The number of elderly patients with subarachnoid hemorrhage has been increasing. In this retrospective study, we aimed to develop guidelines to select patients among octogenarians for surgical clipping of anterior circulation aneurysms. Between Jan. 2001 and Dec. 2010, 3,471 patients were admitted within 72 hours after SAH at 21 participating centers. Of the 3,471 patients, 513 (14.8%) were aged 80–89 years and 75 (2.2%) were over 90 years. Among patients aged 80–89 years, 351 had anterior circulation aneurysms and 68 had posterior circulation aneurysms.
Anterior circulation aneurysms were treated by surgical clipping in 236 patients and by endo-vascular coiling in 48 patients. Favorable outcomes after surgical clipping were obtained in 51 of 95 (53.7%) patients with Hunt & Hess Grades I–II, 21 of 59 (35.6%) patients with Hunt & Hess Grade III, and 8 of 57 (14.0%) patients with Hunt & Hess Grade IV. The proportions of favorable outcome among patients aged 85–89 years were 35.0% in Hunt and Hess Grades I–II and 19.0% in Hunt and Hess Grade III. On the other hand, among patients aged 80–84 years, the rates of favorable outcomes were 58.4% in Hunt and Hess Grades I–II and 44.7% in Hunt & Hess Grade III. The main causes of unfavorable outcome in Hunt & Hess Grades I–II after surgical clipping were delayed ischemic neurological deficits in 18 of 44 patients (40.9%) and surgical procedures in 10 of 44 patients (22.7%).
Our results indicated that surgical clipping for anterior circulation aneurysms is acceptable for 80–89 year-old patients with Hunt & Hess Grades I–II and 80–84 year-old patients with Hunt & Hess Grade III.

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The aim of this study was to analyze technical results and clinical outcomes in octogenarian patients with ruptured intracranial aneurysms treated with clipping or coil embolization. We reviewed the clinical records of 33 patients who underwent clipping or coil embolization for ruptured intracranial aneurysms between February 2003 and September 2012. Among them, 31 patients were female. The aneurysms were located in the anterior circulation in 29 (internal carotid artery: 9, anterior cerebral artery: 12, middle cerebral artery: 8), and in the posterior circulation in 4 (basilar artery: 2, vertebral artery: 2). WFNS grading at initial presentation were as follows: Grade 1: 9; Grade 2: 8; Grade 3: 2; Grade 4: 8; Grade 5: 6.
Twenty-two patients underwent clipping, and 11 patients underwent coil embolization. Twenty-four patients were treated within 72 hours from onset. Clinical outcomes were assessed at three months with the Glasgow Outcome Scale (GOS). Favorable outcome was defined as good recovery or moderately disabled. Technical success was achieved in 32 patients (97%). Procedure-related complications occurred in seven patients (21%), three of which resulted in clinical deterioration. GOS at three months were as follows: good recovery: 5; moderately disabled: 8; severely disabled: 15; vegetative survival: 2. Three deaths occurred, one was procedure-related and two were due to medical complications. Favorable outcomes were significantly associated with lower WFNS grading (WFNS Grade 1) at initial presentation (p＝0.009).
Aggressive treatment of ruptured intracranial aneurysms in octogenarian patients appears to be feasible in patients with mild subarachnoid hemorrhage. Careful patient selection with an interdisciplinary approach may be important to achieve a favorable outcome.

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We report our treatment outcome of patients in the 8th and 9th decade of life who presented with aneurysmal subarachnoid hemorrhage (SAH). We had 31 SAH patients who were older than 80 years. The average age was 87.9-years, and women predominated over men. World Federation of Neurological Surgeons (WFNS) grade was I in one patient, II in four, III in two, IV in four, and V in 20. Nine of the Grade V patients presented out-of-hospital cardiac arrest. Twelve patients were treated for the ruptured aneurysm either with surgical clipping or endovascular coiling. At discharge, three of them were in a good clinical state (modified Rankin Scale 1 or 2). For nine with cardiac arrest and 10 others, the aneurysm was not treated. All patients with cardiac arrest died. Among the others, eight died and two were in poor clinical state (modified Rankin Scale 4 and 5).
In conclusion, most of the SAH patients over 80 years were in poor clinical grade at presentation, and not good candidates for aneurysm treatment. Most of the untreated patients died. On the other hand, one-fourth of the treated ones had good outcome. When we decide the treatment strategies for very old patients, we should be cautious and should also respect the family opinions. But for those who were independent before presentation, aneurysm treatment is a key for survival and good outcome. When the patient is clinically stable, surgical or endovascular treatment and strict postoperative care is an option even for these very old patients.

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To clarify the usefulness of intraoperative monitoring of regional saturation of oxygen (rSO₂), motor evoked potential (MEP) and somatosensory evoked potential (SEP) for carotid endarterectomy (CEA) and indications for internal shunt, we analyzed the results of these monitoring modalities. Twelve consecutive patients (eight men, four women) underwent CEA from January 2010 to July 2013. The mean age of patients was 66.8 years (range, 47–81 years). Intraoperative monitoring of bilateral rSO₂ using near-infrared spectroscopy (NIRS), bilateral transcranial MEP and ipsilateral SEP monitoring was conducted in all patients. The need for shunt placement was determined by a decrease in the rSO₂ value of more than 20% or a decrease of more than 50% in amplitude of MEP or SEP. Six of the 12 patients underwent CEA with internal shunt. In this shunting group, five patients had ≧20% drop in rSO₂, and ≧50% drop in MEP and SEP. In one patient who had no significant change in rSO₂, MEP and SEP, internal shunt was inserted because she had a persistent primitive artery (proatlant artery type 2) from external carotid artery to vertebral artery and required arterectomy of the external carotid artery as well as internal carotid artery. The rSO₂ values and amplitudes of MEP and SEP were unchanged in five out of the six patients who did not have contralateral ICA stenosis and underwent CEA without internal shunt. In one patient who did not have contralateral ICA stenosis, the rSO₂ value could not be measured probably due to a giant frontal sinus. But because the amplitudes of MEP and SEP were unchanged during carotid clamping, the patient underwent CEA without internal shunt. No patients developed perioperative ischemic complications.
Insertion of an internal shunt tube seems appropriate for patients in whom carotid clamping leads to a ≧20% reduction in ipsilateral rSO₂ and a decrease in or disappearance of MEP and SEP amplitude. Insertion of an internal shunt tube appears to adequately restore these parameters.

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Object: Intraoperative monitoring of motor evoked potential (MEP) enables us to detect blood flow insufficiency (BFI) in the anterior choroidal artery (AChA) and the lenticulostriate artery (LSA). We examined the current status and limitation of MEP monitoring to avoid cerebral infarction in the territory of perforating arteries in aneurysm surgery.
Methods: We studied 150 consecutive patients with ruptured (n＝53) or unruptured (n＝97) aneurysms who underwent clipping between September 2009 and August 2012. All patients were fully anesthetized and both transcranial stimulation MEP (TC-MEP) and direct cortical stimulation MEP (DC-MEP) were recorded. The stimulation threshold of TC-MEP was checked at 10-min intervals. The strength of TC stimulation was changed and set at ＋20% of the stimulation threshold because it changed after craniotomy and cerebrospinal fluid (CSF) aspiration. After dural opening, we subdurally inserted a strip electrode with 16 electrodes. The DC stimulation strength was set at ＋2 mA of the stimulation threshold. Electromyograms of the contralateral thenar muscle were obtained. After temporary occlusion of the parent artery or clipping of the aneurysm, both TC- and DC-MEPs were obtained at 1-min intervals until release of temporary occlusion or 20 min after clipping.
Results: While TC-MEP was recorded in all patients, DC-MEP could not be recorded in 18 patients (12%). Although the strip electrode was placed subdurally, in nine patients no recordings could be made at maximal 25 mA stimulation (unknown reasons, n＝7; preexisting hemiparesis (MMT 3/5), n＝2). In another eight patients, we encountered subdural resistance, and one patient presented with a chronic subdural hematoma. The stimulation threshold of TC-MEP was significantly decreased after craniotomy and increased after CSF aspiration. In 143 patients, TC-MEP did not change during surgery; three patients developed transient hemiparesis (MMT 4/5) due to infarction of the genu of the internal capsule. In the other 17 patients, TC-MEP disappeared. In 15 of these, it disappeared after temporary occlusion of the parent artery or aneurysmal clipping but reappeared after release of the temporary occlusion or re-clipping; one patient whose MEP amplitude recovered to 50% of the control developed transient hemiparesis (4/5). Another two patients whose MEP disappeared until the end of surgery developed permanent hemiparesis (4/5).
Conclusions: TC-MEP, which was recorded in all 150 patients, changed in parallel with DC-MEP, suggesting that TC-MEP alone can be used to monitor MEP in aneurysm surgery. A limitation of MEP is that MEP cannot detect BFI of perforating arteries that do not supply the corticospinal tract. MEP is not useful in patients with preexisting hemiparesis. It is unclear to what extent a decrease of amplitude is acceptable, and the degree of postoperative hemiparesis is not predictable in patients whose MEP disappeared. We should understand these characteristics in order to use intraoperative MEP appropriately.

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Flow assessments by indocyanine green videoangiography (ICG-VA) has become common to evaluate cerebral blood flow during vascular surgery. In order to obtain detailed flow information, we have developed a new software named “Flow-Insight” based on the principle of perfusion image processing. In this study, we applied “Flow-Insight” to digital subtraction angiography (DSA) to investigate arrival time (AT), blood volume (BV) and mean transit time (MTT) during endovascular surgery. “Flow-Insight” imported serial DSA data in DICOM format, and calculated integration of a time-intensity curve over time in each pixel for quantitative analysis. We predicted a thrombotic problem by observing delayed BV in a case with an unruptured aneurysm. In addition, several parameters from this application might be reliable predictors, critical alarms and treatment prognosis for endovascular surgery.

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We experienced four cases of ruptured aneurysms arising from the anterior wall of the internal carotid artery (ICA) in the past 12 years. Preoperative 3D-CTA and cerebral angiography showed irregular shaped saccular aneurysms in two cases and small protrusion in the ICA in another two cases. In three of the four cases the tough aneurysmal neck was observed and neck clipping was performed. In one case, a blood blister-like aneurysm was observed and the aneurysm neck and ICA wall were clipped by the root of a fenestrated clip blade. Anterior wall aneurysms of the ICA are classified into the blister type with a blood blister-like configuration or the saccular type (non-blister type) with a relatively tough neck. Saccular type aneurysms can be safely treated by clipping. But it is impossible to distinguish correctly the blood blister-type or saccular type by preoperative 3D-CTA and cerebral angiography. Recently, trapping with an EC-IC bypass has been recommended for ruptured aneurysms arising from the anterior wall of the ICA.
However, we consider that trapping with bypass should not be selected primarily in all cases. Premature rupture should be avoided by gentle maneuvers, minimum brain retraction and subpial dissection of the aneurysm while observing the aneurysm neck in detail. It is important to determine the best treatment: neck clipping, clipping on wrapping, or trapping with EC-IC bypass after careful observation of the aneurysm.

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The optimal timing of surgery for patients with subarachnoid hemorrhage (SAH) has been debated over the last few decades. Recent literature largely advocates “early surgery,” namely within 48 hours after the onset of bleeding, for ruptured cerebral aneurysms. However, early surgery is not always safe for some complicated aneurysms. It can be even hazardous due to the vulnerability of the brain during the acute stage of SAH. Although elective surgery may be a useful option for better surgical outcome for these high-risk aneurysms, the actual risk of postponing surgery in the modern neurosurgical environment has not been well understood.
We retrospectively analyzed the surgical outcome of our patients with SAH between January 2008 and September 2012. Our management policy for SAH is to perform clipping within 48 hours after hospitalization. Among a total of 235 patients with SAH, however, we found 43 patients who were treated after 48 hours from admission for various reasons. We analyzed the characteristics of these aneurysms, reasons for waiting, complications due to awaiting surgery, and outcomes.
Among these 43 patients, the mean waiting period was 11 days (2–69 days, median; 6 days). During this period, we had four cases (9.3%) of rebleeding and three of these four patients died due to rerupture. Other complications included severe pneumonia in three (7.0%), symptomatic vasospasm and hydrocephalus in two (4.7%), respectively. These complications were all successfully treated. The reasons for elective surgery included a tight operating room schedule (23.3%), severe systemic conditions of patients (14.0%), the necessity of high flow bypass (18.6%), the time required for arranging endovascular surgery (14.0%), and elective clipping for aneurysms located in the posterior circulation (4.7%). Symptomatic vasospasm before surgery was observed in two cases (4.7%). Good outcome (GR and MD on Glasgow Outcome Scale) was achieved in 65.2% of patients treated during 3–7 day and in 60.0% of patients treated after seven days or later. The mortality was 11.6%, including three patients with rebleeding.
Although “early surgery” is critical to treat patients with aneurysmal SAH, it is also true that “timing of surgery” is not the only factor affecting the outcome. Our study indicated that elective surgery can be an important option for aneurysms with high surgical risks in the acute phase of SAH under relatively acceptable complication rates and can provide useful data when the elective surgery is carefully planned for those selected cases.

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We report a case of thrombotic giant basilar-tip aneurysm after coil embolization. A 59-year-old man had been treated with coil embolization of a ruptured basilar-tip aneurysm five years earlier. The aneurysm enlarged with a thrombotic component and compressed the midbrain, presenting with bilateral oculomotor palsy and ataxia. We performed re-embolization using a vascular reconstructive device in the hope of inhibiting neovascularization in the intra-aneurysmal thrombus by isolating the residual lumen. At two-year follow-up, the aneurysm had not expanded further and symptoms had not exacerbated.

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During the CEA (carotid endarterectomy) for carotid stenosis in high-risk patients, surgical technical problems and perioperative management problems exist. High-positioned stenosis is one high-risk factor. However, if the distal end of the plaque exists at the second cervical level, CEA is feasible by the usual skin incision with under some conditions: general anesthesia by nasal intubation, lifting up the carotid sheath with fishhooks to maintain a shallow operative field and keeping all manipulation in the carotid sheath, sharp dissecting close to artery to avoid the superior pharyngeal nerve injury, cutting ansa cervicalis in the early operating stage, moving the main trunk of external carotid artery, and using internal shunting systems.
Here, we introduce our surgical technique.

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Endoscopic evacuation of intracerebral hemorrhage has seen significant advances in surgical instruments and techniques. The advantage is a less invasive surgery for a short operation time compared with craniotomy surgery. On the other hand, the main disadvantage is uncertain hemostasis and the potential for postoperative bleeding. To overcome this problem, we employ a unique surgical maneuver involving an endoscopic diving technique that switches between a dry and wet field. This technique, which expands the hematoma cavity by maintaining irrigation by artificial CSF, results in easy identification of small bleeding points and securing hemostasis by observing actively bleeding vessels in a clear visual field. Endoscopic hematoma removal has been positioned as an advanced hematoma removal method using keyhole surgery. Endoscopic diving technique with switching between a wet and dry field can provide safe and effective surgery.
Although more experience is needed to determine whether this technique improves surgical outcomes, the preliminary results are more promising than craniotomy surgery.

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