One of the most important factors for successful operation of unruptured aneurysms is preservation of perforating arteries. Various surgical approaches and methods including MEP and ICG monitoring have been reported. However, a basic safe technique of manipulating the clip blade has not been related.
To preserve perforating arteries, it is important to keep the tip of the blade in the visual field until completion of clipping.
I proposed the “blading technique” in order to insert the clip blade with an adequate depth and place. The ideal depth of blade might spare enough of a very thin wall at the bottom of the aneurysm to shut out flow inlet to the aneurysm and avoid damage to perforating arteries.
In this technique, the operator holds an unlocked clip manipulator and clip in hand. With progression of clip blade to a deeper place, the operator manipulates the blade with 3-dimensional movements. The operator lifts up, pulls down, tilts and retracts the aneurysm minutely by the clip blade, continuously keeping the tip of the blade in sight until completion of clipping. Supportive simultaneous movement of suction device with the other hand is also very important to secure the visual field.

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Neck clipping is a well-established treatment for intracranial aneurysms. After neck clipping, there is a low, but considerable, risk of aneurysm recurrence. Treatment of previously clipped, recurrent aneurysms is one of the most difficult procedures in aneurysm surgery. Sharp dissection around the aneurysm is essential, and the previous clip must be removed to ensure complete obliteration of the aneurysm and to spare the perforating arteries.
We have experienced three cases of previously clipped, recurrent intracranial aneurysms. All three patients with recurrent aneurysms had suffered subarachnoid hemorrhage prior to initial neurosurgical treatment. The intervals between the initial clipping and treatment of the recurrent aneurysms were five, 20 and 32 years. Two of the three recurrent aneurysms were located in the middle cerebral artery while the other one was located in the internal carotid artery; all occurred distal to the clip tines. In all three cases, it was possible to expose the entire length of the previous clip and remove it without rupturing the aneurysm, and re-clipping was successfully completed without surgical complications.
Although a single straight clip had been applied during the initial surgery, we now think it is important to completely obliterate this part of the aneurysmal neck, so multiple clips were placed during the second treatment. We report our experience in surgical clipping of previously clipped, recurrent intracranial aneurysms.

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Proper clipping of previously coiled aneurysms sometimes presents various problems. An increasing number of patients are coming for microsurgical clipping either for recurrences, incomplete coil embolization or its complications. Our objective was to assess the surgical management in such patients. We retrospectively analyzed the clippability of recurrent aneurysm using the rate of the aneurysm’s width at the time of coiling (W) to distance from neck to the compacted coils (H) (W/H ratio) and the volume embolization ratio (VER).
Seven patients with recurrent aneurysm underwent microsurgical clipping between 2008 and 2012. Direct microsurgical clipping of aneurysms with W/H ratio ＜2.0 and VER ＜28% proved to be feasible. Higher VER and W/H ratio affect clippability.

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We describe the incidence of the carotico-clinoid foramen, interclinoid osseous bridge, and pneumatization of the anterior clinoid process (ACP) during surgery for an unruptured paraclinoid aneurysm. We retrospectively analyzed a total of 126 sides of 63 paraclinoid aneurysm cases that underwent extradural anterior clinoidectomy using multidetector-row computed tomography to produce 0.5-mm thick scans. The carotico-clinoid foramen was observed in 15.9% of cases (9.5% unilateral, 6.3% bilateral). The interclinoid osseous bridge was observed unilaterally in 1.6% of cases. Pneumatization of the ACP was observed in 27.0% of cases (22.2% unilateral, 4.8% bilateral).
We describe the problems and technical aspects of such cases when performing extradural anterior clinoidectomy.

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We introduce our program for training microsurgical operators in aneurysm clipping. We also discuss risk management of senior operators in surgical training courses for aneurysm clipping. In this program, the neurosurgical resident is assigned to perform clipping for 20 cases of cerebral aneurysm with relatively low surgical risk. The resident must make a detailed preoperative report on head position, skin incision, craniotomy, dissection of fissure and aneurysm, clip type and assumed risks associated with each procedure. A senior operator then examines and approves the report. Intraoperatively, the resident is required by the senior operator to maintain a bloodless operative field and operate under high magnification to confirm safety. The senior operator confirms in a timely manner that the resident is operating according to the operation plan and also is prepared to deal with unexpected situations such as premature rupture of the aneurysm. The senior operator evaluates each technique of the resident, and takes over temporarily when the resident performs a procedure associated with an increased risk of complications.
Between 2007 and 2012, this program had 10 resident participants, five of whom completed it. In this program, temporary deficits were observed in four cases (4.2%); however, no permanent deficits were noted. This program for aneurysm clipping allows safe, effective training of microsurgical operators.

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Cerebral revascularization is indicated for symptomatic chronic common carotid artery (CCA) occlusion. Although a variety of bypass surgeries have been reported, some of them are high-flow bypasses that carry the risk of hyperperfusion. In this article, we report two different low-flow bypass surgeries with radial artery graft, depending on the hemodynamics of CCA occlusion.
Case 1 was an 82-year-old male who suffered right hemodynamic ischemic stroke with a large area of misery perfusion. Because of right distal internal carotid artery (ICA) occlusion, a left superficial temporal artery-right middle cerebral artery bypass was performed using radial artery (RA) interposition graft. This patient had a good outcome.
Case 2 was a 74-year-old male who presented with intractable recurrent right cerebral ischemic stroke. Because the distal internal carotid artery was patent through collateral flow from the vertebral artery, ipsilateral thyrocervial trunk—RA interposition graft—ICA bypass was performed. Even though the bypass was successful, the patient’s outcome was poor due to postoperative cardiac embolism.
Bypasses using distal vessels of smaller caliber as donor pedicles, such as contralateral superficial temporal artery and thyrocervical trunk, can reduce hyperperfusion risk and make the procedure easier. Bypass patient selection and careful perioperative management are critical to obtain good clinical outcomes from these procedures.

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Background: The indication of extracranial-intracranial (EC-IC) bypass surgery is likely to be limited, because the prognosis for ischemic stroke improves with better outcomes with medical therapy. Therefore, to achieve the maximum benefit in selected cases, an individualized surgical plan tailored to anatomical differences and the purpose of the surgery is necessary. We describe our practical application of 3-D multifusion imaging for “tailored” bypass surgery.
Methods: We selected the ideal recipient artery and simulated the craniotomy preoperatively using 3-D multifusion imaging on a general purpose workstation in 13 cases of EC-IC bypass treated in Kokura Memorial Hospital between October 2011 and October 2012. We identified discrepancies between imaging and the actual intra-operative view, and modified the image editing and operative procedure.
Results: In all 13 cases, bypass flow was maintained. There were positional deviations between the simulated craniotomy and the intra-operative view in two cases initially. In another two cases, we could not select the recipient artery because of insufficient visualization of the brain surface. Both problems were correctable.
Conclusion: We accurately identified the recipient artery that we had selected pre-operatively. This technique can be a stepping stone to “tailored bypass” and could be applied to various cerebrovascular surgeries.

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We examined factors related to hematoma growth in 932 consecutive patients with intracerebral bleeding. Eighty-seven (9.3%) of patients had hematoma growth. The ratio of estimated hematoma volume in the second CT versus that in the first CT in patients with hematoma growth was 2.57±2.52 (mean±SD) times (range: 1.12–17.90 times). The modified Rankin Scale (mRS) at discharge in all patients was 0 (22 patients), 1 (33), 2 (90), 3 (182), 4 (149), 5 (371), and 6 (85).
Bivariate and multivariate analyses both showed that the incidence of hematoma growth was significantly higher in patients with internal administration of an antiplatelet drug, those with high prothrombin time-international normalized ratio (PT-INR), and those with concomitant development of liver disorders including hepatic dysfunction. The odds ratio for hematoma growth was 2.78 in patients with internal administration of an antiplatelet drug, 1.69 in those with high PT-INR, and 2.89 in those with concomitant development of liver disorders including hepatic dysfunction, showing that these factors would be closely related to hematoma growth. In addition, the mRS at discharge was significantly poor in aged patients, patients with a low Glasgow Coma Scale (GCS), those with high systolic arterial pressure, and those with concomitant development of renal disorders including renal dysfunction. Especially relevant was the odds ratio of poor mRS at discharge, which was 0.71 in GCS, and 3.52 in those with concomitant development of renal disorders including renal dysfunction. This suggests that these factors are highly related to low mRS at discharge.
When considering the potential development of intracerebral bleeding in the future, it will be desirable to administer an antithrombogenic drug only to patients for which it is essential. Concomitant administration of antiplatelet drugs and anticoagulants should be avoided as much as possible. When patients with concomitant development of hepatic dysfunction and renal dysfunction develop intracerebral bleeding, administration of an antithrombogenic drug should be minimized due to high risks of hematoma growth and poor prognosis.

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Background: Aneurysmal rupture accompanies intraventricular hemorrhage (IVH) in 13% to 28% of cases and can occur with no or slight subarachnoid hemorrhage. Clinical characteristics of such patients as well as their optimal management remain unclear.
Methods: We performed direct surgery for 197 patients with ruptured cerebral aneurysms in the past four years at our institute. Among them, we studied nine patients (5%) presenting mainly with IVH. The patient age ranged from 44 to 83 years (mean 64 years). They comprised of five men and four women. We retrospectively analyzed the method of treatment and clinical results.
Results: The grading scale score before treatment was five in all the patients in WFNS grading and Hunt & Kosnik grading, which was poor in all cases. The site of the aneurysm was the anterior communicating artery in three, the middle cerebral in two, the basilar, the internal carotid-posterior communicating, tip of the internal carotid, and the posterior cerebral artery in one each. To prevent rerupture, aneurysmal clipping was performed in seven patients, including one via the transventricular approach, and coil embolization in one. To control intracranial pressure, ventricular drainage was performed in nine, and endoscopic evacuation of hematoma in one. While cerebral vasospasm was seen in only one patient because of little subarachnoid hemorrhage, the outcome at discharge was generally poor; modified Rankin Scale score at discharge was 3 in four patients, and 4 or more in five. On the contrary, the outcome was favorable when outflow of the cerebrospinal fluid could be obtained without vasospasm.
Conclusions: In patients with ruptured aneurysms presenting mainly with IVH, initial clinical status was severe probably because of the damage at the ventricular wall due to direct arterial pressure on it. Their treatment must include not only prevention of rerupture, but also control of acute hydrocephalus due to IVH. It is important to surgically obtain the outflow of the cerebrospinal fluid rapidly to obtain favorable outcomes.

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The UCAS Japan, the SUAVe Study, and the ISUIA have shown that the indications for surgical or endovascular treatment of unruptured small aneurysms and asymptomatic aneurysms in elderly patients require careful consideration. We describe three cases of intracranial aneurysms not indicated for surgical or endovascular treatment: a 3-mm middle cerebral artery aneurysm in a 36-year-old woman, a 4-mm pericallosal artery aneurysm in a 74-year-old woman, and an 8-mm posterior communicating artery aneurysm in an 83-year-old woman, which had all enlarged in the observation period and finally ruptured. All three patients had two or more risk factors for aneurysm growth or rupture identified by the UCAS Japan or SUAVe Study, indicating that careful follow-up monitoring for morphological changes in the aneurysm is mandatory, even for a small aneurysm, and especially in young patients with such multiple risk factors.
However, surgical indications are limited for elderly patients, even after aneurysm enlargement, so the appropriate treatment for elderly patients requires careful consideration of the clinical condition of the individual patient.

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We report a surgical case of a ruptured distal posterior inferior cerebellar artery (PICA) aneurysm, and the vetebral artery ended as PICA. A 50-year-old female was admitted to our hospital due to headache, vomiting and disturbance of conciousness. A CT-scan showed diffuse SAH, hydrocephalus and massive hemorrhage in the IVth ventricle. CT-angiography revealed a saccular aneurysm at the cranial loop of the left PICA, and the left vertebral artery (VA) was hypoplastic and ended as PICA. Emergency clipping of the aneurysm and removal of the hematoma in the VIth ventricle with a lateral ventricle drainage were performed. The branching vessel and distal VA were not detected in the surgery.

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