Sugita cerebral aneurysm clips were developed in Japan by Nagoya University professor Kenichiro Sugita. Since 2007, 123 types of the Titanium Clip II have been released. It is difficult for even an experienced neurosurgeon to understand the appropriate use of all the clips. Market research indicates that the straight type and bayonet type are the most commonly used clips. Improper use is due to lack of familiarity with the various clips. Detailed knowledge is necessary to achieve optimal clipping.

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To identify safe and appropriate surgical approaches, we analyzed our experience with posterior cerebral artery (PCA) aneurysms (ANs), and reviewed the literature. We encountered 3 patients with PCA ANs. Two had ruptured ANs, and the third case had an unruptured PCA AN associated with a ruptured anterior communicating artery AN. The locations of the 3 PCA ANs were the P1, P2a, and P2p segments, respectively. All patients had saccular ANs and underwent direct surgery. The anterior temporal approach was selected for the P1 and P2a ANs. For the P2p AN, we initially selected a transchoroidal fissure (trans-CF) approach via the left inferior temporal gyrus. With this approach, exposure of the AN was difficult, as it was located well below the anterior choroidal artery. We then switched to a subtemporal approach intraoperatively to expose the AN. Neck clipping was successful for all the PCA ANs, and there were no complications. P1 and P2a ANs are safely accessed by an anterior temporal approach. A subtemporal approach is suitable for a low-positioned P2p AN; however, a high-positioned P2p and the anterior part of a P3 AN are candidates for a trans-CF approach. The choice of an appropriate surgical approach depends on the segment of the PCA; however, these ANs can be safely treated with direct surgery.

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Aneurysms of the A1 segment of the anterior cerebral artery (A1 aneurysms) are rare and challenging to treat. Two important points are related to the surgical treatment of A1 aneurysms. First, saccular A1 aneurysms are often small, but close to vital perforating arteries. The perforators are commonly attached to the aneurysm dome. The second issue relates to the fact that A1 aneurysms often present as dissecting or fusiform aneurysms that usually involve perforators. We reviewed 4 surgically treated cases of A1 aneurysms, of which 3 were ruptured and 1 was unruptured. The operations were performed by one surgeon (J.I.) from April 2009 to April 2015. The cases comprised 2 saccular A1 aneurysms, of which one was a fusiform A1 aneurysm and the other was a dissecting A1 aneurysm. Neck clipping was performed in 2 cases of saccular A1 aneurysms, causing no neurological deficit. The dissecting A1 aneurysm was trapped surgically, resulting in cerebral infarction in the territory of the perforating arteries. Proximal clipping was performed for the fusiform A1 aneurysm. Fusiform A1 and dissecting A1 aneurysms are special subgroups that require tailored surgical strategies because of the high risk of perforators being damaged. We report a series of 4 patients with A1 aneurysm, focusing on the surgical strategies, with a review of the literature.

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Background: The decision to treat unruptured aneurysms (uANs) includes an analysis of the natural history, risks of treatment, and potential benefits of a lifelong cure for each patient. With the increase in average life expectancy and widespread use of magnetic resonance imaging (MRI), it is estimated that the number of uANs diagnosed in elderly patients will increase. However, outcomes associated with surgical and endovascular treatments for uANs in elderly patients remain unclear.
Objective: The aim of this study was to assess the outcomes in elderly patients with asymptomatic uANs who underwent either clipping or coiling.
Methods: In this retrospective study, 17 consecutive elderly patients (age ≧ 75 years) with asymptomatic uANs underwent clipping or coiling at our institution between April 2010 and March 2015. The clinical (Glasgow Outcome Scale at discharge) and postoperative radiological results in this group were compared with a group of younger patients with uANs (< 75 years, n=93), and with consecutive patients with concurrent subarachnoid hemorrhage (SAH) due to ruptured aneurysms: ≧ 75 years (n = 18) and < 75 years of age (n = 101).
Results: A total of 17 patients ≧ 75 years of age (average: 79.8 years, range 75-85) with a total of 20 asymptomatic uANs were treated with either surgical (n=10) or endovascular procedures (n=8).
In contrast with the overall results in patients with SAH (older patients fare worse than their younger counterparts: good recovery, 22% vs. 56%, respectively), posttreatment neurological deficits in patient with uANs were more common in the younger group (< 75 years old, 5%) than in the older group (≧ 75 years old, 0%); however, there was no statistical difference. On the contrary, the posttreatment occurrence of chronic subdural hematoma in the elderly (16.7%) was more common than in the younger group (1%), and the difference was significant.
Surgically treated elderly patients with uANs had a significantly longer hospital stay than elderly patients who underwent endovascular treatment (25.7 days vs. 5.3 days).
Moreover, among all surgically treated patients with a good neurological outcome, increased age was associated with an increased length of hospital stay. In contrast to the surgically treated group, the length of hospital stay in the endovascular treatment group did not vary with age.
Conclusion: Endovascular and surgical treatments for uAN in patients ≧ 75 years old appear to be feasible and safe.
With regard to safety and length of hospital stay, coiling is a better method than clipping for elderly patients with uAN.

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Objective: Most cerebral ischemic attacks in moyamoya disease are attributable to hemodynamic ischemia caused by hypoperfusion. However, in our experience with moyamoya disease, we have encountered several cases of cerebral infarction of an apparent embolic nature. These cases are presented in this manuscript.
Patients and methods: Since January 2003, 165 patients with confirmed moyamoya disease have been registered in the moyamoya disease database of our hospital. The initial disease type was cerebral infarction in 36 patients (21.8%), transient ischemic attack in 67 (40.5%), cerebral hemorrhage in 36 (21.8%), cerebral infarction and hemorrhage in 1 (0.6%), headache in 13 (7.8%), asymptomatic in 11 (6.6%), and epilepsy in 1 (0.6%). Four patients with cerebral infarction that was apparently embolic in nature were evaluated retrospectively.
Results: The median age of the four patients was 66.5 years (range: 62-84 years). Three (2.9%) of the patients showed cerebral infarction as the initial type of moyamoya disease, and the other patient, who had a bypass surgery 15 years prior, had cerebral infarction on the opposite side this time. Occlusion was present in the posterior cerebral artery of three patients and the anterior cerebral artery of one patient. The patients with occlusion of the posterior cerebral artery had a large infarction extending to the territories of the posterior and middle cerebral arteries. The patient with occlusion of the anterior cerebral artery had severe ischemia bilaterally in the territory of the anterior cerebral artery and on the affected side in the territory of the middle cerebral artery, but recanalization was soon achieved. Cardiogenic embolism was observed in all four patients. Although all four patients had atrial fibrillation, three of them were given antiplatelet therapy. Anticoagulant therapy was given to one patient.
Conclusions: Although rare, cerebral infarction of an embolic nature in moyamoya disease tends to be wide ranging because of the associated acute occlusion of the collateral vessels. Anticoagulant therapy may be appropriate, but poses the risk of intracranial hemorrhage. Further research is needed on anticoagulant pharmacotherapy for preventing stroke in moyamoya disease complicated by atrial fibrillation.

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In the field of vascular surgery, contrast-enhanced imaging using iodinated contrast media (ICM) is essential in determining the diagnosis and therapeutic strategy. However, in a few patients, contrast-enhanced imaging is contraindicated because of hypersensitivity against ICM or thyroid disease. We present two cases of direct surgery for cerebrovascular disease without using ICM in the preoperative evaluation. The first case was that of a 72-year-old woman who had a history of moderate allergy to ICM. She had transient weakness of the right upper extremity. Magnetic resonance (MR) images showed left intracranial internal carotid artery stenosis and multiple cerebral infarctions. Her symptom persisted despite antiplatelet therapy, and follow-up MR images revealed aggravation of the left-sided cerebral infarction. We performed left superficial temporal artery-middle cerebral artery anastomosis. After the operation, her symptoms disappeared. The second case was that of a 71-year-old woman with a history of severe ICM allergy. She presented with right-sided weakness, and MR images showed left internal carotid artery bifurcation stenosis. She underwent carotid endarterectomy for the prevention of recurrent cerebral infarction. We could perform treatment on schedule and found no perioperative complication in the 2 cases. By using multimodality evaluations, we could perform safe and secure surgery in the patients with hypersensitivity against ICM. Tailor-made decision on whether direct surgery should be performed with or without contrast medium examination is necessary for patients with hypersensitivity against ICM.

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The purpose of this study was to evaluate the efficacy of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). Between April 2006 and April 2014, a total of 57 patients with carotid artery stenosis underwent CEA in our institution. Among them, 7 patients (12.3%; 5 males, 2 females; mean age 74.9 ± 4.5 years) with significant coronary artery disease underwent combined CEA and CABG. Three patients had symptomatic stenosis, with mean degree of stenosis of 71 ± 20% according to the North American Symptomatic Carotid Endarterectomy Trial method. Although one patient (14%) developed postoperative recurrent nerve paralysis, and another patient (14%) died due to postoperative intra-thoracic hemorrhage, technical success had been obtained in all 7 patients without any peri-operative neurological or cardiac complications. It is well known that 30% to 40% of patients with carotid stenosis have coronary artery disease. When CABG is performed in cases of significant carotid stenosis, the risk of perioperative stroke increases. One of the approaches to solve this problem is combined CEA and CABG. Though it might a need longer time for surgery and carries a higher risk of surgical bleeding compared with a single surgery, it can decrease both neurological and cardiac ischemic complications. In our experience, combined CEA and CABG is a preferred surgical approach for high-risk patients.

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Background: Surgical clipping is considered the primary option for ruptured small aneurysms (s-AN; 3 mm or less), because coiling has been associated with a relatively high risk of procedural error. With the advent and development of coiling techniques and materials, several studies showed that coiling of a ruptured s-AN can be performed with acceptable risk. However, the best management strategy for a ruptured s-AN remains unknown.
Objective: The aim of this study was to assess the outcomes of ruptured s-ANs in patients who underwent surgical clipping, and to identify the clinical characteristics of these aneurysms.
Patients and Methods: In total, 237 patients who presented with aneurysmal subarachnoid hemorrhage (SAH) between April 2008 and March 2015 were evaluated. Aneurysms were classified as small (≤3.0 mm), medium (3.0 mm ≤ 12.0 mm), large (12.0 mm ≤ 25.0 mm), and giant (≥25.1 mm), based on their largest dimensions. Various factors were analyzed, including the preoperative Hunt and Kosnik grade and Fisher groups, the aneurysmal location, multiplicity, and procedural complications. Clinical outcomes were assessed using the Glasgow Outcome Scale (GOS) at the time of discharge. In the case of multiple aneurysms, we identified the ruptured aneurysm based on its bleeding pattern on computed tomography (CT) or on surgical findings.
Results: In 28 (11.8%) of 237 patients, an s-AN was identified as the lesion responsible for the SAH. The most frequent site of a ruptured s-AN was the anterior communicating artery. In a comparison with larger aneurysms, ruptured s-ANs were significantly more common in the pericallosal artery, internal carotid-anterior choroidal artery, and vertebral-posterior inferior cerebellar artery bifurcation, but less so in the middle cerebral artery. There were no procedure-related complications during the clipping of ruptured s-ANs. The clinical outcomes (GOS) of 28 patients with ruptured s-ANs were as follows: good recovery (GR) 17 (60.7%), moderate disability (MD) 6 (21.4%), severe disability (SD) 0 (0%), vegetative state (V) 1 (3.6%), and death (D) 4 (14.3%). Thus, the overall outcomes of ruptured s-ANs were significantly better compared with outcomes of larger aneurysms: GR 106 (50.7%), MD 48 (23.0%), SD 18 (8.6%), V 7 (3.4%), and D 30 (14.4%). In 43 (18.1%) of 237 patients, multiple aneurysms were identified. The largest aneurysm had not ruptured in 10 (23.3%), and an s-AN had ruptured in 6 (14.0%) of the 43 patients with multiple aneurysms.
Conclusion: Surgical clipping for ruptured s-ANs was not associated with procedural complications, but the overall outcomes were similar to those reported for coiling. Considering its ability to identify correctly the rupture site in cases with multiple aneurysms, surgical clipping remains an invaluable treatment strategy.

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Anastomosis of the superficial temporal artery (STA) to the middle cerebral artery is useful for internal carotid occlusion cases. However, in the case of common carotid artery (CCA) occlusion, another bypass strategy should be sought because of insufficiency of STA blood flow. Various bypass strategies have been reported for common carotid artery occlusion, but no report describing a systematic surgical strategy has been published yet. We report five cases of symptomatic CCA occlusion treated with arterial grafts. In each case, the donor artery was determined according to the patency of the ipsilateral external carotid artery (ECA) and vertebral artery (VA). Consequently, all the cases were treated with vascular reconstruction successfully, and the symptoms disappeared postoperatively. Thus, categorization of CCA occlusion according to the patency of the ipsilateral ECA and VA could guide decision making regarding the appropriate bypass strategy systematically, even with approximately 20-cm arterial grafts.

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The treatment strategy for ruptured bilateral vertebral artery dissection (VAD) is still controversial. We report two cases of ruptured bilateral VAD successfully treated with conservative and surgical treatments. Case 1 was that of a 48-year-old man who had a left occipital headache from 1 week before admission. On the day of onset, he had a severe sudden headache at the right occipital lobe followed by loss of consciousness. Head computed tomography (CT) on admission revealed subarachnoid hemorrhage (Fisher group 3), dominantly in the right prepontine and ambient cistern. Cerebral angiography revealed bilateral intracranial VAD. The right VA showed dilatation, and the left VA showed a string sign. We considered that the VAD ruptured on the right side, based on the CT image. As severe stenosis occurred in the left VA, we decided conservative therapy as a treatment strategy for case 1. The stenosis of the left VA was normalized 4 weeks after onset. The patient underwent ventriculoperitoneal (VP) shunt at the same period. The right VA dilatation was stable. Finally, the patient had no neurological deficit and was discharged 56 days after onset.
Case 2 was that of a 55-year-old woman who had a right occipital headache a week before admission. The headache worsened, and she was brought to our hospital in an ambulance. Head CT performed on admission revealed subarachnoid hemorrhage (Fisher group 3), dominantly in the right prepontine and sylvian fissure. Cerebral angiography revealed bilateral intracranial VAD. The right VA showed a pearl and string sign, and the left VA showed dilatation with wall irregularity. We considered that VAD ruptured on the right side based on the CT image. As right VA angiography revealed that the perfusion territory of the right anterior inferior cerebellar artery (AICA) covered the posterior inferior cerebellar artery (PICA), we performed proximal clipping of the right VA. The postoperative course was good, and the left VA stenosis was normalized at 1 month after onset. The patient underwent a VP shunt at the same period. He was discharged 60 days after onset without any neurological deficit.
We successfully treated two cases of ruptured bilateral VAD. For deciding on an appropriate strategy for this disorder, the dominancy of VA, the dissection type such as dilatation or stenosis, the collateral flow from the posterior communicating artery, and the perfusion territory of PICA and AICA should be considered in each case.

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We report two cases of surgical repair of iatrogenic common carotid artery penetration of a hemodialysis catheter. One case was that of a 65-year-old man with chronic renal failure who had a misplaced hemodialysis catheter in the right common carotid artery. The catheter was removed immediately, and manual compression over the skin was applied to the injured site of the artery. Angiography revealed a pseudoaneurysm in the right common carotid artery. The patient underwent repair of the lesion under general anesthesia. A hole with a diameter of 4 mm was intraoperatively observed at the anterior wall of the right common carotid artery. The hole on the wall was sutured without inspection of the intima. Postoperative diffusion-weighted magnetic resonance imaging revealed acute ischemic lesions in the right frontal lobe. Postoperative angiography revealed an intimal flap in the anterior wall of the right common carotid artery. The other case was that of a 65-year-old woman with a misplaced hemodialysis catheter in the right common carotid artery, which caused nausea and vertigo. Diffusion-weighted magnetic resonance imaging revealed acute ischemic lesions in the right cerebellar hemisphere and left occipital lobe. Angiography revealed accidental placement of a catheter in the right common carotid artery. The patient underwent repair of the lesion under general anesthesia. A hole with a diameter of 4 mm was intraoperatively observed at the anterior wall of the right common carotid artery. Arteriotomy was additionally performed for inspection of intimal flaps, which were then trimmed. Postoperative diffusion-weighted magnetic resonance imaging revealed no additional abnormal lesions. Postoperative angiography revealed smooth arterial walls of the right common carotid artery. These findings suggest that when surgical repair is performed for patients with iatrogenic common carotid artery penetration of a hemodialysis catheter, the intima of the arterial wall is often dissected by the force of the catheter insertion. Thus, arteriotomy should be added, and the dissected intima should be trimmed to prevent artery-to-artery embolism.

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