As the aging of society advances and intravascular treatment progresses, we reconsidered the role of craniotomy for patients with subarachnoid hemorrhage (SAH) due to ruptured cerebral aneurysm.

Materials and Methods: A total of 512 patients (age range, 29-96 years; 361 women) with SAH were treated in the last 10 years at our institution. Severity, treatment, outcome, and complications, among other factors were examined in all cases and in radical treatment cases (n=465). The patients were divided into two groups by period, 2007-2011 (n=247) and 2012-2016 (n=265). Craniotomy was the firstline treatment in the first period, but the indications for endovascular treatment expanded in the second period.

Results: Over the course of 10 years, there has been significant progress in the aging of society. Although the distribution of disease severity did not change, the proportion of patients with comorbidities (existing disabilities and complications involving other organs) increased significantly. On multivariate analysis, age, cerebral infarction due to vasospasm, disease severity, and comorbidity were predictors of unfavorable outcomes (modified Rankin scale score 3-6) at discharge.

When the first and second periods were compared, the percentage of patients who underwent endovascular treatment increased from 6.5% to 20%. The frequency of surgical complications was not significantly different between the two periods, at approximately 25%. The overall rate of unfavorable outcomes was unchanged. The outcome was well maintained regardless of aging because patients with comorbidities were mainly treated endovascularly.

Conclusions: The role of endovascular treatment for SAH is increasing. Safety and robustness should be considered when determining which treatment modality should be selected for a particular aneurysm.

From 1864 cases included in the database compiled for a prospective multi-institute study concerning reassessment of World Federation of Neurologiral Surgeons (WFNS) grades, 702 elderly patients (≥65 years old; E group) and 782 younger patients (≤64 years old; Y group) were found to meet the entry criteria for this study (1, open or intravascular surgery for aneurysmal obliteration performed within 72 hours after subarachnoid hemorrhage [SAH]; 2, assessment of severity of symptomatic vasospasm [SVS] was completed using SVS grade [Table 1]). Neurological grade on admission in the E group was significantly worse than that in the Y group, consequently causing a significantly worse overall outcome in the E group. Incidence of SVS was 22.8% in the E group and 22.2% in the Y group, which was not significantly difference between the two groups; however, the incidence of unsuccessful rescue therapy for SVS was significantly higher in the E group (72.5% of cases of rescue therapy for SVS) than in the Y group (44.8%), which strongly indicates the importance of preventive treatment regimens for SVS over rescue treatment after the development of SVS, especially for elderly patients. The usefulness of the SVS grade for precise evaluation of the result of rescue therapy for SVS was identified in this study.

Introduction: The number of elderly patients with aneurysmal subarachnoid hemorrhage (SAH) is increasing with the aging of the population, placing a greater financial burden on the healthcare system. Aggressive treatment produces better outcomes than conservative care, but it is more expensive. The Japanese government has established a Diagnosis Procedure Combination (DPC) protocol that promotes a combination of surgical and conservative treatment for acute SAH patients, but there has been no research on the efficacy of this protocol with respect to patient age. The aim of this study was to compare patient outcomes and costs between patients under 50 years old and those 80 years and older.

Methods and Materials: We retrospectively collected the medical records of 259 consecutive SAH patients who received acute phase surgical treatment and preventive clinical care during the vasospasm period following SAH who had been admitted to our hospital between January 1^st, 2005 and June 30^th, 2017. Patients who received aggressive treatment were then divided into two age groups: those under 50 years of age (n=58) and those 80 years and older (n=21) for a total of 79 patients. The modified Rankin scale (mRS) was used to compare outcomes between the two age groups. Medical bills were used to compare the total cost of treatment between groups.

Results: Older patients tended to have poorer outcomes and higher medical costs than their younger counterparts. In the older age group, 10 cases (47.6%) were mRS 0-2 after treatment compared to 50 cases (86.2%) in the younger group. Older patients tended to enter care with a higher mRS and this may account for the results in our study. Patients 80 years and older spent 5,640,823 yen on average compared to 4.526.911 in the under 50 group. Unlike the prospective payment system of the USA, the Japanese DPC uses a point system that reimburses the hospital based on the procedure and length of stay in the hospital. Older patients tended to have longer length of stays and this contributed to the increased medical costs.

Discussion: Older patients had worse outcomes and spent more on treatment than younger patients. Advanced age does not preclude successful surgery for SAH, rather the initial clinical status is the strongest indicator of future outcomes. Further research is warranted to determine the cause of these differences in outcomes and to determine if aggressive treatment is ultimately the best treatment for patients over 80 years old.

Many middle cerebral artery (MCA) aneurysms tend to be treated with direct clipping rather than coil embolization because of their anatomical characteristics and location. In the surgical treatment of MCA aneurysm, a standard pterional approach and distal trans-sylvian approach are performed. The standard pterional approach can provide wide exposure of the whole M1 segment of the MCA, including IC bifurcation, in which the parent artery is can be easily controlled, while the transsylvian approach may be performed for distally located small MCA aneurysms following a less invasive small craniotomy.

When the sylvian fissure is dissected, the arachnoid membrane should be sharply dissected preserving the pia mater and vascular structure between the frontal and temporal lobes. The counter pressure and choice of correct plane between the sylvian veins are keys to appropriate wide opening of the sylvian fissure. The obliteration of the dome of the aneurysm occasionally needs a combination of multiple clip applications to eliminate the pathological wall from systemic circulation. To prevent perforating artery obliteration and avoid branch occlusion, indocyanine green videoangiography, Doppler ultrasound sonography, and motor evoked potential are useful.

In the case of severe subarachnoid hemorrhage with sylvian hematoma, prophylactic external decompression prevents brain herniation. However, we should pay attention to the risk of paradoxical brain herniation after external decompression when lumbar spinal drainage is placed.

We developed a three-dimensional hollow elastic model of cerebral aneurysm that is useful for pre-surgical simulation. However, a certain amount of time and skill is necessary to fabricate the model. Therefore, we made several improvements to make the process easier. In this article, we describe our improved fabrication method. The original method starts with processing the data of a patient's 3-dimensional (3D) computed tomographic angiography examination and then using a 3D printer to make a plastic (acrylonitrile butadiene styrene: ABS) model. The support material made at the time of molding is then removed and the surface is smoothed. Next, liquid silicone mixed with curing agent is applied to the ABS model. After curing the silicone, the ABS is dissolved with xylene. The following improvements were made to this method later. In early cases, the surface of the ABS was scraped with a knife to smooth it, but a method of dissolving in the organic solvent, e-solb, was adopted. Initially, the model was moved until the silicone cured to prevent dropping caused by gravity. This operation became unnecessary by immersing the model after silicone coating in glycerin aqueous solution. To accelerate the curing, the solution was heated to approximately 50-80°C. We also started using e-solb to promote dissolution of the ABS. As a result, the time for fabricating the model was reduced without any degradation in quality. The model enables a hollow elastic cerebral aneurysm model to be easily and inexpensively manufactured. We believe this model is useful for pre-surgical simulation of cerebral aneurysm clipping and/or coiling. The main disadvantage is that it is difficult to secure an accurate and uniform thickness because the silicone is applied by hand. We hope that 3D printers can eventually make models from very soft materials suitable for blood vessel models.

Objective: Extracranial-intracranial direct anastomotic bypass is an established surgical treatment method for moyamoya disease in adults with an ischemic presentation. Although various procedures, including direct-indirect complex bypass, have been reported, the optimal method is yet to be elucidated. The purpose of this study was to clarify the usefulness of superficial temporal arterymiddle cerebral artery (STA-MCA) single anastomosis, which is the simplest mode of direct bypass surgery without an additional indirect procedure for ischemic moyamoya disease in adults.

Methods: Sixty-four hemispheres of 46 patients with adult-onset (≧16 years) ischemic moyamoya disease who underwent bypass surgery during the recent 3.7 years were analyzed. In all cases, STA-MCA single anastomosis was performed without additional indirect procedures. Perioperative complications, hemodynamic improvement in single-photon emission computed tomography findings (SPECT), extent of angiographic revascularization, and neurological events during the follow-up period (mean ± SD: 773 ± 380 days) were evaluated.

Results: Cerebral infarction and subdural/epidural hematoma were found in 2 (3.2%) and 3 (4.8%) cases, respectively, and 21 (33.9%) cases presented with transient neurological deficits presumably caused by local hyperperfusion. None of the cases showed neurological sequelae at discharge. The cerebral blood flow in the MCA territory showed significant elevation after surgery. In all cases, bypass patency was confirmed using angiography, and the extent of angiographic revascularization was more than two-thirds of the MCA territory in 56 (5%) of the cases and one-third to two-thirds in 38 (7%). The only neurological event that occurred during the follow-up periods was transient ischemic attack in 2 patients.

Conclusion: The present study provides reasonable grounds for choosing simple STA-MCA single anastomosis as the first choice of treatment for adult-onset ischemic moyamoya disease.

Purpose: The benefits of endovascular mechanical thrombectomy in patients with large vessel occlusion involving the internal carotid artery or the middle cerebral artery (MCA) M1 segment have been proven in several recent randomized trials. However, the efficacy of mechanical thrombectomy in patients with distal occlusion of the MCA M2 segment was controversial in these trials. Our study aimed to prove the efficacy and safety of aspiration thrombectomy performed in patients with M2 occlusion using the Penumbra 4MAX aspiration catheter.

Materials and Methods: Our study included 20 participants with acute M2 occlusions who underwent endovascular thrombectomy from January 2014 to February 2018 using Penumbra 4MAX by a direct first aspiration technique (ADAPT). We retrospectively examined the initial National Institutes of Health stroke scale (NIHSS) scores, diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography scores (DWI-ASPECTs), successful recanalization rates [Thrombolysis in cerebral infarction scale (TICI) 2b/3], favorable clinical outcomes [Modified Rankin scale score (mRS) 0-2 at discharge], and intracranial hemorrhage after the procedure.

Results: Twenty patients (13 males) underwent endovascular thrombectomy; their mean age was 71.1±13.1 years (range 39-96 years), mean initial NIHSS score was 18.0±7.3 (range 7-27), and mean DWI-ASPECTs was 7.8±1.5 (range 6-11). Sixteen patients received recombinant tissue plasminogen activator (rt-PA) before endovascular therapy. The successful recanalization rate (TICI 2b/3) was 80% (16/20), and favorable clinical outcomes (mRS 0-2 at discharge) were observed in 70% (14/20). Asymptomatic hemorrhagic infarction was diagnosed in 10% (2/20), symptomatic hemorrhagic infarction in 5% (1/20), asymptomatic subarachnoid hemorrhage in 5% (1/20), and symptomatic subarachnoid hemorrhage in 0% of the patients.

Conclusion: Aspiration thrombectomy using the Penumbra 4MAX catheter might be a safe method, capable of achieving a high rate of successful recanalization and favorable clinical outcomes in patients with M2 occlusions.

We report a case of collaborative treatment using surgical and radiological approaches for a ruptured dissecting aneurysm around the proximal posterior cerebral artery (P1-P2) and the posterior communicating artery. A 37-year-old woman was admitted to our hospital with a severe headache for 3 days. On admission, a computed tomography scan revealed a subarachnoid hemorrhage and a cerebral angiogram showed a dissecting aneurysm involving the proximal posterior cerebral artery (P1-P2) and posterior communicating artery. Although parent artery occlusion was indispensable for complete treatment, it posed the risk of ischemic complications in the right posterior cerebral artery distribution. A preoperative assessment of her three-dimensional digital subtraction angiogram enabled the consideration of a more feasible approach of collaborative treatment using surgical and radiological techniques. A successful outcome was obtained at the right P1 occlusion using coils and by the placement of the superficial temporal artery-posterior temporal artery bypass, followed by proximal clipping of the right posterior communicating artery. She was discharged without any neurological complications after 38 days.

The information obtained from the angiogram was accurate and aided us in determining the appropriate approach to treatment. In this case, collaborative therapy was appropriate. Such procedures may be considered under certain circumstances and collaborative treatment using surgical and radiological approaches may be necessary for anatomically complex diseases.

Detachable-tip microcatheters are widely used for brain arteriovenous malformation (AVM) embolization. They have significant advantages. First, the risk of catheter entrapment with Onyx is low and less tension is needed for detachment of the tip when compared to the retrieval of nondetachable-tip microcatheters, which is associated with a lower risk of vessel rupture during retrieval. Second, long reflux of embolization material is allowed to create a firm plug, which makes it possible to obtain better lesion penetration. Third, the pressure-cooker technique or the transvenous approach using detachable-tip microcatheters has increased the number of AVMs that could be cured by embolization alone. Detachable-tip microcatheter is an indispensable tool for AVM embolization especially with Onyx since the catheter increases the safety and efficacy of the procedure. However, more aggressive embolization may lead to complications. It is always important to analyze the angioarchitecture of AVM thoroughly and discuss the management in a multidisciplinary team to determine the aim and goal of each embolization procedure and to avoid complications.

Background: Intracranial hemorrhage after endovascular revascularization for acute ischemic stroke is associated with a poor outcome.

Case Presentation: An 86-year-old man developed sudden left hemiparesis. He had a baseline National Institutes of Health Stroke Scale (NIHSS) score of at least 16 and showed no improvement with intravenous administration of tissue plasminogen activator (tPA). Cerebral angiography was performed with conscious sedation, which confirmed an occlusion of the superior division of the right middle cerebral artery (MCA). Microcatheter was used to penetrate the MCA during manipulation of the occluded vessel. We performed transarterial embolization with n-butyl 2-cyanoacrylate (NBCA) to treat intraprocedural arterial perforation during acute revascularization therapy. Hemostasis along with patency of parent artery was achieved. Postoperative computed tomography (CT) confirmed no hemorrhagic lesion.

Conclusion: We concluded that embolization using NBCA might be acceptable to be one of the effective hemostatic agents for this purpose.

A vertebral-posterior inferior cerebellar artery (VA-PICA) aneurysm is rare. Although endovascular treatment might be chosen for many patients with VA-PICA aneurysms, neck clipping is still an important and significant treatment for VA-PICA aneurysms because coil embolization carries the risk of PICA occlusion. During craniotomy, the perforator may cause injuries to the dura mater and brain tissues because of the unparallel inner and outer cortices of the occipital bone near the sigmoid sinus. Care should be taken not to damage the large mastoid emissary vein. A large quantity of bone wax for the hemostasis of the mastoid emissary vein may cause sigmoid sinus occlusion. The vertebral and basilar arteries are basically located behind the lower cranial nerves. During the dissection of aneurysms, damage to these nerves should be avoided. Ring clips are also useful in preserving these nerves.