An extremely rare case of arteriovenous malformation (AVM) in the region of the middle cerebral artery, the main trunk of which was occluded asymptomatically, is presented. Immediately followed by an uneventful excision of the entire AVM, a massive brain swelling occured unexpectedly. This was successfully treated with high-dose barbiturate therapy associated with other standard measures of controlling increased intracranial pressure. Based on this experience, the author stressed that massive intraoperative brain swelling possibly due to normal perfusion pressure breakthrough can also occur in patients with not so large AVMs, provided the preoperative impairment of autoregulation is severe enough. In addition, high-dose barbiturate therapy will be the method of choice for the treatment of massive intraoperative brain swelling.

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The therapeutic results of our 104 cases of cerebral arteriovenous malformation (AVM) during an 18-year period were reported. At the first admission, 73 patients were operated on and 21 were treated conservatively. One patient died immediately without surgery.
Four of the 21 conservatively treated patients were readmitted for rebleeding and one of them died. The three others were successfully treated by a total removal, silicone-ball embolization and carotid ligation, respectively. The latter patient died latter at the third admission due to repeated bleeding.
Fifty of the 73 operated AVMs were doing well by successful total removal of the AVMs, and three AVMs could be totally removed at the second admission for rebleeding after previous palliative surgery. As the AVMs were thought to be large with a high shunt flow, staged operations were performed in the three cases. One of two cases with partial ligation of the feeding arteries resulted in repeated bleeding after the surgery and the other died of rebleeding.
Fatal cases after direct surgery were restricted to large, deep-seated medial parietooccipital AVMs, which could not be managed without severe difficulties because they had multiple blood supplies from the anterior, middle and posterior cerebral circulation. These AVMs need preoperative, deliberative discussion.
For five AVMs that were larger or difficult to reach and resect, we app lied with good result silicone-ball embolization in two, alon alpha embolization in one and fibrinogen-thrombin chemical thrombolizations in two. These patients are doing well with no rebleeding. The carotid artery or feeding artery ligation method is not recommended from our experiences with cases of rebleeding.

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Six Japanese patients with cerebral arteriovenous malformation were treated by radiosurgery at Karolinska Hospital. These patients were angiographically followed up for one to three years. In four cases, the lesions were disappeared angiographically and in two diminished in size. Radiosurgery could be evaluated as a promising technique for future neurosurgery, not only for cerebral arteriovenous malformations, but also for neoplastic lesions of rather small size.

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The options for the management of cerebral arteriovenous malformations (AVMs) must be balanced against the risk-effectiveness of various therapies while considering the natural course of these lesions. The use of conventional radiotherapy has been advocated in the treatment of inoperable AVMs (such as deep-seated and/or large ones) in the past, but in spite of some occasional successes, this technique has generally been considered ineffective and has been abandoned. Recently, Drake emphasized the value of radiation therapy for such lesions.
We have treated one patient with stereotactic radiosurgery and two with conventional radiotherapy and will report the follow-up results. We will also discuss the problems of radiation treatment for AVMs as compared with conventional radiotherapy with radiosurgery.
Case 1 was a 10-year-old girl who had a small AVM (about 15×15×10mm) fed by the anterior choroidal and lateral branches of the posterior cerebral artery and drained through the basal vein situated in the right medial temporal lobe extending into the internal capsule She had only homonymous hemianopsia one month after hemorrhage. An operation was not performed because of the risk of sacrificing the internal capsule and problems in the patient's family,
Radiosurgery was undertaken four months after onset; two radiation fields with 14-mm collimetors were used and 25 Gy each were given to the nidus of her AVM (total dose was 50 Gy) The follow-up angiography revealed gradual reduction in size, and, 14 months after the irradiation, complete obliteration was detected. Twenty months after the treatment, CT showed minimal contrast effect in the previous site, but she is doing well except for only homonymous hemianopsia.
Case 2 was a 21-year-old male who had a medium-sized (about 25×25×20mm) AVM fed by perforators from the anterior cerebral, middle cerebral and posterior communicating arteries and drained into the basal and middle cerebral veins located in the right temporal lobe adjacent to the temporal horn of the lateral ventricle. An operation was not performed because of the location of the AVM and the fact that there was no neurological deficit. He was irradiated using 10 MV X-rays through two 40×30mm and four 30×30mm portals with a total of 21 Gy in 16 treatments over 27 days, 0.5-3 Gy per taertment. The nidus of his AVM was encompassed by a 90%isodose level of the maximum dose on the dose reconstruction plan.
The follow-up angiography showed a slight reduction in size and hemodynamic changes 16 months after initial treatment, so that he received an additional 30 Gy through a 20×20mm portal with the horizontal arc rotation method in 20 fractions over 29 days. He has no neurological deficit three months after the second treatment.
Case 3 was a 19-year-old female who had a medium-sized (30×25×20mm) AVM fed by perforators of the anterior, middle and posterior cerebral arteries and drained into the thalamostriate vein situated in the right caudate head. We did not perform surgery because of the risk of sacrificing the internal capsule and the fact that she had no neurological deficit.
The irradiation was given with a total dose of 40 Gy in 20 fractions over 29 days through four 40×40mm portals with 10 MV X-rays. The nidus was encompassed accurately by a 90%isodose curve on the dose reconstruction plan. She has no neurological deficit six months after the treatment.
With regard to the literature dealing with radiation treatment for AVMs and also considering our experiences, the following problems may exist: 1) size of the AVM (especially in the nidus), 2) accurate determination of the irradiation field and dosimetry, 3) systematic and careful planning of the follow-up, 4) appropriate choice of radiation method and determination of the total dose to the target, 5) the risk of rebleeding during the latent period before the obliteration,

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A case of arteriovenous malformation of the right cerebellopontine angle region distinctly diminished by radiation therapy was reported.
A 49-year-old man was admitted complaining of headache, vomiting and walking disturbance.Enhancement CT and angiography revealed a large arteriovenous malformation of the right cerebellopontine angle region. The patient was treated with linac of 6,400 rads in total tumor doses after V-P shunt. He gradually improved, and it was verified by CT and angiography that the malformation had distinctly diminished after the radiation therapy.
The effectiveness of radiation therapy for AVM was discussed.

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Feeder clipping of cerebral arteriovenous malformation was performed in five cases in our clinic prior to 1971. Their results in long-term follow-up were studied and reported. Intracerebral hemorrhage had occurred in one case and re-enlargement of nidi was seen in the other four. Three of these five patients were operated on again, and the nidi were removed completely. Moderate neurological deficits remained in all three cases. We would like to emphasize that clipping of the feeding artery does not reduce the possibility of hemorrhage from the arteriovenous malformation. Recently, we experienced one patient who was operated on by the “two-stage” method, and the nidus was removed completely following feeder clipping at the first-stage surgery. Feeder clipping might be efficient for pretreatment in connection with radical surgery.

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Six out of 80 cases of intracranial arteriovenous malformation (AVM) were operated on by clipping of the feeding artery (feeder clipping) during the years from 1978 to 1983. Two patients were operated on by two-staged feeder clipping, two were treated by embolization and feeder clipping, and the rest were feeder clipping and staged excision. The size of the AVM and the flow of the A-V shunt were decreased in all cases.
In this series, the authors considered the indications of feeder clipping of AVM are as follows;
1. huge or deep unresectable AVM
2. clinical pictures
1) mass effect
2) progressing stroke by the steal phenomenon
3. high flow of the A-V shunt
Feeder clipping, however, involves some problems such as confirmation of the feeder during the operation, a rapid change of hemodynamics or normal perfusion pressure breakthrough and longterm follow up. The authors have coped with difficulties in performing angiography during the operation, in maintaining the systemic hypotension during and after the operation, in measuring the regional cerebral blood flow and in proceeding with the embolization or staged operation. The authors confirmed that feeder clipping of AVM is not ideal, but of supplementary value in some cases.

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A case of optico-chiasmal, hypothalamic arteriovenous malformation (AVM) operated on with feeder clipping was reported.
Case: A 21-year-old male with an attack of subarachnoid hemorrhage was admitted to our clinic on August 28, 1983. Neuroradiological examinations disclosed AVM at the suprasellar and hypothalamic regions. Superselective angiography using a micro-balloon-catheter clearly showed fine feeding arteries arising from the bilateral internal carotid artery and the right posterior communicating artery. The first feeder clipping was performed one month later. Operative findings were optico-chiasmal, hypothalamic AVM. Postoperative angiography showed decreased blood supply from the ICA, but increased blood supply from the posterior circulation. Although the postoperative course was uneventful, the second feeder clipping will be performed against the feeders from the posterior circulation.
Feeder clipping is often elected as the alternative treatment for AVM that is not amenable to direct excision. Graded feeder clipping may be a better procedure than one-step clipping because of its safety and effectiveness in reducing the blood supply to the lesion.
Superselective angiography using a micro-balloon-catheter is quite useful not only for determining the feeding arteries precisely, but also for evaluating the hemodynamics of AVMs.

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We presented eight cases of arteriovenous malformation in the vincity of the medulla oblongata, located ventrolaterally at the cervicomedullary junction.
All patients developed subarachnoid hemorrhage and the initial symptoms were not specific except for severe nuchal rigidity and headache. Four cases were surgically treated. Satisfactory results were obtained by clipping of the feeding arteries and coagulation of the abnormal vessels with a bipolar coagulator. Three patients died, and two of them were autopsied.
Bilateral vertebral angiography is the best method for diagnosis and the open mouth projection is essential because shortened vascular figures of vertebral arteries can be corrected and because abnormal vessels can usually be found in the open mouth space. In our cases the C₂ radiculomedullary artery, anterior spinal artery, posterior spinal artery and the abnormally dilated artery branching from the posterior inferior cerebellar artery and vertebral artery to flow into the lateral-inferior portion of the madulla oblongata participated as feeding arteries. The draining veins empty into the anteromedian medullary vein, transverse pontine vein and petrosal vein cranially and into the desending anterior spinal vein and intervertebral venous plexus caudally.
As the lesions were located at the lateral and ventral surface of the medulla oblongata, total removal was difficult by surgical procedures. If the anterior spinal artery is not the main feeding artery, the purpose of the operation can be attained by clipping or ligaturing the other feeding arteries and then coagulating the arteriovenous malformation located in the medulla oblongata. It is impossible to treat this surgically by the dorsal approach. It may be necessary to resort to other methods, such as the transclival approach.

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The purpose of this study is to clarify the surgical indication for intracerebral arteriovenous malformation (AVM) based on retrospective study.
The case records of 150 patients with cerebral AVMs who were admitted to the Department of Neurosurgery, Tokyo Women's Medical College (TWMC) between 1969 and 1984 were reviewed. The clinical manifestation was mostly related to hemorrhage and less frequently to epilepsy or to a cerebral steal syndrome, and the risk of hemorrhage in AVMs tended toward small, deep-seated lesions and infratentorial lesions.
Eighty malformations were completely excised, in nine patients only a partial excision could be carried out, in eight occlusion of feeding vessels was done and 53 cases were followed without surgery for from six months to 29 years.
Good results were obtained in the 80 patients treated with total excision, operative mortality was 3.7% and total mortality 8. 8%. Results of partial excision were variable, in two cases, death occurred after another hemorrhage and six patients had a good outcome. Forty-six of the 53 nonsurgical patients received conservative medical treatment. The duration of follow-up ranged from six months to 26 years. Forty-two cases (91. 3%) had a satisfactry outcome and in two cases, death occurred after another hemorrhage.

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Four cases of dural arteriovenous mulformation (AVM) in the posterior fossa are described. The first patient, a 47-year-old man, had symptoms of intracranial hypertension and bruits on the right occipital region. He was treated by ventriculoperitoneal shunt surgery, and intracranial hypertension improved. The second patient, a 58-year-old woman, and the third patient, a 63-year-old woman, had episodes of unconsciousness and bruits on the bilateral occipital regions. The second patient did not have an episode of seizure after conservative treatment with an anticonvulsant. The third patient was treated for embolization of the bilateral occipital arteries with Biobond (EDH-Adhesive), and the bruits and the seizure improved without an anticonvulsant. The last patient, a 33-year-old woman, had left exophthalmos, conjunctival chemosis and bruits on the left orbital and occipital regions. She was treated for embolization of the bilateral occipital arteries with Biobond. The exphthalmos and conjunctival chemosis disappeared, but the bruits were not changed. Embolization was also performed on the posterior branch of the left middle meningeal artery, which was the main feeder of her dural AVM, and the bruits decreased.
The authors have not undertaken a radical operation for dural AVM because of the high risk of the surgery and the possibility of recurrence of the AVM. Therefore, slight bruits remain in all patients now. However, all patients returned to a useful daily life. Consequently, we thought that embolization of the main feeders of dural AVM should be the first choice before a radical operation is performed.

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Intracranial dural arteriovenous malformation (dural AVM) is one of the most intractable cerebrovascular diseases.
Recently, the interventional radiological technique has been available for this lesion, and the results have been reported to be satisfactory by some authors. Nonetheless, it is certain that many patients are troubled with remnants or recurrences of such lesions.
At first, the authors stress the importance of evaluation of venous hemodynamics by means of cineangiography for reasonable selection of the method of treatment.
This series includes two cases of spontaneous carotid-cavernous fistulas and two of dural AVM in the posterior fossa. They were divided into two types from the viewpoint of venous hemodynamics. The one is the slow-flow dural AVM, which manifests stagnation of contrast material in the superior ophthalmic vein in cases of spontaneous CCF or cortical venous reflux with sinus obstruction in cases of dural AVM in the posterior fossa. The second is fast-flow dural AVM, which shows no evidence of the above. In this series, Cases 1, 2 and 3 belong to the former type, Case 4 to the latter.
In addition, the authors indicate the plan of treatment in our institute and discuss the application of radiotherapy.
Finally, we also stress the postoperative follow-up examination by means of cineangiography.

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From 1981 to 1984, 13 cases of so-called spontaneous intracerebral hematoma were treated in our hospital. Nine of these patients were male and four were female. They ranged in age from 27 to 67 years with a mean of 51. The location of the hematomas detected by CT was as follows: five in the frontal, four in the parietal, four in the occipital, three in the temporal and three in the parietal and occipital regions, respectively. One patient had an infratentorial hematoma. Twelve hematomas were located on the right side and seven on the left side. Headache was the most common symptom, and hemiparesis, aphasia, hemianopia and mental or psychic abnormality were manifested according to site and extent of the hematomas. Disturbance of consciousness was rather mild at the first attack of intracerebral hematoma. Angiographic examinations revealed a small angiomatous malformation in only two cases. Hematoma was removed surgically, and the wall of the lesion was carefully examined by surgical microscope to find any causative vascular abnormalities. Thus, three small arteriovenous malformations, one cavernous angioma and one small plexiform angioma were detected by pathological examination of specimens removed from the hematoma wall.
Rebleeding occurred in five out of the 13 patients at one to 18 months after the initial hemorrhage, and one showed second and third hemorrhage at three and 10 months, respectively. Rebleeding occurred at the same site in two cases and at a different site in three. We could not detect any small vascular malformations by arteriographic examinations in the rebleeding group. Hewever, fine torturous or tiny tangled arterioles around small arteries were demonstrated on the late arterial or precapillary phase of arteriography in three cases. Histopathological examination of specimens from the hematoma wall in these cases revealed marked arteriosclerotic changes with splitting and duplication of the internal elastic lamina.
The prognosis of rebleeding cases was discouraging. Four patients died and one remained in a vegetable state in our series. On the other hand, the clinical course of eight patients without rebleeding was uneventful.

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Neck clipping of an aneurysm of the internal carotid artery situated in the cavernous sinus is difficult because of the anatomical features. Thus common carotid ligation or trapping with STA-MCA anastomosis is the usual choice for such an aneurysm. We succeeded in clipping the aneurysmal neck situated in this portion through a contralateral pterional approach.
A 65-year-old man suffered from severe headache and epistaxis. He was nearly alert and had signs of meningeal irritation. CT scanning revealed subarachnoid hemorrhage. Left CAG demon-strated a C3 portion aneurysm projecting medially. The aneurysm, 5mm in diameter, was located proximally apart from the origin of the ophthalmic artery. On the 26th hospital day, a direct ap-proach was successfully undertaken.
The technical procedure of the operation in this case was demonstrated on video and discussed in this paper.

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