infarction in the left internal capsule.
Although it is thought that the cutting of the anterior choroidal artery in the lateral ventricle is safe, care should be taken when cutting the anterior choroidal artery even in the lateral ventricle because the branch(es) originating from the plexal segment of the anterior choroidal artery could penetrate to the cerebral parenchyma and feed the internal capsule.

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We report a case of a ruptured accessory anterior cerebral artery (AccACA) aneurysm in a 77-year-old man suffering from intracerebral hemorrhage in the right frontal lobe. Angiography demonstrated a triplicated anterior cerebral artery and an aneurysm located above the corpus callosum growing from the distal portion of the AccACA. The aneurysm was clipped by direct surgery and he was discharged without neurological deficit. AccACA are not so rare, but cases of AccACA aneurysm are extremely rare.
In introducing this case, we discuss AccACA and AccACA aneurysm.

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