The vulnerable plaque associated with motion of intraplaque contents plays an important role symptomatic carotid stenosis. Embolic stroke often recurs and can worsen in prognosis. Carotid endarterectomy is mainly selected for the surgical treatment to avoid embolic risk. However, care must also be taken in the surgical procedure to avoid risk.

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Japan now has a large number of centers that can perform magnetic resonance imaging. Further, the brain check-up system has also improved considerably. Thus, many unruptured intracranial aneurysms (UIA) have been diagnosed recently, and some of these are treated in an evidence-based manner. However, with the increase in the diagnosis of UIA, cases of rupture of UIA are supposed to be increasing.
To test this hypothesis, we compared cases of rupture of UIA with subarachnoid hemorrhage (SAH) treated at Tokyo Dental College Ichikawa General Hospital between January 2002 and December 2006 (the early period) with those between January 2007 and December 2011 (the latter period). UIA was previously diagnosed in 1 of 100 SAH cases (1.0%) in the early period and in 11 of 132 SAH cases (8.3%) in the latter period. This difference was significant.
We evaluated the following risk factors in patients with rupture of UIA in both groups: UIA location, size, bleb, UIA multiplicity, history of hypertension, habit of smoking, and family history of SAH. Most patients in both groups had several of the evaluated risk factors, and all cases of rupture occurred in female patients in the both periods. On the other hand, two patients in the latter group presented with only one risk factor.
Our results suggest that the number of cases of rupture of previously diagnosed UIA have increased recently. To prevent the occurrence of rupture, we recommend that female UIA patients with several risk factors be treated with the obliteration of UIA. Further, clinicians should be alert to the risk of rupture in patients with only one risk factor, and periodic follow-up might be essential for such cases.

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We examined cases in which cerebral aneurysms ruptured during the follow-up period. From 1993 to 2010, we encountered 14 such cases, and the mean age of the patients was 62.6 years (age range, 39–81 years; M: F＝8: 6). Nine cases were incidental, three were associated with ruptured aneurysms and two were symptomatic. Five cases involved the anterior communicating artery (A-com); four, the middle cerebral artery; three, the internal carotid artery; and two, the basilar artery. The size of the aneurysm at diagnosis ranged from 1 to 33 mm, and 50% of the aneurysms were smaller than 5 mm; moreover, 80% of the A-com aneurysms were smaller than 3 mm. The mean latency period to rupture was 22.3 months (ranged 13 days to 53 months), and in five cases (35%), the ruptures occurred within one year. Seven patients who had World Federation of Neurological Surgeons (WFNS) Grade I–IV hemorrhage survived after discharge, while seven patients of WFNS Grade V died. In nine patients in whom the morphological change could be assessed, the mean growth rate of the size of the aneurysm was 1.9. In our study, many of the ruptures occurred in the early years of the follow-up, and this suggests that the interval of follow-up with 3D-CTA or MRA should be shorter in the early period after aneurysm detection.

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Cilostazol, a selective inhibitor of phosphodiesterase 3, is a peripheral vasodilator and an anti-inflammatory agent and causes antiplatelet aggregation; therefore, it may help attenuate vasospasm after subarachnoid hemorrhage (SAH). Statins are known to have pleiotropic vascular effects, some of which may interrupt the pathogenesis of delayed neurological deficits following SAH. We evaluated the effects of administration of both cilostazol and atorvastatin in preventing cerebral vasospasm following SAH in 216 patients treated with surgical clipping three days after SAH between 1999 and 2011. The patients were classified into two groups: 139 controls (Group A) and 46 patients (Group B) who received 200 mg/day cilostazol and 5 mg/day atorvastatin from postoperative Day 2 to Day 14. As a result, the incidence of vasospasm as observed on angiography, symptomatic vasospasm, and new cerebral infarction due to vasospasm as observed on CT were apparently lower in the cilostazol and atorvastatin group than in the control group. Cilostazol and atorvastatin may be able to prevent vasospasm; however, simultaneous investigations in multiple institutions are required to further understand and clinically apply these drugs.

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To evaluate the efficacy and safety of intermittent intracisternal urokinase (UK) injection therapy used in combination with arachnoid plasty (AP) on subarachnoid clot clearance (SCC), we retrospectively analyzed serial computed tomography (CT) findings in 40 patients presenting with Fisher Group 3 subarachnoid hemorrhage (SAH) from ruptured intracranial aneurysms in anterior circulation. SCC was evaluated using average CT number and the Hijdra CT scoring system for each basal cistern. The average clearance rate (CR) on postoperative Day 4 exceeded 80% in most areas of the basal cistern whereas in areas where residual clots were mainly observed (distal sylvian- and interhemispheric fissures), CR was approximately 50 to 60%. The incidence of symptomatic vasospasm (SVS) [total (T)-SVS＝17.5%; irreversible (I)-SVS＝7.5%] was lower than in our historical controls during the past three years (2004–2006) (T-SVS＝31.0%; I-SVS＝23.8%) and reported observations (T-SVS＝29.0–32.0%).
Despite inherent technical limitation, our protocol for UK injection with AP is simple and labor-saving. Data in the present study suggest that our protocol is an effective approach for early SCC at least in and around the basal cistern, and that it may be of value in preventing SVS when employed in combination with other multimodal therapeutic approaches.

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Clipping surgery for an anterior choroidal artery aneurysm (AChAN) is associated with a high risk of ischemic complications, because the anterior choroidal artery (AChA) supplies critical territories, such as the internal capsule. We retrospectively analyzed 40 patients (age range, 34–79 years; mean age, 55.3 years old), comprising 11 males and 29 females, with AChAN who were treated in our institution between 1998 and 2010. Clipping surgery was performed for 24 ruptured and 16 unruptured aneurysms. Aneurysm size ranged from 3 to 12 mm (mean, 5.2 mm). Surgery was performed with higher priority given to the AChA than to the complete neck clipping. None of the patients experienced infarct in the AChA territory. The modified Rankin scale score at discharge was 0–1 in 38 patients (95%). Residual neck, confirmed by postoperative angiography, was identified in 20% of the aneurysms, which is higher than that seen with usual aneurysmal neck clipping. However, none of the patients had rebleeding or regrowth during the follow-up period (mean, 10.6 years; range, 2–14 years).
Monitoring with motor evoked potentials, micro-Doppler, indocyanine green videoangiography, and endoscopy may help reduce the risk of ischemic complications.

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We describe the treatment of ruptured vertebral artery dissecting aneurysms (VADAs) involving the posterior inferior cerebellar artery (PICA) and elucidate an association between the vascular territory of the PICA and the changes in aneurysmal morphology after endovascular proximal occlusion (PO).
We treated five cases of ruptured VADA involving the PICA by endovascular PO just after angiography on the day of onset. We classified the PICAs into two types: PICAs that bifurcated into the medial and lateral trunk (Type A) and PICAs that did not bifurcate and supplied only a small area (Type B). We then compared changes in aneurysmal morphology after PO by contralateral vertebral artery angiography.
Three Type A PICAs and two Type B PICAs were assessed. In the three Type A cases, a whole aneurysm was observed just after PO. These aneurysms had increased in size 1–2 weeks after PO in two cases but remained unchanged in the third case. In all three cases, an occipital artery-PICA bypass and PICA clipping were performed during the subacute stage. In the two Type B cases, the aneurysms were partially observed just after PO, but 1–2 weeks later, the aneurysms were not apparent and no further treatment was required.
After PO during the acute stage of ruptured VADA involving the PICA, the aneurysms with Type A PICAs were more likely to remain; therefore, additional treatment with PICA revascularization and PICA clipping should be planned for such cases. However, for aneurysms with Type B PICAs, no additional treatment was required.

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Accessory anterior cerebral artery (accessory ACA) is a type of median artery of anomalous triplicate ACA. Aneurysmal formation at accessory ACA is extremely rare. We report a case of ruptured fusiform aneurysm at the anomalous bridging vessel connecting lt. A2 and accessory anterior cerebral artery. A 32-year-old female presented with severe headache. Neurological examination was normal. Computed tomography showed diffuse subarachnoid hemorrhage. Left carotid angiography demonstrated the aneurysm arising from the anomalous bridging vessel. The shape of the anomalous bridging vessel looked like an aneurysm originating from lt. A2 and the dome attaching to the accessory ACA. We performed trapping for the fusiform aneurysm at the anomalous bridging vessel. The patient was ambulatory on discharge.

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We report a case of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass for rapid deterioration of visual acuity due to retinal ischemia in a patient with chronic internal carotid artery occlusion.
A 72-years-old male suffered pain in the right eye that was diagnosed as neovascular glaucoma caused by ocular ischemia due to right internal carotid artery occlusion. Brain perfusion single-photon emission tomography imaging revealed normal cerebral blood flow and reduced cerebrovascular reactivity to acetazolamide in the right cerebral hemisphere. He was treated with medication and his symptom resolved. Five months later, a pain in the right eye recurred and intraocular pressure was abnormally elevated. Visual acuity in the right eye rapidly deteriorated during six days. Cerebral angiography showed retrograde blood flow of the right ophthalmic artery toward the right internal carotid artery. Antegrade blood flow to the right retina and right choroid retinal blush were not visualized. The patient underwent an urgent STA-MCA bypass when visual acuity in the right eye was light perception. The visual acuity was postoperatively improved and was 0.32 at four months after surgery. Postoperative cerebral angiography showed reduction in retrograde flow of the ophthalmic artery to the internal carotid artery and perfusion of the right central retinal artery by the collateral flow via the external carotid artery. The right choroid retinal blush was also visualized.
STA-MCA bypass for retinal ischemia due to chronic internal carotid artery occlusion may improve decreased visual acuity.

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A 36-year-old man in normal health presented with giant aneurysm of the right VA manifesting as subarachnoid hemorrhage. The left VA was occluded, and a balloon occlusion test (BOT) of the right VA was positive. The patient was treated with aneurysmal trapping and high flow bypass (EC-RA-V4 bypass). The patient suffered from acute epidural hematoma on eight days after the surgery. Intraoperative observation revealed that the arterial bleeding was from the RA, so hemostatic suture was performed. After the surgery, the RA-VA bypass was occluded. He died of brain stem infarction 22 days after surgery.
Although the outcome of this case was poor, we think that EC-RA-V4 bypass remains an important option in similar cases.

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In our acute stroke care center, we sometimes encounter problems of deep vein thrombosis (DVT), a problem that has been increasing in recent years. There is presently consensus regarding the treatment for urgent cases of DVT, but there is no established policy regarding non-urgent cases. We reviewed the therapeutic courses of the three cases (of which two were symptomatic and the other asymptomatic) in which the stroke patients had a complication of DVT in our facility.
The first case was a 61-year-old male, who developed atherothrombotic stroke and was administered with intravenous treatment with tissue plasminogen activator. During the course, the patient was found out to have pain and swelling in the paralyzed lower leg. DVT was found, and anticoagulant treatment was administered, followed by inferior-vena-cava (IVC) filter detention. The second case was a 79-year-old female, who developed atherothrombotic stroke and was administered with anti-coagulant treatment. Respiratory discomfort was observed, and a detailed examination revealed she had a complication of pulmonary embolism (PE) and DVT. After the immediate IVC filter detention, additional anticoagulant treatment was administered. The third case was an 81-year-old male who underwent conservative treatment for brain hemorrhage. D-dimer rose during the course, and a detailed examination revealed a thrombus in the pulmonary artery and the vein in the paralyzed leg. Although he had no symptoms, elastic stockings were used to prevent PE, and anticoagulant treatment was administered.
DVT has been reported about 10 percent of the patients hospitalized in rehabilitation hospitals, and it is important to detect asymptomatic DVT in stroke patients with paralysis at an early stage. Urgent cases in which PE and symptoms in lower legs are observed can be treated with IVC filter and catheter, for example. But asymptomatic DVT often goes unnoticed, and there is no consensus on its treatment. We suggest that anticoagulant treatment and the use of elastic stockings are effective in treating DVT.

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