In our country, the onset of subarachnoid hemorrhage is occurring later in life, making the determination of treatment plans for unruptured cerebral aneurysms in elderly patients more important.
Fifty-one of 294 consecutive clipping operations for asymptomatic unruptured cerebral aneurysms less than 20 mm in diameter over the past 11 years were conducted on 50 elderly patients over 70 years old. All these patients were able to maintain independent lifestyles without deterioration in intellectual function or serious medical complications, and had an average hemispheric cerebral blood flow (CBF) of more than 35 ml/100 g/min preoperatively. We evaluated intellectual function using Wechsler Adult Intelligence Scale-Revised (WAIS-R) and frontal lobe function tests, and local CBF changes with SPECT before and after surgery. Long-term prognosis with modified Rankin Scale (mRS) was also assessed in 22 elderly patients who underwent direct surgery more than five years before.
Outcome at discharge in 48 patients was mRS 0 except for two patients with aggravation of renal dysfunction and venous infarction. The latter two patients were assessed at mRS 2. Evaluation of postoperative significant deterioration in intellectual function did not show significant differences between patients over 70 years old and non-elderly patients. Both diffuse hypoperfusion and focal reduction of CBF in ipsilateral frontal lobe were found more significantly in elderly patients (P<0.0001).
Among 21 patients followed more than five years after direct surgery, only one patient died, due to aggravation of renal insufficiency. For an average observation period of 102 months (63–143 months), long-term outcome was assessed at mRS 0 in 18 cases.
Direct surgery has little influence on outcome or intellectual function in elderly patients more than 70 years old when preoperative higher brain function and cerebral blood flow evaluation are considered. These patients can be expected to maintain normal functions as long as any healthy senior citizen.

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Long-term outcomes of the surgically treated unruptured intracranial aneurysms (UIA) are not well known. We conducted this study to clarify the surgical results and the long-term outcomes of the surgically treated UIA.
Seventy-three consecutive patients who were surgically treated and were followed over five years were enrolled in this study. Mean (median) age was 58.3 (59) years. The location of aneurysm was as follows: internal carotid in 32%, middle cerebral in 27%, multiple in 23% and so on. In the aneurysmal size, medium (4–11 mm) was most common (55%), followed by large or giant (12 mm or more) one (16%).
Results: 1) Permanent surgical morbidity was 5.5% and mortality was 1.4% (one case due to fulminant hepatitis). 2) Surgical treatment of the single aneurysm: craniotomy in 57 patients and intervention (GDC embolization) in four. 3) Mean (median) follow-up period was 8.6 (8) years. 4) Regrowth of the aneurysm was observed in one patient (1.4%), and de novo aneurysms were visualized in three (4.5%). 5) Long-term outcomes: modified Rankin scale 0–1 in 65 patients (89%), and six in five (7%). 6) Factors related to outcomes: cardiovascular events were seen in five patients; cerebrovascular in three patients and cardiac in two.
It is concluded that long-term outcomes of UIA were fairly favorable, and cardio- and cerebrovascular events were the main factor related to unfavorable outcome.

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The last 10 years, neuro-endovascular treatment has been widely accepted and is becoming more popular, both because devices have become more developed and because the treatment is supported by evidence.
Our neurosurgical department at Asahikawa Medical University Hospital exists in a city with a population of 360,000. Although the department has had two physicians with Japanese neuro-endovascular board certification for 10 years, both of them were absent for two years (between 2007 and 2009).
We divided a recent 10-year period into two periods: when the endovascular physicians were present and when they were not to investigate clinical activities and practical operations such as the number of treatments, surgical time and number of admissions.
The total number of operations was 1,871. The period when the neuro-endovascular physicians were there (60 months) had 916 cases, and the other periods (78 months) had 955 cases. The number of cases of neuro-endovascular treatment was 145 and 41, respectively. During the period with the physicians, not only the total number of endovascular treatments, but also the average monthly case volume of all neurosurgical operations increased significantly. The surgical time for cerebral aneurysm and cervical carotid stenosis was significantly shorter with endovascular treatment than open surgery.
The existence of neuro-endovascular physicians increases the efficiency of neurosurgical treatment and stimulates department activity.

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Measurement of cerebral blood flow (CBF) is necessary for the management of childhood moyamoya disease. Computed tomography (stable Xe CT) enhanced by three minutes of inhalation of stable xenon is an established method for measurement of CBF. In this retrospective study, we evaluated a decrease in serial scan times in stable Xe CT in childhood moyamoya disease in order to lessen the effective dose.
CBF values obtained by usually performed stable Xe CT were evaluated in 12 patients with childhood moyamoya disease. Clinically, nine serial scans were performed as usual. In this retrospective study, CBF was calculated based on nine serial scans (S9), based on seven serial scans out of the obtained nine serial scans (S7), and based on five scans out of the obtained nine serial scans (S5).
Both S7 and S5 had a significantly simple linear correlation with S9 as follows:
S9=1.642+1.031×S7, S9=2.726+0.983×S5. CBF maps obtained by S9, S7, and S5 were almost identical.
In childhood moyamoya disease, measurement of CBF using stable Xe CT with performance of five serial scans in each slice can be used to lessen the effective dose.

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Subarachnoid hemorrhage with intracerebral hematoma is frequently observed. However, aneurysmal rupture with only intracerebral hematoma is rare. In case of intracerebral hematoma requiring emergency hematoma evacuation, it is very important for establishing operative strategy to determine whether the hematoma resulted from aneurysmal rupture. That is why we analyzed eight cases experienced from January 2007 to July 2010 in our hospital. Four cases were classified as putaminal hemorrhage type. The other four cases were classified as subcortical hemorrhage type. Symptoms in all cases consisted of disturbance of consciousness and hemiparesis as in ordinary intracerebral hematoma. Short M1 and ruptured aneurysm with upward projection were observed in the putaminal hemorrhage type. On the other hand, the average length of M1 and ruptured aneurysm with lateral projection were observed in subcortical hemorrhage type.
During the same period, there were 17 cases of putaminal hemorrhage requiring emergency hematoma evacuation based on the primary diagnosis. Four of 17 cases were due to ruptured aneurysm defined as the putaminal hemorrhage type. Those accounted for 23.5% of “putaminal hemorrhage requiring hematoma evacuation.”
It is important for emergency hematoma evacuation to recognize cerebral vascular abnormalities.

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Treatment of ruptured vertebral dissecting aneurysms involving the posterior inferior cerebellar artery (PICA) still poses a challenge because of the necessity of revascularization of the PICA. Below we report the case of a ruptured vertebral dissecting aneurysm involving the PICA treated with endovascular coil embolization and without a revascularization procedure. A 38-year-old man was admitted to our hospital with subarachnoid hemorrhage caused by a right vertebral dissecting aneurysm involving the origin of the PICA.
A right vertebral angiogram clearly revealed that the entry was at the distal part of the dissecting aneurysm medial-inferiorly, and that the PICA had arisen at the proximal part of the dissecting aneurysm lateral-superiorly in the early arterial phase. Furthermore, it was evident that the contrast medium had moved from the middle to the lower section inside the dissection lumen in the late arterial phase. We embolized the dissecting lumen and entry with coils assisted by flow control of the ipsilateral vertebral artery (VA). Thereafter, we preserved the PICA by framing and filling the coils while maintaining blood flow of the VA. We embolized the distal part of the dissecting aneurysm with coils additionally via the contralateral VA, and we selectively obliterated the dissecting aneurysm finally without employing a revascularization procedure. No post-procedural ischemic event occurred in this case. During the follow-up period, there were no occurrences of rebleeding or ischemic events, and no additional surgical procedures were required. The PICA, which maintained its patency during the procedures, was clearly visible for a long time by magnetic resonance angiography (MRA) examination.
When VA dissecting aneurysms involving the PICA with selective coil embolization and without branch revascularization are treated, it is important to identify the entry. In addition, selective and adequate tight embolization of the dissection lumen and VA is useful during the acute stage, and dose not require revascularization.

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After the International Subarachnoid Trial reported favorable outcomes in a coiling group in treatment for ruptured cerebral aneurysms, we decided to treat ruptured aneurysms by coiling as our primary choice. In this paper, we report our clinical results over the past three years (2008–2011) and discuss the results and limitations of coiling. Of 119 aneurysms, we performed clipping in 54 cases and coiling in 65 cases. Many anterior (Acom) and posterior communicating artery aneurysms were treated by coiling. On the other hand, most middle cerebral aneurysms were cured by clipping in this series. Hospitalization tended to be slightly shortened, and neurological status was slightly better in the coiling group at discharge.
Coiling appeared to be effective in treatment for more than half of ruptured aneurysms. However, in this study, coiling was difficult in a few Acom aneurysms because of their shape and access route up to the aneurysms. Moreover, attention must be paid to rebleeding and retreatment, especially when primary coiling is not done perfectly.

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We describe a technique of a trans-sylvian STA-SCA anastomosis for the vertebrobasilar insufficiency. The procedure utilizes the combined pterional/anterior temporal approach and tentorial edge resection, and anastomosis is performed at the anterior pontmesencephalic segment of the SCA just lateral to the oculomotor nerve. This can provide a wider and shallower microsurgical space than the standard STA-SCA anastomosis via subtemporal approach; however, validation of this procedure is mandatory for it to become an alternative to the routine STA-SCA anastomosis.

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Background: Intima-media thickness (IMT) of the carotid artery can be used to evaluate atherosclerosis of the whole body. Carotid artery endarterectomy (CEA) is a typical treatment for carotid artery stenosis, but a detailed repair mechanism of the operated carotid intima-media site, under medicated cilostazol or aspirin, has not been clarified yet. We therefore started this observational study on temporal changes of the max IMT with particular emphasis on the operated area and report the results of an interim analysis.
Methods and objects: Patients who were free of ischemic heart disease, underwent CEA between June 2004 and April 2008 in our hospital and were medicated with aspirin or cilostazol alone as a postoperative management were enrolled. The max IMT was measured at the common carotid artery (CCA) and internal carotid artery (ICA) in the operated area, respectively, and at the CCA including the operated area after CEA by carotid duplex.
Results: Twenty-two patients and 26 patients were included in aspirin group (Group A) and cilostazol group (Group C), respectively, for the analysis set. In the historical background of patients and the stenosis characteristics, % stenosis rate before CEA and max IMT in all CCA areas after one month of CEA showed significant differences (p=0.039, 0.032, respectively) in the two groups. Not much difference was shown between the two groups on max IMT of the operated CCA area. In the operated ICA area, significant differences between 24–36 months value (p=0.040) in Group A and 1–12 months value (p=0.026) in Group C were shown. In all CCA areas, changing patterns of max IMT produced a significant difference (p=0.011: linear mixed effects model) in the two groups.
Discussion: In Group C, both the max IMTs of CCA and ICA in the operated area characteris-tically reached a plateau after 24 months. On the other hand, they tended to increase through the observation term in Group A. It is thought that this different growth pattern was based on different effects of aspirin and cilostazol in the blood vessel repairing process.
Conclusion: The results of this study suggest that aspirin and cilostazol have different effects on the vascular repair process after CEA or IMT thickening.

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We report two cases of cervical carotid artery dissection that presented neurological deterioration due to middle cerebral artery embolism under anti-thrombosis therapy. Case 1: a 58-year-old man was admitted to our hospital with right ophthalmic pain and minor stroke (NIHSS=2/42). While he was initially treated with anti-platelet and anti-coagulation therapy, he suddenly developed left hemiplegia and disturbed consciousness (NIHSS=25/42) due to tandem occlusion of the middle cerebral artery and the internal carotid artery. The patient was treated by endovascular stent-assisted thrombolysis with subsequent dramatic improvement. The self-expandable stent that was deployed in the dissected carotid artery expanded to maximum size. Case 2: a 59-year-old man was administered anti-platelet therapy for minor stroke (NIHSS=1/42) due to cervical artery dissection. After one week, he developed motor aphasia and right hemiparesis (NIHSS=8/42). Because a recanalization of middle cerebral artery happened immediately, anti-coagulation therapy was added without interventional therapy. The patient showed good recovery (mRS=1), and the carotid artery dissection was revealed to be restored with complete recanalization after three weeks.
Anti-coagulation or anti-platelet therapy has been recommended in the case of carotid artery dissection. It is unclear whether stent-deployment of cervical artery dissection for endovascular thrombolysis is the best treatment or not.

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A dolichoectatic aneurysm is a giant fusiform aneurysm characterized by elongation, tortuosity, and ectasia. It represents 0.1% to 0.7% of cerebral aneurysms, and usually presents with compression of the brain stem or occlusion of penetrating branches; however, there are no reports of acute total occlusion of the basilar artery in a patient with the dolichoectatic aneurysm and no prodromal symptoms. Here, we report a case of a 60-year-old man presenting to our emergency department with acute vertigo and disturbance of consciousness. He had a medical history of hypertension that was being treated with antihypertensives, and had visited another center three years previously for evaluation of vertigo, and was diagnosed as dolichoectatic aneurysm of the basilar artery. As he had no symptoms other than vertigo, antihypertensives were prescribed for blood pressure control. A cranial CT scan revealed a mass lesion adjacent to the right pons. Digital subtraction angiography (DSA) showed accumulation of contrast material in the peripheral segment of the left vertebral artery, indicating total occlusion of the basilar artery. Endovascular treatment was performed, with intra-arterial urokinase injection and mechanical fragmentation of the thrombosis in the occluded segment of the main trunk of the basilar artery. However, it was not possible to reopen the basilar artery and the patient developed cerebellar infarction. We performed immediate surgical decompression and ventricular drainage; however, he died on day 9 after admission.
To our knowledge, this is the first report of acute total basilar artery occlusion in a patient with dolichoectatic aneurysms.

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