In subarachnoid hemorrhage cases with multiple cerebral arterial aneurysms, it is important to identify the ruptured aneurysms. We previously reported the usefulness of the contrast-enhanced motion-sensitized driven equilibrium three-dimensional turbo spin echo (MSDE-3D-TSE) sequence method, which allows vessel wall imaging by visualizing enhancement of ruptured aneurysms at a high rate. The present study examined the usefulness of this method in cases with multiple ruptured cerebral arterial aneurysms. Between September 2011 and September 2014, magnetic resonance imaging (MRI) using the contrast-enhanced MSDE-3D-TSE sequence method was performed before surgery in 22 patients with acute-phase subarachnoid hemorrhage and a total of 53 cerebral arterial aneurysms. Among the 53 aneurysms, 30 (56.6%) showed enhancement of the aneurysmal wall. All 22 ruptured aneurysms showed enhancement. However, 8 unruptured aneurysms also showed enhancement (sensitivity: 100%, specificity: 73.3%). Ruptured aneurysms showed greater enhancement than unruptured aneurysms, and ruptured aneurysms were identified at a high rate. In cases with multiple cerebral arterial aneurysms in which ruptured aneurysms were difficult to identify with conventional methods, the contrast-enhanced MSDE-3D-TSE sequence method was extremely useful.

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Background: Various options that focused on securing all aneurysms using any available technique (endovascular, 1-stage clipping using unilateral or multiple craniotomies, or second-stage clipping) have been advocated for use in the treatment of multiple intracranial aneurysms (MIA). However, surgical management of MIA is still controversial.
Objective: For patients with MIA, our policy has been to treat all aneurysms, ruptured and unruptured, in a 1-stage operation, using multiple craniotomies if necessary, but only when changing of the patient's position is not required. The purpose of this study is to evaluate the safety and effectiveness of 1-stage clipping procedures for MIA.
Patients and methods: From October 2004 to March 2016, we retrospectively identified 92 patients with MIA. Patient characteristics and surgical outcomes for MIA were compared to those of 270 cases with a single intracranial aneurysm (SIA) clipped during the same period at our hospital, as well as 38 MIA cases that underwent 1-stage coiling as reported by Solander in 1999. Data included: age, sex, aneurysmal location and size, preoperative clinical Hunt and Kosnik Grade (H & K), procedure-related complications, symptomatic spasm (SS), infarction due to spasm, and postoperative hydrocephalus. Outcome at discharge was assessed using the Glasgow Outcome Scale (GOS).
Results: Except for age, clinical characteristics of MIA and SIA patients did not differ. One-stage multiple craniotomies for radical clipping of MIA were performed in 20 patients, whereas single craniotomies were performed in 72 MIA patients. The clinical outcomes (GOS) in 92 patients with MIA were as follows: good recovery (GR) 73 (79.3%), moderate disability (MD) 17 (18.5%), severe disability (SD) 1 (1.1%), vegetative state (V) 0 (0%), and death (D) 1 (1.1%). When comparing these cases with SIA patients at our institution, as well as with MIA patients who underwent 1-stage coiling in Solander's study, no difference in overall outcome was observed. In addition, while the risk of surgical complications was significantly higher in MIA patients than in SIA patients, there was no difference in the occurrence of infarction due to spasm or hydrocephalus. Although the occurrence of infarction due to spasm did not differ between MIA and SIA patients, the occurrence of SS in preoperative H & K Grade 3 patients differed significantly between SIA patients and confined MIA patients managed with a single craniotomy rather than one-stage multiple craniotomies.
Conclusions: This study suggests that aggressive surgery, such as 1-stage clipping for MIA, is not associated with negative outcomes. Therefore, we recommend that whenever feasible, all MIA should be treated with a 1-stage operation. However, in terms of spasm, we should balance the benefits and risks of 1-stage MIA clipping using a single craniotomy with greater risk of SS versus SIA clipping in a single craniotomy and MIA clipping in multiple craniotomies, particularly for poor grade subarachnoid hemorrhage patients.

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We report a rare case of ruptured dissecting aneurysm of the right anterior cerebral artery A1 segment associated with multiple unruptured saccular aneurysms, including a left internal carotid aneurysm of the C2 segment, right middle cerebral artery aneurysm, and basilar bifurcation aneurysm. Initial computed tomography and magnetic resonance imaging performed 2 days after the onset failed to reveal subarachnoid clot, necessitating bilateral craniotomy to detect and treat the responsible lesion. All aneurysms were successfully occluded in a two-stage operation. Because of subtle angiographic findings, a dissecting aneurysm of the A1 segment may be overlooked as a cause of subarachnoid hemorrhage, especially in association with multiple saccular aneurysms. As it is sometimes difficult to detect a ruptured aneurysm among multiple cerebral aneurysms despite extensive neuroimaging, surgery is still necessary when a patient presents with subarachnoid hemorrhage.

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Background and purpose: The usefulness of endovascular thrombectomy for acute ischemic stroke has recently been shown in several randomized control trials. We retrospectively analyzed the efficacy of actions to reduce revascularization and treatment times in elderly patients and assessed the difference in treatment times and recanalization rates using different devices.
Object and methods: We reviewed the clinical records of 64 consecutive patients who underwent endovascular thrombectomy for acute ischemic stroke between July 2014 and February 2016. We adopted various approaches to reduce the time to recanalization.
Results: A total of 54 cases (85%) had a thrombolysis in cerebral infarction (TICI) score exceeding 2B. The number of cases with a favorable modified Rankin Scale (mRS) score of 0-2 at discharge was 23 (36%), and there were 6 (9%) deaths. We significantly reduced the arrival to puncture time by approximately 40 minutes, from 113.7 to 74.2 minutes, and the prognosis tended to improve. The puncture to recanalization time was the shortest in the stent retriever alone group, and the rate of TICI 3 was high in this group.
Conclusions: Adopting various approaches to reduce the recanalization time is important for improving patient prognosis. The prognosis in elderly patients tends to be poor; however, the optimal treatment regimen should not be selected according to age because some elderly cases demonstrated a favorable outcome.
The present findings suggest that the use of a stent retriever should be the first choice of treatment for such patients.

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Conventional coil embolization for large carotid cavernous aneurysms (CCAs) is limited because of inadequate ability to prevent recurrence or reduce mass effects. Although trapping of the parent artery may be the most radical treatment, it also has a risk of ischemic complications due to intracranial perfusion disorders associated with external-internal arterial bypass. We present the results of 20 patients with large CCAs successfully treated using a flow-diverter (Pipeline^TM embolic device: PED) and discuss the safety and efficacy of this device.
Twenty patients (19 women), mean age 71.3 years old, with large CCAs greater than 10 mm in maximum diameter, including 4 giant CCAs, were treated with the PED over a period of 3 years. Preoperative dual antiplatelet therapy was administrated and PED deployment over the orifice of the aneurysm with post-dilatation using a microballoon for sufficient stent apposition was performed in all cases. Two patients required multiple telescoping stents. Clinical and radiological evaluation with magnetic resonance imaging (MRI) was performed at 1, 3, and 6 months. Angiographic follow-up was performed at 6 months.
The PED was satisfactorily deployed in all patients. Post-angiogram imaging showed stagnation of contrast with an eclipse sign in 17 cases. One patient with a complex giant aneurysm required 5 telescoping stents and encountered temporary ischemic symptoms due to the complex techniques. Of 15 patients with ocular motor impairment, improvement of symptoms was observed in 11, including 6 with complete resolution of symptoms during 3 to 6 months of follow-up. However, 7 patients demonstrated temporary worsening at 2 weeks postoperatively, with subsequent marked recovery within 3 months. Angiography at the 6-month follow-up showed complete occlusion in 64% (7/11) of patients, and MRI showed reduction of aneurysm volume in 82% (9/11).
Use of a flow-diverter for large CCAs provided clinical and radiological efficacy in all of our cases. Postoperatively, the PED was capable of shrinking aneurysm size and improving symptoms caused by a mass effect, without sacrificing the parent artery. Further analysis and follow-up of these cases will be necessary to verify the long-term results.

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We report herein five cases of symptomatic brainstem cavernous malformations (CM). Specific surgical approaches were designed to directly access each lesion. Neuronavigation and intraoperative monitoring were used. Four lesions underwent gross total resection, and one was subtotally partially removed. None of the patients developed new neurological deficits and all cases showed an improvement based on the modified Rankin Scale and the Karnofsky Performance Status. Although brainstem CM have a relatively high rate of re-bleeding, thus adversely affecting the neurological status of the patient, recent reports have demonstrated favorable outcomes after their resection. Hence, surgical removal can be recommended for cases of symptomatic brainstem CM, particularly those with re-bleeding. An optimal surgical approach, providing direct access to the lesion, is critical for successfully resecting brainstem CM.

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We report a case of ruptured recurrent arteriovenous malformation (AVM) treated with endoscopic evacuation of massive intraventricular hemorrhage (IVH) following radical resection of AVM in the acute phase. A 45-year-old man was transferred to our hospital in coma. He had been treated for a ruptured AVM at the age of 8. Computed tomography (CT) and CT angiography showed massive IVH and intraparenchymal hemorrhage (IPH) in the left temporal and occipital lobes, with abnormal vessels surrounding the hemorrhage. We diagnosed a ruptured recurrent AVM, and initially evacuated the IVH in both the anterior horn and third ventricle using neuroendoscopy. We subsequently removed the residual IPH and IVH and resected the AVM. Neurological symptoms gradually improved, and the modified Rankin scale score was 2 on discharge. Endoscopic evacuation was useful in a case of ruptured AVM with massive IVH.

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We present a rare case of callosal disconnection syndrome caused by rupture of an anterior communicating artery aneurysm (Acom AN). A 51-year-old man with a consciousness disturbance was transported to our hospital. Head computed tomography showed subarachnoid hemorrhage (SAH) associated with thick hematoma in the pericallosal cistern. Three-dimensional computed tomography angiography (3D-CTA) suggested that a forward-projected Acom AN was a potential source of the bleeding. We used a left pterional approach based on these findings. Neck clipping was performed according to the intraoperative finding that the source of the bleeding was a backward-projected Acom AN which could not be seen on 3D-CTA images. On awakening after surgery, the patient had a callosal disconnection syndrome. An Acom AN can rupture in the case of SAH associated with thick hematoma localized to the pericallosal cistern. Surgery should be based on consideration of this possibility in addition to that of a mechanism in which the Acom AN jets backward.

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本誌前身誌「脳卒中の外科研究会講演集」12 巻（1984 年）「超音波ドプラー法による脳動脈瘤手術中の血 行動態に関する検討」p367 の英文氏名の配列に誤りがございましたので，ここに訂正させていただきます．
【誤】 Yoshikazu Okada, Takeshi Shima*, Shigejiro Matsumura*, Masahiro Nishida and Tohru Uozumi
【正】 Yoshikazu Okada, Masahiro Nishida, Tohru Uozumi , Takeshi Shima* and Shigejiro Matsumura*

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