The incidence of postoperative chronic subdural hematoma (CSH) after clipping surgery for unruptured intracranial aneurysm (UIA) is reported to be in the range of 1.8–13.3%. Recent reports revealed that an increase in subdural fluid collection (SFC) during the first postoperative week is a significant risk factor for CSH after UIA surgery.
Accumulating evidence from various studies indicates the potential benefit of arachnoid plasty in the prevention of SFC/CSH after surgery for intracranial aneurysms. In addition, Gorei-san, a Kampo medicine that exerts a hydragogue effect through aquaporins, has been suggested as a useful option for conservative management of CSH in which symptoms are either absent or minimal. Here, we retrospectively analyze the effects of arachnoid plasty and Gorei-san on the prevention and management of postoperative CSH after clipping surgery for UIA.
Between January 2008 and December 2012, 42 patients underwent clipping surgery for UIA in anterior circulation using front-temporal craniotomy. Arachnoid plasty was performed immediately after UIA clipping. Four patients (9.5%) developed CSH after the surgery. In one case, a head injury during the postoperative period caused CSH. By excluding this case, the true incidence of postoperative CSH in our study was 7.1%, which was consistent with data shown in previous reports of case series without arachnoid plasty. The previous reports, however, included symptomatic cases and cases requiring surgical intervention. In contrast, all CSH cases in the present study were asymptomatic and improved without surgical treatment. Among the four CSH cases, three received Gorei-san during the postoperative period.
Preventive administration of Gorei-san was started in 10 patients who showed increasing SFC in the postoperative period (1–2 weeks). In nine of the 10 cases, SFC diminished in one to two months. The remaining case developed CSH, which was eventually cured with conservative management.
Symptomatic cases of CSH after UIA surgery often require surgical evacuation. Data in the present study suggested that intraoperative arachnoid plasty in combination with Gorei-san administration in cases that show increasing postoperative SFC or evidence of asymptomatic CSH might help prevent such detrimental complications.
Further studies are required to clarify the precise effects of this therapeutic approach.

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Although the 2009 guidelines for the treatment of cerebrovascular disease indicate carotid endarterectomy (CEA) as a first-line treatment for patients with carotid stenosis, carotid stenting (CAS) has been performed about twice as often as CEA. Reasons for this finding may include: 1) a lack of surgeons familiar with CEA; 2) scarcity of teaching systems for CEA; and 3) medical or social tendencies toward performing less invasive surgery. However, the number of CEA surgeries has not decreased over the last decade. Indications for CEA or CAS should be determined according to the condition of the patient and the technical skills of the surgeon. Favorable factors for CEA include: 1) unstable plaque; 2) plaque with ulcer; 3) plaque with floating thrombus; 4) plaque with severe calcification; 5) excessively tortuous access route; 6) patients who are considered at excessive risk of needing to stop antiplatelet therapy in the future.
To keep CEA as an effective surgical option, surgeons should perform CEA with a complication rate ＜3% and a low restenosis rate, and should create teaching systems for CEA surgeons.

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Cerebral revascularization bypass surgery in a deep corridor is challenging. Successful revascularization depends not only on anastomosis technique but also on the setting of the operative field. In this article, we describe detailed preparation specific to deep bypass surgery to help developing neurosurgeons start performing this operation. We discuss sufficient exposure of the recipient artery, aspiration of excessive cerebrospinal fluid, optimal preparation of the donor artery, and proper choice of operative instrument.

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The preservation of perforating arteries is important to gain a favorable outcome in surgery for cerebral aneurysms. At our hospital, factors relating to difficulties in preservation of these vessels are analyzed in a video. There are several technical solutions to related surgical problems.
1) proximal clipping or aneurysm trapping
2) dome clipping to decrease aneurysm volume
3) special dissection technique in case of tight adhesion between perforator and aneurysm
4) neck clipping technique without detachment of perforator adhesion
5) dome cutting for obtaining better perforator blood flow
These solutions can lead to a good outcome in cerebral aneurysm surgery by producing a better preservation rate of the perforator.

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We assessed the safety and efficacy of combined endovascular coil embolization of ruptured anterior communicating artery (Acom A) aneurysms and endoscopic surgery for intracerebral and/or intraventricular hematomas.
We reviewed 20 consecutive patients treated by endovascular coil embolization for ruptured Acom A aneurysms and analyzed initial WFNS grade, Fisher grade, aneurysm size, dome/neck ratio, periprocedural adverse event, symptomatic vasospasm, cases of hydrocephalus requiring shunt operation, mRS at six months after onset, and recanalization that required additional treatment.
Initial endovascular therapy was successfully accomplished in every case. Combined endovascular coil embolization and endoscopic intracerebral and/or intraventricular hematoma were selected in four cases. Periprocedural thromboembolic events were observed in three cases, without definite adverse effects on clinical outcome. One patient died due to elevated intracranial pressure one day after the treatment. Symptomatic vasospasm was observed in one patient. Shunt operations were required in three cases. Fourteen patients (70%) had good or excellent outcomes (mRS≦2) at six months after onset. Follow-up angiography was performed at six months after the treatment in all cases, and recanalization was observed in four aneurysms.
Endovascular coil embolization for ruptured Acom A aneurysm is safe and effective. Combined endovascular therapy and endoscopic surgery for intracerebral and intraventricular hematoma seems promising for improving patients’ prognosis.

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Confirmation of blood flow in the arteries around the aneurysm is crucial in aneurysm surgery. Although intraoperative fluorescence video angiography is useful for this purpose, the limited observation field under a microscope makes it difficult to confirm blood flow in the arteries behind the parent arteries or the aneurysm. We developed intraoperative endoscopic indocyanine green (ICG) video angiography to overcome this weak point of microscopic fluorescence video angiography, and used it in nine patients with cerebral aneurysms. During clip placement, the endoscope was inserted to confirm aneurysm occlusion. Then, fluorescence video angiography was performed to observe blood flow via the endoscope as well as the microscope. The blood flow in the perforating arteries was clearly demonstrated in all but one case in which the adequate placement of the endoscope was difficult because of the optic nerve. There was no complication related to the procedure.
In conclusion, the technic is very useful and facilitates intraoperative real-time assessment of patency of the perforating arteries behind parent arteries or aneurysms.

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Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis prevents cerebral ischemic attack by improving cerebral blood flow in patients with moyamoya disease (MMD). STA-MCA anastomosis is generally recommended for adult MMD patients with ischemic symptom, but its efficacy for elderly patients is unclear.
Among 144 consecutive cases with MMD undergoing STA-MCA anastomosis with pial synangiosis in 197 hemispheres, nine patients (10 hemispheres) were over 60 years old (mean 63.5 years old). The incidence of surgical complications including infarction and cerebral hyperperfusion (CHP) was compared to those of the patients under 60 years old.
In nine elderly patients undergoing revascularization surgery for 10 hemispheres, the incidence of symptomatic CHP was as high as 30% (3/10), and two of the three patients developed intracranial hemorrhage in the acute stage. One patient developed cerebral infarction at the remote area during the blood pressure lowering against CHP (10%, 1/10). The incidence of symptomatic hemorrhage due to CHP was significantly higher in elderly patients (20%, 2/10) compared to younger patients (1.6%, 3/187) (p＝0.0101). Regarding final outcome of elderly patients, seven patients showed improvement of modified Rankin Scale, and two temporarily deteriorated but recovered to the preoperative status three months after surgery.
Elderly patients with MMD may potentially have a higher risk of intracranial hemorrhage due to CHP compared to younger patients. Surgical indication should be carefully decided for elderly MMD patients, and intensive peri-operative management is essential to avoid surgical complications including CHP and ischemia.

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While the number of elderly patients who presented with aneurysmal subarachnoid hemorrhage (SAH) has been increasing, its optimal management in that population remains controversial. Therefore, we retrospectively reviewed the treatment outcomes in 49 consecutive patients aged between 80 and 94 years who presented with SAH.
The neurological World Federation of Neurological Surgeons (WFNS) grade at the time of admission was Grade I in 7, Grade II in 11, Grade III in 8, Grade IV in 13, and Grade V in 10 patients. Of the 49 patients, 28 underwent coil embolization, and 7 (25%) had a favorable outcome (mRS: 0–2) at discharge, while in 21 (75%) the outcome was poor (mRS: 3–6). Six patients underwent clipping; the outcome was favorable in one patient (17%) and poor in 5 (83%). Of 15 patients under conservative therapy none had a favorable outcome. A low WFNS grade (I–II) was significantly associated with a favorable outcome (p＜0.05).
Although the treatment outcome in elderly patients with SAH was poor, radical treatment of ruptured aneurysms should be considered if their WFNS grade is low.

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We report two cases that showed giant waves in motor evoked potential (MEP) after carotid artery occlusion and discuss the significance of this phenomenon. During carotid endarterectomy (CEA), MEP and somatosensory evoked potential (SEP) are monitored to determine the use of intraluminal shunting in our department.
The first case was a 68-year-old male. An MEP giant wave appeared three minutes after carotid artery occlusion, while the amplitude of SEP decreased about 50%. After shunting, the MEP amplitude recovered and maintained recovery until the end of surgery. The SEP amplitude showed a decrease of up to about 10% even with shunting but recovered at the end of surgery. The second case was an 80-year-old male. An MEP giant wave appeared four minutes after carotid artery occlusion, while the amplitude of SEP decreased about 50%. After shunting, the MEP amplitude recovered and maintained recovery until the end of surgery. The SEP amplitude showed a decrease of up to about 70% but recovered at the end of surgery.
In early ischemia, excitability of pyramidal neurons increases because of cell depolarization due to calcium influx, and the transmission of inhibitory neurons is decreased. These changes cause an increase of the MEP amplitude. We were able to detect early ischemic changes by observing an MEP giant wave.
An MEP giant wave after carotid artery occlusion is a warning sign of ischemia even if such a waveform is recorded. Reperfusion should be achieved as soon as possible because MEP giant waves indicate ischemic intolerance.

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Patients presenting with angiographic demonstration of missing main trunk of middle cerebral artery (MCA) from the vicinity of its origin and multiple plexiform arterial networks along the normal route of M1 segment of MCA have been reported as “Spontaneous middle cerebral artery occlusion with moyamoya phenomenon (MCAO-Mo),” MCA aplasia/dysplasia, or twig-like MCA. It has been suggested that such vascular conditions are distinct from moyamoya disease and degenerative steno-occlusive diseases of MCA such as atherosclerosis. More recently, aplastic or twig-like MCA (Ap/T-MCA) has been proposed as a term that comprehensively defines a diagnosis for such anomalous conditions.
We recently experienced a pediatric case of Ap/T-MCA presenting with intracerebral and intraventricular hemorrhage, which was successfully treated with ventricular drainage and conservative management for Ap/T-MCA. Since this juvenile case had neither angiographic findings that suggested arterial dissection nor a medical history that might cause such a cerebrovascular condition, this case would support the above-mentioned putative congenital etiology of Ap/T-MCA.
We also summarized the data from reported cases of MCAO-Mo and Ap/T-MCA, and evaluated their clinical/radiological characteristics and disease, including eight pediatric cases, to identify characteristics findings for these anomalous conditions that might point to an optimal therapeutic approach.

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A 74-year-old woman presented with dysphagia, hoarseness, dry cough and deep pharyngeal pain that persisted and gradually progressed despite medication and nerve block anesthesia. A CT scan showed an unusually tortuous left cervical carotid artery that compressed and displaced the trachea and esophagus. Surgery was conducted to shorten the common carotid artery by resection of a 2-cm segment and to transpose the tortuous cervical internal carotid artery. Immediately following surgery, the patient’s pre-operative symptoms resolved.
Tortuous cervical carotid artery is a rare cause of both specific and non-specific pharyngeal and laryngeal symptoms. Transposition and shortening of the tortuous artery is effective in reducing or eliminating the symptoms for cases in which the tortuous artery is identified as the cause of the symptoms.

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