A long-term study of 43 patients with aneurysms at the posterior communicating artery (PCoA) that had resulted in subarachnoid hemorrhage (SAH) was carried out. Twenty-nine of them survived for more than six months after common carotid ligation following SAH, and the other 14, who were conservatively treated, survived for more than six months after the last SAH, which had occurred before admission. In 22 of the patients, long-term follow-up was discontinued because of death (due to rebleeding or other causes), but all the remaining 21 patients are still in the follow-up study. The mean period of follow-up was 15 years and one month. The shortest period of follow-up was one year and the longest 22 years. Fatal rebleeding was observed in one (fatal rebleeding-rate 5.3%) of 19 patients who had had total ligation of the common carotid artery. Rebleeding was observed in six (60%) of 10 patients who had had partial ligation, and fetal rebleeding was later observed in five (fatal rebleeding-rate 50%) of these six patients. Rebleeding was observed in six (43%) of the 14 conservatively treated patients, and fatal rebleeding was later observed in five (fatal rebleeding-rate 36%) of these six patients.
Judging from the results of this study, it was certified that total ligation of the common carotid artery for ruptured PCoA aneurysms controls rebleeding more effectively than partial ligation or conservative treatment.

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Neck clipping is technically difficult in some cases of intracranial aneurysm. Cervical carotid ligation and coating of an aneurysm have been employed as an alternative method in such patients.
One of the four cases that had undergone cervical carotid ligation in our hospital developed subarachnoid hemorrhage eight years after surgery and was found to have multiple aneurysms including three in the contralateral carotid and one in the basilar system.
If carotid ligation plays a role in the contralateral aneurysm formation due to hemodynamic changes in the cerebral circulation, it should at least be avoided for younger patients.
Extracranial and intracranial bypass surgery is recommended prior to or at the time of carotid ligation because it may prevent ipsilateral ischemic complications as well as the development of a contralateral aneurysm following the ligation.
Among seven patients who underwent coating operations with muscle pieces and Biobond, one rebled from the previously coated aneurysm six years after surgery. The coating method should be indicated only for small and/or fusiformed aneurysms that can be completely coated.

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Twenty-two cases of giant cerebral aneurysms were reviewed in terms of incidence, location, symptomatology and the results of surgical treatment. Surgical outcome of direct operation and carotid ligation was compared in 16 of the 22 patients. The incidence of giant aneurysms was 4.6% among 476 cerebral aneurysms. The patients were six men and 16 women, with a mean age of 57 years. There were 15 aneurysms of the internal carotid artery (68%), three of the anterior communicating artery, two of the basilar artery and two of the middle cerebral artery.
Subarachnoid hemorrhage had occurred in six (50%)of the 12 patients with a nonthrombosed aneurysm, and in two (25%) of the eight patients with a partially thrombosed aneurysm. The overall incidence of subarachnoid hemorrhage was 41%, and the incidence of rebleeding was four (44%) out of nine.Cerebral ischemic episodes were noted in five (23%) of the 22 patients.
The results of surgery were as follow: there were five excellent cases, one good case and one deceased case out of the patients treated by carotid ligation or trapping and three excellent cases and three deceased cases in the patients treated by clipping. Six patients treated by carotid ligation or trapping had no subsequent neurological deficit in the follow-up period, which ranged from one to 10 years with a mean of 6.5 years. Overall mortality was five of the 12 patients with a nonthrombosed aneurysm and two of the eight patients with a partially or completely thrombosed aneurysm.

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Eight cases of giant ICA aneurysms were treated by indirect operation. Five cases were treated by CCA ligation (Group I), and three by ICA ligation with STA-MCA anastomosis (Group II).
Overall mortality was 12.5% (1/8), and seven patients are living usefully at present.
Preoperative enhanced CT findings of these seven aneurysms were divided into two patterns. Pattern A is full enhancement of the aneurysmal cavity (4 cases), and pattern B is partial enhancement of aneurysmal cavity (3 cases). In one case, CT scan could not be performed, because it was before the CT era.
We evaluated the effects of surgery by postoperative enhanced CT scan. The postoperative enhancement of aneurysmal cavities was classified into three types. Type I is no change or enlargement of the aneurysmal cavity. Type II is reduction of the aneurysmal cavity. And Type III is no enhancement of the aneurysmal cavity.
We considered that Type II and Type III showed the effectiveness of the operation. Two cases of CT pattern A were Type I (no effect of ligation) while only one of CT pattern B was Type I. Based on these results, we concluded that proximal ligation has more effectiveness in cases of CT pattern B (thrombosed giant aneurysm).
In total, five aneurysms of these seven cases showed reduction in size or disappearance on CT. The effectiveness of proximal ligation was evaluated precisely in correlation with CT scan.

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Nine giant aneurysms at the cavernous portion were experienced from 1973 to 1983. Surgical treatment was performed in eight cases, while one was treated conservatively. Common carotid clamping was undertaken in seven cases and aneurysmorrhaphy following internal carotid trapping was undertaken in seven cases and aneurysmorrhaphy following internal carotid trapping in one. During the follow-up study, eight patients were living useful lives, seven with clamping and one with aneurysmorrhaphy. Giant aneurysms were classified into three types by CT scan and angiographical findings. Type I was nonthrombosed, Type II was partially thrombosed, and Type II was totally thrombosed. Each of these was analyzed for postoperative change of clinical symptoms and morphological change on sequential CT scan. Follow-up periods were from one year to five years and 10 months.
As for the three Type II cases, the lumen of the aneurysm diminished in one, but remained unchanged in two after clamping; preexisting oculomotor nerve palsy in two cases and abducent nerve palsy in one case totally recovered. On the other hand, as for Type II, the lumen of the aneurysm disappeared in all three cases about one year after clamping. Oculomotor nerve palsy partially recovered in one case, but preexisting ophthalmoplegia was unchanged in two. One patient developed transient ischemic accident.
One case of Type III, which was tumorous aneurysm, must have been managed by aneurysmorrhaphy for removal of mass effect and symptomatic brain compression diminished after the operation. It was reflected that preexisting intraaneurysmal thrombosis altered the effect of common carotid clamped. The method of treatment for IC cavernous aneurysms are reviewed with respect to this classification.

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If, at direct exposure, it is impossible to clip the neck of a giant aneurysm because of its size, location and a neck not suitable for clipping, ligation of the proximal parent artery presents an alternative surgical treatment.
Ten patients with intracranial aneurysms were treated by ligation of the proximal parent artery. The locations of the aneurysms were intracavernous in four patients, paraophthalmic in one, basilar in one and vertebral in the other four. Four patients were managed by combining the ligation with EC-IC bypass.
In six patients with giant intracranial aneurysms, the effect of ligation was followed by repeated CT scans with angiographic correlation. The aneurysm thrombosed soon after ligation, and with time, gradually organized with a reversal of the mass effect. In the other four patients who had had symptoms of hemorrhage, no evidence of hemorrhage was seen postoperatively.
The main concern is the safety of the ligation, though no ischemic signs developed in this series. Recently, we have often used the balloon catheter technique and select the patients who may not tolerate ligation observation of the changes of consciousness and neurological signs, EEG monitoring, measurement of back pressure and checking cross-circulation in the angiogram during clamping the artery by inflating the balloon are undertaken. Our policy is to use an abrupt occlusion of the proximal parent artery combined with the EC-IC bypass on the same day. In on patient who showed ischemic symptoms during the Matas test, a vein graft between the external carotid artery and the middle cerebral artery was used in order to give a larger flow, which can provide better protection, and resulted in good clinical application.

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Recently, the results of neck clipping for intracranial aneurysm have shown great improvement because of the development of techniques and instruments (surgical microscopes, newly designed clips and others). However, it is not rare that a clip cannot be applied to an aneurysm neck in some cases, depending on the shape, the size and the site of the aneurysm.
From 1968 to 1983, we have experienced about 1, 200 cases of intracranial aneurysms at Chiba University and its affiliated Hospitals. The authors have analyzed 63 cases in which a clip was not applied (coating: 46 cases; proximal ligation: 8 cases common carotid ligation: 9 cases). In coating cases, there were five ophthalmic aneurysms, 17 posterior communicating aneurysms, three anterior choroidal aneurysms, eight anterior communicating aneurysms and 16 middle cerebral artery aneurysms. The results were as follows: good recovery in 34, moderate disability in four, severe disability in four, two vegetative cases and six dead by the Glasgow Outcome Scale.
Rebleeding was seen in only one coating case among our series, and this patient died. Thus, the results of proximal ligation and common carotid ligation were favorable.

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The study included two patients under carotid ligation associated with STA-MCA double anastomosis for intracavernous giant aneurysm and six patients with occlusion of the internal carotid artery. All cases underwent rCBF measurement using single photon emission tomography within three hours after cerebral attack or ligation. Cases of internal carotid artery occlusion were classified two types under rCBF study. One was a marked global ischemic flow pattern, more than 50% reduction, in the affected side with hemispheric flow reduction in the healthy side. This type did not demonstrate any cross-circulation from the healthy side by angiography. The other was a focal ischemic flow pattern in the affected side, especially the watershed region, with a slightly hemispheric flow reduction in the healthy side. This type demonstrated good cross-circulation from the other side. Surgical adaptation of carotid ligation for giant carotid aneurysm was the existence of crosscirculation. It was possible to have a focal ischemic lesion under only carotid ligation as well as ICA occlusion, even if the patients had good cross-circulation. In order to associate with STA-MCA double anastomosis, it was assumed that the focal ischemic lesion and slightly global reduction of the healthy side (diaschisis) could be prevented.

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Fifteen consecutive cases of intracranial aneurysms of the interal carotid artery treated with occlusion of the cervical carotid artery were included in this study. STA-MCA anastomosis was performed before occlusion of the cervical artery in 11 cases. In nine patients, the artery was occluded gradually with Selverstone or Crutchfield clamps (“gradual” occlusion) with or without placement of an EC/IC bypass. Postoperative cerebrovascular complications developed in two of the nine gradually occluded cases. Discussions were focused on the high risk of “thromboembolic” complication in the course of gradual occlusion of the artery; Accelerated blood flow (“jet” flow) at the partially occluded portion of the vessel may readily detach a piece of thrombus and embolize distal cerebral arteries. In this respect, “abrupt” ligation of the carotid artery may be a treatment of choice when postoperative “low-perfusion” syndrome can be avoided. Among several conventional methods of predicting patient's tolerance for immediate carotid occlusion, intraoperative measurement of the cortical blood flow by the thermoelectric method may have special significance in estimating complicated changes of intracranial hemodynamics caused by artificial EC/IC bypass and therapeutic occlusion of the cervical carotid artery. In six cases, intraoperative measurement suggested sufficient preservation of the cortical blood flow at the test occlusion of the internal carotid artery and the vessel was ligated “abruptly.” No neurological deficits occurred in these cases.
The use of digital subtraction angiography and dynamic CT for the postoperative follow-up was also discussed.

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As a method of preoperative evaluation of the tolerance for carotid ligation, namely, of assessing intracranial collateral circulation, we have measured, using oculocerebrovasculometry(OCVM), the pressure of the ophthalmic artery with and without carotid compression and have calculated the ratio of the pressure of the ophthalmic artery to the systemic blood pressure (OAP/BrBP).
In those who presented no cerebral ischemic signs or EEG abnormalities with carotid compression, the OAP/BrBP ratio was 0.763±0.063 (mean±S.D., N: 18) without carotid compression, declining to 0.373±0.136 with ipsilateral carotid compression. The reduction of rCBF (three-dimensional measurement) with carotid compression in these nine cases remained around 10%. There was a good correlation between the %-reduction of the rCBF and the OAP/BrBP ratio, which were obtained under carotid compression (r: 0.758, N: 16, p<0.001).
One case manifested no cerebral ischemic signs or EEG abnormalities with preoperative carotid compression, but during the carotid endarterectomy procedure, she showed an ipsilateral decrease of alpha wave power without the appearance of slow waves with the carotid clamp. The preoperative rCBF was decreased with carotid compression in about 45% (59ml/100g/min., 81% of the normal value). In this case, the OAP/BrBP ratio with carotid compression was 0.313.
In another case, contralateral cerebral ischemic signs and ipsilateral EEG abnormalities (appearance of 6-7 Hz theta waves) developed with carotid compression. The reduction of rCBF with carotid compression was 51% (33 nit/100g/min., 45% of the normal value). In this case, the preoperative OAP/BrBP ratio was decreased remarkably to 0.114.
It is thought that in those whose OAP/BrBP ratio with carotid compression is above 0.3, the intracranial collateral circulation may have developed well and the ICA ligation may be tolerable. The lower limit of the OAP/BrBP ratio with carotid compression for tolerable ICA ligation is believed to be around 0.3.

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It is important to determine the safety of internal carotid artery (ICA) ligation in order to identify those patients who are likely to develop severe cerebral ischemia if this procedure is carried out. For the purpose of reducing the risk of ICA ligation, temporary balloon occlusion by the Swan-Ganz method was performed. Observations of neurological state (tolerance test) and carotid artery back pressure, A-J blood sampling for gas analysis (PjO₂,% CBF reduction), cerebral angiography for assessing collateral circulation, EEG monitoring, and rCBF measurement by the xenon inhalation method were undertaken during temporary ICA occlusion.
Our diagnostic procedure allows the risk associated with ICA ligation to be estimated more exactly.

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A 62 year-old female had grade II subarachnoid hemorrhage from a giant aneurysm of the basilar artery at the right superior cerebellar artery (SCA), which was feeding an arteriovenous malformation (AVM) in the right cerebellar hemisphere. She had been suffering from right hemifacial spasm for more than 20 years. Surgery was performed through the left pterional transsylvian approach. Neck clipping was impossible. Instead, the basilar artery was clipped proximal to the SCA. The patency of the bilateral posterior communicating artery seen on preoperative angiography was assured intraoperatively. The postoperative course was complicated with left oculomotor palsy and right hemiparesis, both of which improved gradually. Right hemifacial spasm disappeared completely within one week after surgery.
Postoperative angiography showed i) an enlarged right posterior communicating artery, ii) aneurysm size decreased by 10%, iii) the right SCA decreased to one third of its preoperative size. The patient's poor heart condition made further treatment for the AVM inadvisable, and she was discharged to her home, where she could take care of herself. Seven months later, however, she fell into coma due to intracerebellar hemorrhage from the AVM and expired 10 days later. The autopsied brain revealed only a narrow infarction in the left paramedian region in the upper pons, which was due to prophylactic occlusion of the perforators. Microscopically, a decreased number of neurons and central chromatolysis were seen in the right facial nucleus. These might have been related to hemifacial spasm.

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Among 181 cases of 189 posterior circulation aneurysms, there were 65 with 69 vertebral aneurysms and 20 with 21 fusiform aneurysms. Dissecting aneurysms and true fusiform aneurysms were included in this series.
1) Angiographical differentiation between the two above pathological processes is very difficult in some cases. Most dissecting aneurysms have a dilated portion and a narrowing of various degrees (“pearl and string sign”).
2) In a long-term follow-up study, a proximal clip occlusion of the vertebral artery and Biobond coating were effective in preventing recurrent hemorrhage. There were no postoperative deaths and no rebleeding, but two cases of ischemic stroke lateral medullary syndrome-were found. Both were treated by a proximal clip occlusion distal to the posterior inferior cerebellar artery. The patency of the distal vertebral artery and its perforators were important. Probably a long distal cul-de-sac vertebral artery is more risky than a shorter one.

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In the literature, 30% of VB system aneurysms are reported to be fusiform and not amenable to neck clipping. The authors reported 14 cases of VB fusiform aneurysms that were not possible to exclude from the circulation with a surgical clip or ligature. In our series, intracranial proximal occlusion of the vertebral artery was performed in three cases, coating or wrapping in four, and only a shunting operation was done in three cases. In the remaining four cases, conservative management was continued without any surgical intervention.
The natural courses of the conservatively managed patients were relatively benign, as were the postoperative courses of the surgically treated cases. One patient died of a progressive mass effect of a giant aneurysm, which was not eliminated by a shunting operation. In another case of a giant VB fusiform aneurysm, angiographical obliteration of the aneurysm was obtained by proximal clipping of the ipsilateral intracranial vertebral artery.
Recent reports have described the occurrence of dissecting aneurysms in the VB system. Some of these aneurysms may be angiographically indistinguishable from fusiform aneurysms, unless they show a typical“double lumen”sign. In our series, only one patient was surgically verified to be a dissecting aneurysm, in which a subadventitial hemorrhage was observed in the vertebral artery just proximal to the PICA origin. Some of the other cases were suspected of dissecting aneurysm on angiography, although they were not surgically verified.
The authors' experience indicated that proximal occlusion of the vertebral artery is the procedure of choice in the treatment of ruptured or mass-effect-producing fusiform or dissecting aneurysms in the VB system.

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Six cases of unclippable vertebral aneurysms were treated by therapeutic occlusion of the proximal vertebral artery. Of these, three were clipped at the vertebral artery proximal to the posterior inferior cerebellar artery (PICA), and all of them had postoperative embolic complications or fatal subarachnoid hemorrhage. On the other hand, two patients in whom the vertebral artery was clipped distal to the PICA and one whose PICA was absent and vertebral artery was clipped proximal to the aneurysm did well without any neurologic deficits. Possible mechanisms of complications are discussed, and the importance of sparing the PICA from clipping is emphasized.

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Sequential measurement of internal carotid artery (ICA) stump pressure was performed by the preoperative balloon occlusion test using a wedge pressure balloon catheter in carotid aneurysm unsuitable for direct neck clipping.
Two patterns of the time course of this stump pressure, which diminished by ca. 60%immediately after the balloon inflation, were demonstrated during the balloon occlusion of the ICA.
(i) In the pattern in which the stump pressure was maintained at a low level, gradual occlusion of the ICA would be reasonable.
(ii) In the other pattern, in which the stump pressure was elevated to the level of ca. 70%within five minutes, one-stage occlusion of the ICA would be possible.

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Extracranial to intracranial (EC-IC) bypass surgery with an autologous venous graft significantly increases the cerebral blood flow (CBF) as compared with superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis.
When the ipsilateral CBF via the anterior communicating artery (ACoA) and/or posterior communicating artery (PCoA) is not sufficient after the carotid ligation, this procedure is protection against cerebral ischemia by supplying the blood through the venous graft.
On the contrary, when the ipsilateral CBF via the ACoA and/or PCoA is not reduced effectively by the carotid ligation, meaning that the blood flow to the aneurysm is still maintained, this bypass surgery can prevent the aneurysm from rupturing by diverting the blood from the lesion.
In conclusion, in addition to the conventional methods of internal carotid ligation and STA-MCA anastomosis, EC-IC bypass surgery with an autologous venous graft is recommended as one of the useful procedures for the inoperable giant internal carotid aneurysms.

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Since the introduction of the operative microscope and various clips, aneurysm surgery has become safe. But there are still some aneurysms that are difficult to be clipped because of location, direction or size.
Four hundred and sixty cases of intracranial aneurysms were operated on from September 1976 to March 1984. In 17 cases clipping was not possible. Thus, the purpose of this paper is to evaluate those aneurysms which could not be clipped and to provide useful information for further treatment.
17 cases in which clipping was impossible included six internal carotid ophthalmic giant aneurysms, two internal carotid bifurcation giant fusiform aneurysms, two posterior communicating big aneurysms, one posterior cerebral artery giant aneurysms, one middle cerebral artery thrombosed aneurysm, three basilar artery aneurysms, one vertebral aneurysm, and one case of Megadolico Basilar and Carotid artery.
Ligation of the internal carotid artery following STA-MCA anastomosis was done in six cases of internal carotid ophthalmic anerysms. Ophthalmoplegia or visual disturbance developed in two patients more than a week after the operation probable at the time the aneurysm thrombosed. Therefore, these ophthalmic aneurysms should he clipped using fenestrated clips, or coagulated or punctured to reduce their size.
Cases of giant fusiform aneurysm of internal carotid bifurcation or Megadolico Basilar and Carotid artery present more risk of cerebral infarction than of bleeding. Therefore, treatment to prevent cerebral infarction in these aneurysms must be undertaken. There were three cases of thromhosed aneurysm, of the basilar artery, vertebral artery and middle cerebral artery respectively. There is no operative indication for completely thrombosed aneurysm.
Feeder clipping was performed in two cases of big aneurysms of the posterior communicating artery, and the postoperative course was good without any neurological deficit. Angiography revealed that the aneurysm was not exposed postoperatively. Therefore, if the aneurysm was fed by only the posterior communicating artery in the angiogram, feeder clipping of the posterior communicating artery is one of the methods of treatment.

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For cerebral aneurysm, the approved method of treatment is to clip the neck of the sac, but for aneurysm in certain positions or of large size, this method may prove impracticable.
Three such cases of giant aneurysm at the cavernous portion of the internal carotid artery have recently been treated at this hospital.
The initial symptom in all cases was disturbance of the ocular movement. Neurological findings on admission showed abducens nerve palsy in two cases and oculomotor nerve palsy in the third.
CT scan after infusion of contrast media revealed a high-density area at the cavernous portion of the internal carotid artery in each case, and cerebral carotid angiography demonstrated a giant aneurysm at the cavernous portion with a diameter more than 25 mm.
Gradual ligation of the internal carotid artery was performed with STA-MCA anastomosis in two cases and a trapping of the internal carotid artery with STA-MCA anastomosis in one.
In two cases, the operation results were excellent and in the third quite good. Postoperative CT scan showed the formation of a thrombus in the cavernous portion.
Finally, the pathogenesis of late ischemic events after trapping of the internal carotid artery with STA-MCA anastomosis was discussed.

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A case of high cervical and a case of intracavernous sinus ICA aneurysm were treated with ICA ligation combined with STA-MCA bypass. There was good resolution of mass signs and no ischemic complications.
This method of treatment is effective not only for the improvement of clinical signs but also for the prevention of post ligation ischemia.
There have been some reports stating that STA-MCA bypass does not always prevent cerebral ischemia after the ICA ligation, especially in cases with critically low residual CBF during trial ICA occlusion.
For these cases, gradual ICA ligation paralleling the development of bypass-flow, or more electively high flow graft bypass might be considered.

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Ten patients with internal carotid giant aneurysm were managed by combining internal carotid artery (ICA) ligation with an STA-MCA anastomosis. Pre-, intra- and postoperative hemodynamics were examined by angiography and/or with a bidirectional ultrasonic Doppler flowmeter. Intraoperative Doppler flow measurement of the STA on the side of the anastomosis showed that the flow increased with an increase of ipsilateral ICA trial occlusion and the flow pattern changed from an external to an internal carotid type. Carotid occlusion was completed one to five days after the start of gradual occlusion. The degree of occlusion was adjusted by the monitor of the flow patterns recorded by the Doppler flowmeter at the poststenotic region. Bypass patency was confirmed in all anastomoses by postoperative transcutaneous Doppler flow studies.
Postoperative serial CT studies revealed total occlusion of the aneurysm in nine patients and a remarkable decrease in size in five. In the remaining aneurysm, at the intracranial bifurcation of the ICA, intraaneurysmal thrombosis was subtotal and a supplemental clip was applied to the Al segment. Although five patients developed TIAs or diabetes insipidus simultaneously with aneurysmal occlusion, there were no permanent neurological deficits. Only one patient, the one in whom neck clipping of the aneurysm was performed by direct intracranial surgery with temporary occlusion of the ICA, developed permanent neurological deficits.

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The authors reported two cases of dolichoectasia surgically treated by STA-MCA anastomosis.
Case 1: A 50-year-old woman noticed right motor and sensory disturbances. CT scan revealed a mass lesion showing high density with some contrast enhancement located at the left frontal lobe to the ambient cistern. Angiography demonstrated an abnormally tortuous and dilated left internal carotid artery at the C₁ to C₃ portion and extremely delayed circulation time. The operation was performed to clip the proximal portion of the internal carotid artery after STA-MCA anastomosis. The postoperative course was excellent, and the angiogram demonstrated good functional anastomosis and obliteration of the dolichoectasia.
Case 2: A 53-year-old men had experienced left hemiparesis in 1978. In 1981, he again no-ticed deteriorated right motor and sensory function. CT scan showed a mass lesion having contrast enhancement by the clivus. Angiography demonstrated the tortuous and dilated vertebrobasilar artery and the dilated internal carotid and middle cerebral (M₁) arteries. Emission tomography (Tomomatic 32) revealed diffuse low perfusion of the cerebrum, especially at the right frontoparietal area. STA-MCA anastomosis was performed to improve the cerebral blood flow and left hemiparesis.
These two cases suggested a possibility of surgical treatment of dolichoectasia by STA-MCA anastomosis.

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It is very difficult to totally resect a large arteriovenous malformation in the posterior fossa. We have experienced a patient who was treated successfully utilizing a balloon catheter for temporary occlusion of the basilar artery under the administration of “Sendai cocktail” (20% mannitol, vitamin E, dexamethazone) and perfluorochemicals.
The patient was a 14-year-old female who developed sudden onset of SAH with ventricular rupture and left cerebellar hemorrhage. Angiography disclosed a large left cerebellopontine angle arteriovenous malformation fed by two superior cerebellar arteries and the anterior inferior cerebellar artery and drained by the superior petrosal vein. We thought it very hazardous and difficult to undertake total resection by the conventional approach, so we considered utilizing the balloon catheter technique to occlude the feeding arteries for the adjunctive intraoperative procedure. Superselective angiography and a tolerance test were performed under the administration of “Sendai cocktail” and monitoring of auditory brain stem response (ABR) was undertaken. Total resection of the malformation was successfully performed by the unilateral suboccipital approach. Balloon catheters were introduced to the main feeding arteries (one into the anterior inferior cerebellar artery and the other into the basilar artery where the superior cerebellar artery originated)through introducing an indwelling catheter by the transfemoral route. Under the administration of “Sendai cocktail” and perfluorochemicals, catheters were inflated for temporary occlusion and the malformation was resected uneventfully. Temporary occlusion was performed under ABR monitoring for as long as 46 minutes.
The postoperative course was uneventful.
This is thought to be the first case applying a balloon catheter for intraoperative temporary occlusion of the basilar artery. If this technique is utilized with “Sendai cocktail” and perfluorochemicals, it is very safe to perform temporary occlusion of any intracranial arteries that are accessible for the intravascular approach and indications of surgical treatment of arteriovenous malformation will be extended to those thought to be inoperable by the conventional approach.

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The intravascular use of isobutyl 2-cyanoacrylate in two patients with intracranial arteriovenous malformations is described. The monomer was introduced into each nidus at craniotomy through the main feeding arteries, while temporary clipping of other arteries was performed. Total excisions of malformations were done under minimal bleeding.
The problem of this procedure was to occlude normal vessels by the overflow of the monomer from the nidus. It is advisable to inject less than a sufficient amount of the monomer.

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A right parasagittal AVM involving the posterior frontal and parietal lobes was treated by embolization with cyanoacrylate monomer (Aron alpha A). Angiograms revealed successful obliteration of the lesion with a small residual tuft in the two and a half years follow-up period. The present paper described the intraoperative embolization techniques and resultant sequential changes of the malformation.
Case: A 36-year-old housewife was admitted in September, 1981 with a history of generalized convulsion and frequent episodes of the left face and upper trunk numbness of five years duration. No definite abnormalities were disclosed on neurological examination. Right carotid angiograms demonstrated AVM approximately 6 cm in diameter fed by the precentral and central arteries of the right middle cerebral artery and the callosomarginal and pericallosal arteries of the anterior cerebral artery and drained into the superior sagittal sinus. A right frontoparietal craniotomy was performed, and 1.0 ml of cyanoacrylate monomer loaded in a tuberculin syringe with a 26 gauge needle was injected into both the malformation and dilated precentral artery. Three injections in the AVM itself and one in the precentral artery were performed. A clip was also placed on the right central artery immediately proximal to the AVM.
Further intravascular embolization was not attempted in the feeding branches of the right anterior cerebral artery. On immediate postoperative right carotid angiograms, the AVM was not opacified via branches of the right middle cerebral artery, but small residual malformation filled via the pericallosal artery of the anterior cerebral artery.
Angiograms obtained two and a half years after the surgical procedure disclosed further reduction in size of opacification, and the process of obstruction in the AVM after intravascular embolization was estimated to be in progress.

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The authors have treated 12 cases of cerebral AVM, five cases of dural AVM and three cases of cutaneous AVM by embolization with Aron-alpha (alkyl-α-cyanoacrylate) since 1978 according to their opinion that the most ideal method for the treatment of AVM is to completely embolize the nidus itself and to make the emboli attach to the vascular network closely for prevention of recurrence. In addition, such a method should be safe and easy. All eight cases of dural AVM and cutaneous AVM were completely embolized. Nine of the 12 cases of cerebral AVM were completely embolized with cyanoacrylate. The remain three were partially embolized. In four cases, the AVM was removed following the embolization with cyanoacrylate in order to examine how to embolize the nidus. Thus Aron-alpha attached firmly to the vascular network of the AVM-and made a hard mass like a calcification, and recurrence seems unlikely to occur. Therefore, embolization using Aron-alpha is a good treatment in difficult deep-seated AVM and dural AVM because it is easy. safe and prevents recurrence.

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Fourteen cases of arteriovenous malformations (AVM) of the brain, dura and scalp were embolized with ethyl-cyanoacrylate. Injection of the ethyl-cyanoacrylate was performed either by direct puncture of the feeding arteries or transfemoral catheterization with a detachable and leak balloon catheter. For every injection, 0.3 to 1.0ml of cyanoacrylate was used. With additional surgical removal, eight AVMs were totally eradicated and the remaining AVMs were partially embolized. Among the AVMs, dural AVM was most suitable for the cyanoacrylate embolization, and a high rate (67%) of total embolization without surgical intervention was obtained.

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Two cases of large arteriovenous malformations successfully removed following artificial nidus embolization by silastic spheres are reported.
Case 1: A 27-year-old housewife was admitted to our department with the chief complaint of episodes similar to alexia, apraxia and aphasia lasting for a few minutes, which started four years prior to the admission. Neurological examination at admission showed no abnormalities. A left internal carotid angiogram taken at admission showed the presence of a large arteriovenous malformation in the left parieto-temporo-occipital region fed by three branches of the left middle cerebral artery and two branches of the left posterior cerebral artery. To facilitate successful excision without neurological deficits, nidus embolization by silastic spheres was performed via the left internal carotid and the left vertebral arteries. The nidus was significantly reduced with decreased diameters of feeding arteries on the angiogram made following nidus embolization. Total removal of the nidus was successfully performed 15 days following completion of embolization, and it was found that separation of the nidus was much easier compared to a surgical procedure without preoperative embolization mainly because of reduced tension of each vessel into the nidus. The postoperative course was uneventful.
Case 2: A 27-year-old male was admitted to our department with three episodes of subarachnoid hemorrhage. He was neurologically asymptomatic at admission. A right internal carotid angiogram taken at admission showed the presence of a large arteriovenous malformation in the medial portion of the right frontoparietal lobe and corpus callosum mainly fed by the right pericallosal artery. Nidus embolization by silastic spheres was planned for making surgical removal easier. To prevent the Silastic spheres from straying into the right middle cerebral artery, a balloon, introduced into the M₁, was inflated for a few minutes, during which time in jection of the Silastic spheres was performed via the right internal carotid artery. The nidus was significantly reduced and its total removal was successfully done 28 days following the embolization.
The authors stressed the efficacy of nidus embolization for large arteriovenous malformation prior to surgical excision and discussed indications of preoperative artificial embolization.

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This paper reports our experiences of transcatheter embolization using Ivalon particles in nine cases of dural arteriovenous malformations (AVM). The embolization was done for the purpose of decreasing abnormal arteriovenous shunts.
Catheterization was undertaken through the femoral artery in six cases and through the common carotid artery in three. Ivalon (polyvinyl alcohol foam) particles,0.5×0.5×0.5mm in mean size, were instilled with normal saline and contrast material half-and-half. The emboli were injected as gently as possible under an image intensifier.
In eight cases of dural AVMs, embolization resulted in a remarkable decrease in the size of the malformation. One patient had a small dural AVM in the posterior fossa dura, which was occluded. In two cases of malformation, a CT scan was done after embolization, and both showed a decrease of the contrast enhancement lesions, considered intracranial drainage veins of the malformations. Most patients with malformations, had clinically favorable results when treated with embolization alone.
Subsequent to embolization, irradiation was performed in four patients with idiopathic CCF and the malformation disappeared completely in two cases and partially in one.
No major side effects were encountered in this series. We should pay attention to vascular anomalies before embolization to prevent possible catastrophes.

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The authors described two cases of dural arteriovenous malformation treated by arterial embolization.
In a case of transverse sinus dural arteriovenous malformation, embolization was performed by the use of Gelfoam and in another case of cavernous sinus dural arteriovenous malformation, Gelfoam coated with Gutta-percha was used.
In the experimental brain stem infarction in the dog, we found a thrombogenic effect of Guttapercha. Therefore we used Gutta-percha Gelfoam for arterial embolization in one case. If Guttapercha Gelfoam is implanted in the arteriovenous malformation exactly, it promotes the thrombogenesis of the fistula and gives rise to the possibility that dural arteriovenous malformation can be occluded.

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The authors reported a case of posterior fossa dural AVM (so-called mixed pial-dural AVM). Angiography revealed complicated feeding vessels, which were suspected to be due not only to the occlusion in the transverse venous sinus on one side, but also to marked circulatory disturbance caused by stenosis on the other. This finding suggests that such a case with the nidus in the bilateral venous sinuses would be intractable to surgical intervention alone and might be a good candidate for selective embolization or radiation combined with a surgical procedure.

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Dural AVM of the transverse and sigmoid sinus occupies 63% of the all intracranial dural AVMs. However, radical removal of this type of AVM had been hazardous due to severe intraoperative hemorrhage. We performed artificial embolization of the AVM nidus from the main feeder and ligation of the ECA just prior to radical surgery for the dural AVM. Total bood loss during the operation was estimated to be less than 500 ml.
A 43-year-old female patient was admitted to our clinic complaining of left pulsatory tinnitus and intractable headache. Marked bruit and pulsation were noticed in her left retroauricular area. The selective ECA, ICA and VA angiography revealed an AVM nidus around the junction between the left transverse and sigmoid sinus. The nidus was fed by the left occipital artery and many branches of the medial meningeal artery and accessory meningeal artery, and drained into the left transverse sinus, of which the distal end was completely occluded by the AVM nidus. Gelfoam and Ivalon powder were used for artificial embolization through the occipital artery, and the radix of the ECA was ligated just prior to the radical surgery. The total removal of the dural AVM including the nidus and draining sinus could be achieved with minimum bleeding during the operation. All symptoms subsided, and the AVM disappeared angiographically after the operation, with only a small temporary skin erosion of the scalp flap remaining.

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For the treatment of dural arteriovenous malformations, conjugated estrogens were infused continuously through a catheter, inserted into the external carotid artery. In nine of 11 cases (81.9%), therapeutic effects on the angiogram, such as total or partial disappearance of the nidus, were observed. As for adverse reactions, to the drug there was parotitis (7 of 11 cases), liver dysfunction (2 of 11), and gynecomastia (1 of 11). These symptoms were easily corrected by discontinuing or reducing of the estrogen dosage. There were no serious adverse reactions and recurrence was not observed. Therefore, this chemical embolization method using estrogen is an easy, safe and effective treatment for dural arteriovenous malformations.

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Dural arteriovenous malformation offers many problems with regard to its treatment. The most effective therapy is total extirpation. However, complete extirpation would be technically very difficult and may expose the patients to great hazard.
Ligation of the external carotid artery and/or occipital artery is not sufficient in most cases, because of multiple arterial tributaries.
Transcatheter artificial embolization by Gelfoam was attempted in two inoperable cases. Many materials have been used as therapeutic emboli. Though Gelfoam is reabsorbable and revascularization has been reported, it is the most popular material. It is easy to handle and to inject through a catheter. The results in both cases were satisfactory, and clinical symptoms disappeared.
Artificial embolization is very available and should be performed when surgical removal is not indicated, it is also utilized for presurgical devascularization and with radiotherapy.

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A case of dural arteriovenous malformation (AVM) in the posterior fossa in the region of the transverse sigmoid sinus (TSS), which had a total of eight feeders, was reported. It required four surgical procedures until the clinical symptoms completely disappeared.
The patient was a 51-year old male who had been a professional bicycle racer for 10 years. He had hit his head many times while racing. With sudden onset, headache and tinnitus occured at the end of March, 1980. Loud bruit was heard on the left side of his neck and was the only symptom of neurological deficit. Six-vessel study showed a dural AVM in the region of the left transverse sigmoid sinus, which was supplied by (1) the middle meningeal artery, (2) the posterior meningeal branch of the occipital artery, (3) the posterior meningeal branch of the ascending pharyngeal artery, (4) the posterior auricular artery, (5) the parietal branch of the superficial temporal artery (STA) via the left external carotid artery, (6) the posterior meningeal branch of the right occipital artery via the right external carotid artery and (7) the artery of Bernasconi and Cassinari of the meningohypophyseal trunk via the left internal carotid artery. The sigmoid sinus showed marked stenosis.
First step on July 2, 1980: The left occipital artery, STA and internal maxillary artery were embolized using a detachable balloon. Bruit ceased for only five days. Second step on Aug. 12: The left external carotid artery was ligated at its origin. But bruit was not stopped by this proce-dure. Third step on Sept. 5: Left occipital and suboccipital craniectomy was performed. Separation of the periostium from the occipital bone and dural resection above and below the left transverse sinus was undertaken. The superior petrosal sinus was cut off. Bruit was stopped for three months. The posterior meningeal branches of the right occipital artery via the right external carotid artery and (8) the same branches of the left occipital artery via the left vertebral artery were still active and drained into the left TSS.
Fourth step on March 20, 1981: Left occipital and suboccipital craniectomy was done again. Ligation and cut of the transverse sinus at its origin and endpoint were performed without any cocomplications. Bruit ceased completely. Various surgical treatments have been considered for the management of TSS dural AVM. Intravascular embolization would not be sufficient and a radical procedure would be required in such a severe case, supplied not only by the ipsilateral external carotid artery, but also by the ipsilateral internal carotid and vertebral arteries and the contralateral external carotid and vertebral arteries.

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Last year, we reported a 28-year-old female whose right internal carotid giant aneurysm was successfully treated with the detachable balloon technique with subsequent complete recovery both neurologically and socially.
At this time we investigated follow-up angiograms to evaluate the aneurysm and hemodynamic states.
On the 40th postoperative day, the angiogram showed a right internal carotid artery occluded at the point 1.5cm distal to the bifurcation, where an external carotid artery branched off an accessory meningeal artery and a twig of the internal maxillary artery, draining into an inferolateral trunk of the cavernous portion. Retrograde filling of an ophthalmic artery was seen from an anterior deep temporal artery.
The C₂-C₄ segment of the internal carotid artery was filled via these arteries, but was prominently elevated and compressed by giant aneurysm.
Approximately one year after the operation, these angiographic findings were almost unchanged except that collaterals and the C₂-C₄ segment were larger, and the latter took the normal course.
From these findings, we discussed the danger of rerupture because of retrograde or anterograde cerebral blood flow to an aneurysm of the cavernous and petrosal portion, and of delayed cerebral ischemic episodes.

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The balloon Matas' test (temporary occlusion of the internal carotid artery with a 4.8F Swan-Ganz type double lumen catheter) was performed on four patients with large to giant aneurysms of the internal carotid artery, and two of them were treated by means of internal carotid arterial occlusion with Debrun's detachable balloon catheter. In one patient, neurological deterioration (lowering of the consciousness level, aphasia and right hemiparesis) appeared just after temporary occlusion of the left internal carotid artery and it disappeared just after reopening the internal carotid artery. This patient did not show any neurological deterioration due to the classical Matas' test (compression of the common carotid artery with the fingers). This shows the efficiency of the balloon Matas' test. The other three patients tolerated the balloon Matas' test for 15-70 minutes and no neurological deterioration was found during the examination. Two of these three patients underwent permanent internal carotid arterial occlusion with Debrun's detachable balloon catheter. The internal carotid artery was occluded just at the proximal part of the canalicular portion, and the detached balloon was inflated a little more to avoid migration of the balloon. These aneurysms were confirmed to be occluded with thrombus formation from the follow-up computerized tomographic findings. No TIA or cerebral infarction was noted during the one-to-six-month follow-up period.

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One case of a large carotid-ophthalmic aneurysm was treated by clipping of the neck and intra aneurysmal injection of cyanoacrylate. A 52-year-old woman noticed progressive visual deterioration in her left eye for six months. On admission, visual examination revealed a left inferior nasal quadrantanopsia and a left atrophic disc. Visual acuity was 0.05 on the left. CT scan confirmed the presence of a suprasellar mass, which angiography proved to be a large left carotid-ophthalmic aneurysm directed superomedially. The aneurysm was explored in September 1983. The neck was clipped with a Heifetz clip during temporary occlusion of the carotid artery in the neck. Post-operative angiograms demonstrated that the clip had slipped. The aneurysm was re-explored. The neck was occluded with a long Sugita clip with the aid of temporary carotid occlusion. As there was still some filling of the aneurysm, a second Scoville clip was applied. The aneurysm was then discolored. After the aspiration of the aneurysm, cyanoacryate was in into the sac during temporary trapping of the carotid artery to secure the obliteration of the aneurysm. Postoperative angiograms revealed successful occlusion of the aneurysm and filling of the residual neck in the cavernous sinus. Visual acuity in the left eye improved to 0.3, although the field deficits persisted. Injection of cyanoacrylate into the aneurysm is an effective procedure in cases where multiple maneuvers fail to keep the aneurysm collapsed. However, the disadvantage of this method is undesirable embolization through the neck. Therefore, the injection of cyanoacrylate should be carried out during temporary trapping of the carotid artery and/or clipping of the neck of the aneurysm.

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Endovascular occlusion by various catheterization techniques was carried out to treat 13 cases of intracavernous aneurysms and cerebral arteriovenous malformations.
In four cases of giant aneurysms, internal ligation of the carotid artery was performed by the detachable balloon technique without significant complication.
The attempt at aneurysmal closure failed in two cases. In one remaining patient, the temporary occlusion of the carotid artery resulted in a marked decrease of the aneurysmal size.
Calibrated-leak balloon catheterization with fluid embolization was used to treat cerbral arterio-venous malformation.
Postoperative angiography revealed a definite decrease in shunt flow, but partial filling remained in five of six cases.
No neurologic improvement was obtained after the procedures.

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The results of bronze wire embolization of an intracranial massive aneurysms in three cases suggest that this method is effective in situations where neck clipping or encasement is inapplicable. A giant aneurysm, 7cm in diameter, was embolized with 430cm of bronze wire. Two large aneursms 1.5 to 1.7cm in diameter were embolized with 47cm and 162cm, respectively, of bronze wire. The angiograms in all three cases show a luminal occlusion, the largest one with complete obliteration of the aneurysmal lumen and two with about 80 percent obliteration. None of the subjects bled during the follow-up period, which ranged from 14 to 28 months. In the case of an ophthalmic aneurysm, third nerve palsy and defect of the visual field improved following the reduction of the pulsative pressure of the dome.

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In the surgical treatment of miliary intracranial aneurysm smaller than the diameter of the artery, there have been cases in which neck clipping was difficult or premature rupture occurred as a result of clipping. Thus cautious judgment is needed to choose the surgical technique. The appropriate surgical treatment of these cases was described on the basis of the experience of our clinic.
Among 588 patients with intracranial aneurysm that have been experienced up to the present, 29 had miliary aneurysm. These included five unruptured cases and 24 ruptured ones. Among the cases of ruptured miliary aneurysm, six were unoperated, three because of death and three did not agree to the operation as they had come to our hospital in the chronic term. In one of the unoperated cases, a small aneurysm was observed at the trifurcation of the MCA by autopsy, and rupture was also recognized by histological examination. It was difficult to diagnose the case as intracranial aneurysm. Of the 18 operated cases, clipping was performed in 12, clipping and coating in two, coating in two, wrapping in one and suture in one. It was because a clip could not be placed satisfactorily in one case and blood was seen from the neck of the aneurysm in another that both clipping and coating were performed. One case was wrapped with muscle pieces because a clip could not be placed.

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Surgical difficulties in treating aneurysms arising at the arterial wall and unrelated to fork and their histopathological characteristics were discussed. We named these aneurysms“blister aneurysms”in view of the following characteristics:(1) arising at the arterial wall unrelated to fork, mostly at the cisternal portion of the internal carotid artery,(2) hemispheric shape and small in size, i. e., 1 to 4mm in diameter, and (3) fragility. We experienced five cases of blister aneurysms. Their outcome was severe disability in one and death in four.
The causes of death were: ICA trapping due to intraoperative premature rupture in two cases and cerebral infarction due to ICA stenosis resulting from Sandt's encircling clipping and preoperative rerupture in one case each.
Arteriosclerosis around the aneurysm, in addition to defective internal elastic lamina, was the outstanding histopathological finding in the autopsy cases. Fibromuscular dysplasia was also noted in one case. The true mechanism of such blister aneurysm is unclear. Stehbens stated that small aneurysms have rather thinner walls.
For such reasons as mentioned above, our surgical attitude with regard to blister aneurysms is as follows. Neck clipping is contraindicated in most cases, even if the aneurysm has a clippable neck because the aneurysmal neck may be unable to tolerte the tension of the clip.
Safer surgical techniques for such aneurysms are summarized as follows: at first, secure the ipsilateral cervical internal carotid artery prior to accessing the aneurysm and thereafter (a) muscle encasement of the aneurysm,(b) EC-IC bypass followed by intravascular balloon occlusion of the parent artery at the aneurysmal neck or (c) EC-IC bypass after application of Sandt's encircling clip.
Treatment with Sandt's clip alone may cause arterial narrowing, and additional bypass on the ipsilateral ICA territory may be mandatory.

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During aneurysm surgery, we often encounter small hemispherical bulging on the arterial wall nearby which is extremely thinned at the tip. Since we confirmed that such pathology could be the cause of subarachnoid bleeding in one patient in 1978, we have collected 26 cases of such early aneurysmal change, so-called immature berry aneurysm. In this investigation, we positively operated on those cases in which though the apparent berry aneurysm was not identified on cerebral angiography, CT scan suggested the localization of the source of bleeding.
The subjects included 14 males and 12 females. From the severity on admission, they were not always mild cases, but 38% belonged to grade 3 or 4 on Hunt and Kosnik's classification.
The most common site was on the internal carotid, followed by the middle cerebral artery and the anterior communicating artery.
As the treatment, coating only was undertaken in 10 cases, clipping in nine and clipping plus coating in four. Autopsy was performed in four cases, which revealed basically the same histological change as berry aaeurysm.
In conclusion, in cases of immature berry aneurysm, both the diagnosis and treatment are rather difficult and the prognosis is relatively poor.

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Electrothrombosis by copper wire insertion into the cavernous sinus through a frontotemporal craniotomy was undertaken in five cases of CCF.
A direct current was applied until a thrombus was confirmed angiographically, and the wires were left in place. The closure of the fistula was verified by intra-or-postoperative angiograms. However in two cases the preoperative sixth and third nerve palsy temporarily worsened after the operation and in one case the internal carotid artery was obstructed, which necessitated EC-IC bypass.
The results of thrombosis in five cases of CCF suggest that intracavernous wire thrombosis may prove to be the treatment of choice.

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In the present case the thrombosis of a spontaneous CCF by a combination of hypotension and radiation therapy was attemped.
The patient, a 50-year-old female, had experienced a tinnitine bruit on the left side for about six months. For one month there was also double vision and impairment of the left eye. When she was hospitalized, the bruit was inaudible but the left eye protruded with some hyperemia and edema. There was double vision in every direction except for straight ahead. The CCF was revealed only in the left internal carotid angiogram. The arteriovenous shunt showed relative high flow and pressure. When the systemic blood pressure was decreased by the hypotensive drugs, the bruit became weak and transient. The radiation therapy was commenced, and after 2000 rads, the CCF had decreased in size. The radiation therapy was finished at a total dosage of 3600 rads. On the patient's discharge from the hospital, some visual impairment remained, so hypotensive drugs were continued. The symptoms gradually improved. It was confirmed by the angiography one year that the CCF had completely disappeared, and there was no recurrence in the ensuing 12 months.
We wish to emphasize that the decrease of systemic blood pressure brings a decrease of pressure and flow of the shunt with consequent thrombosis. This is a new method for the treatment of small vascular anomalies.

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Ligation of the external carotid artery (ECA) and selective artificial embolization of the ECA and its branch have been applied to the spontaneous carotid cavernous fistula (SCCF). However, these techniques were not effective for the SCCF fed by the internal carotid artery (ICA). Moreover, ICA occlusion at the fistula of the low flow dural AVM has been reported to be risky. We have promoted complete spontaneous cure of the SCCF by repeated Matas' manipulations.
Case 1) A 65-year-old female was admitted to our clinic complaining of left proptosis, restricted eye movement, impaired visual acuity and chemosis. Serial and cineangiography revealed a left SCCF fed by the ICA through the meningohypophyseal trunk and drained into the ophthalmic veins. Matas' manipulation was applied to the left common carotid artery starting from 5 min/day and increased gradually to 20 min/day for four weeks. The symptoms subsided, and the shunt disappeared angiographically.
Case 2) A 66-year-old female was admitted to our clinic complaining of right oculomotor palsy, trigeminal neuralgia and slight proptosis. Serial and cineangiography revealed a right SCCF fed by the ICA through the meningohypophyseal truuk and drained into the petrosal sinuses. Matas' manipulation for 20 min/day was applied to the right common carotid artery for two weeks until the oculomotor palsy subsided. As pulsatory tinnitus appeared about a week later, Matas' manipulation for 30 min/day was continued every day for a month. Then the symptoms subsided, and the shunt disappeared angiographically. It seems worthwhile to try repeated Matas' manipulation prior to surgical and/or intravascular surgical intervention for SCCF.

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A case of traumatic carotid-cavernous fistula (CCF) treated with Debrun's detachable balloon was reported. A pseudoaneurysm was detected because of deflation of the iodine-inflated balloon. A 51-year-old woman was struck on the left frontotemporal area on November 21, 1982, and she began to complain of a bruit in the left frontal area about one hour after the injury. Progressive proptosis, pulsatile exophthalmos, conjunctival congestion and retinal hemorrhage of the left eye became apparent two months later. When examined on admission, she had developed left oculomotor, trochlear and abducens nerve palsy. The left carotid angiograms showed a CCF located between the anterior ascending and horizontal segment of the internal carotid artery. She was treated by endoarterial silicone-inflated balloon catheterization, the bruit disappearing immediately after the embolization. A carotid angiogram was repeated after the treatment because the patient complained of recurrence of the bruit. This disclosed a reappearance of the CCF due to migration of the balloon. The second attempt at embolization failed because of severe spasm of the internal carotid artery. Finally, the CCF was occluded with an iodine-inflated balloon under general anesthesia. Shortly after the last treatment, clinical signs and symptoms completely disappeared.
Repeated angiograms demonstrated a pseudoaneurysm probably due to deflation of the iodine-inflated balloon, though no noticeable neurological deficits have been found to date. Some aspects of pseudoaneurysm following the detachable balloon technique for traumatic CCF were briefly discussed.

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Two cases of arteriovenous malformation fed by small arteries and lying within the basal ganglia were presented.
Cerebral angiography revealed an abnormal vascular network like moyamoya disease. It also showed that the drainer had a particular orientation with an umbrella- or medusae-like pattern radiation toward the single draining vein like a venous angioma.
In one case, the malformation, which involved the putamen and the insula, total extirpation was carried out. In the other case, the malformation, which involved the area from the frontal base to the caudate nucleus, was treated only by feeder clipping.
The obscure locations of these lesions made them more difficult to resect than the usual arteriovenous malformation.

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In has been believed for a long time that total nidus removal is the best method of surgical treatment for intracranial arteriovenous malformation. Ordinary procedures are as follows : first, clipping of the feeding arteries, then nidus stripping and finally cutting off the draining veins. So that operative brain damage was significant, and this was one reason to avoid total removal of deepseated arteriovenous malformations. There have been many cases of this disorder in which total extirpation is difficult, and they have been dealt with by feeder clipping, often in vain. We suppose that the main aim of arteriovenous malformation surgery should be changed to draining vein obstruction. For this purpose it is neccessary to use a different route of invasion and/or divided operation, serial CAG during the operation and bipolar coagulation of nidus vessels. After many experiences, we knew that when serial CAG showed no visualization of the nidus, it became possible to obstruct the main draining vein. If all drainers were obstructed and revealed any abnormal bulging or hemorrhage from the nidus, they might be rendered harmless by thrombosis in a short time. Thus, nidus stripping is of no use.
Practically, at first, every feeding artery and draining vein except the main drainer are obstructed. Then, the main drainer can be temporarily clipped when the nidus is invisible by serial CAG. After observation of the nidus for about 30 minutes for abnormal local bulging or hemorrhage, permanent obstruction of the main drainer is performed. This is the entire procedure.
If residual arteriovenous malformation is revealed postoperatively, the second operation must be planned in the same way, and usually almost all nidus vessels are thrombosed and treatment is quite easy, according to our experiences. We have successfully treated many cases of arteriovenous malformation by this method and believe in its usefulness.

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