For making an experimental subarachnoid homorrhage that closely simulates human aneurysmal rupture, a needle previously inserted into the posterior communicating artery is subsepuently withdrawh by traction on a thread. Biphasic sqasm is revealed by measurement of cerebral blood flow and angiography after rupture of the artery; the early spasm lastsd 60 minutes and the late spasm begins 3 or 4 hours after subarachnoid hemorrhage and continues for several days.
Effects of vasoactive drugs and sympathectomy on the early and late spasm are studied utilizing vertebral angiography. Papaverine and isoxsurprine injections into the vertebral artery release both early and late spasm, which suggest these spasm are a manifestation of the local muscle contraction. The antiserotonin agent, methysergide, releases the early spasm, while it does not relax the late spasm. The alpha blocking agent, phentolamine, releases the early spasm, but it scarcely relaxes the late spasm. In sympathectomized dogs, the early spasm is revealed milder than in the untreated dogs. However, the late spasm is demonstrated to the similar extent as seen in the untreated dogs. The authors emphasize an etiological difference in the early and late spasm.
The study on microcirculation in the hypothalamus using perfusion technique with colloidal carbon after rupture of the artery reveales that spasm is induced with ischemic changes in the hypothalamus. Aside from blood chemicals, the authors speculate that changes in sensitivities of the cerebral blood vessels which might be influenced by the vasomotor center in the hypothalamus should play an important role in producing vasospasm.

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During the past three years from 1971 to 1973, 413 cases of cerebral aneurysms have been experienced in our clinic, in which direct intracranial operation was carried out mainly by the ligation and/or clipping of the aneurysm neck in 393 cases. Post-operative statistics showed that the cases which were operated on within the first week after the last subarachnoid hemorrhage, had the highest mortality and morbidity rate. A closer analysis of the 64 cases with surgery within the first week revealed that the highest and second highest mortality and morbidity rates were in cases with operations on the 3 rd and 4 th days following the last hemorrhage, respectively. However, only one of 17 cases operated on within 48 hours died. And furthermore follow-up studies, taken 6 months to 3 years after discharge, showed that the remaining 16 cases were working and leading a useful life.
In the study of 31 cases operated on within the first 4 days after the aneurysm rupture, the most remarkable fact is that the post operative results were good in cases with surgery on the 1st or 2 nd day, even if the pre operative conditions were severe, such as Grade III or IV by Hunt and Hess' classification. On the contrary, in cases operated on in the 3 rd or 4 th-some of them Grade I or II, so-called “good risk patients”-deteriorated and cases graded III and IV all worsen or died.
The important factors affecting the patient's condition after an aneurysm rupture seem to be the degree of the increased intracranial pressure caused by the hematoma and circulatory disturbance of the cerebrospinal fluid and the degree of brain destruction caused by the intensity of the arterial blood from the rupture. Therefore it is reasonable that an early aneurysm surgery, within 48 hours, including the removal of the hematoma and the reduction of the high intracranial pressure by ventricle drainage is effective not only to prevent a possible fatal re-rupture, but also to improve the patient's poor pre-operative condition. In addition an operation within 24 hours greatly lessens the possibility of the occurrence of post-operative vaso-spasms by the removal of the subarachnoid clot existing around the brain artery, which may play a major role in producing vasospasms. The surgical results closely correlated with the incidence of vasospasms which were: 14.3%, 60%, 83.3%and 75% for the 1st, 2nd, 3 rd and 4 th days respectively.
Although in cases operated on, in 3 rd and 4 th days continuous high intracranial pressure aggravates the conditions, the most detrimental factor affecting the poor surgical results may be attributable to cerebral infractions due to vasospasm, especially those which appear in the postoperative stage.

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It is well recognized that the communicating hydrocephalus following the rupture of intracranial aneurysms is one of factors which causes the disturbance of consciousness.
In this report we analyze the surgical experience with this complication and discuss the etiological factors.
1. The communication hydrocephalus following the rupture of intracranial aneurysms are divided into acute and chronic form.
2. Acute communicating hydrocephalus may develop within 24 hours after onset and the frepuency is about 10% (6 out of 66 cases).
3. Ventriculocranial index on carotid angiogram is the reliable prognostic measure of shunting procedures.
4. Intraventricular pressure is high in acute communicating hydrocephalus and becomes normal in chronic stage.
5. The incidence of chronic communicating hydrocephalus is about 10% (6 out of 66 cases).
6. There are two types of chronic communicating hydrocephalus. One developes from and another developes gradually after onset.
7. The intraventricular pressure of the former case is high in acute stage and the latter shows the intermittent high pressure lasting for 20-30 minutes.
8. Indication for shunting procedures should be determined by combination of clinical pictures, ventriculocranial index, findinge of cisternography and EEG. Our operative criteria are presented.

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Disturbance of consciousness in acute stage, so far, has been classified by using a set of technical terms such as coma, stupor, somnolence, confusion and so on. However, the definition of such terms has a different nuance from one clinic to another, and this made the comparison of the data on the same topics incomplete and incorrect. Because of this, it is true in most neurosurgical clinics in Japan that the severity of the disturbance of consciousness has long been described with grades of the responsiveness to different stimuli laden to the patients.
In order to obtain an universal classification on this matter, possibility ef quantitative and qualitative gradings has been searched by means of combining the following three factors; arousal, responsiveness to mechanical and verbal stimuli, and the contents of consciousness. Table shows our proposal of quantitative and partially qualitative grading of the disturbance of consciousness in acute stage. Deep coma, coma and semicoma in the contemporary usage belong to grade III in our classification; stupor, lethargy, hypersomnia, somnolence, and drowsiness belong to grade II, and delirium, confusion, and senselessness belong to grade I.
Features of this new grading of the disturbance of consciousness in acute stage have been discussed.
Table: New grading of level of consciousness in acute stage (So-ocalled 3-3-9 formula) Grade III. The patient is unable to be arousen with any forceful mechanical stimulus, and
(300) 3. is not responsive at all except for change of respiratory rhythm,
(200) 2. is responsive with slight movements including decerebrate response, or
(100) 1. is responsive with combative oropurposeful movements.
Grade II. The patient is able to be arousen with mechanical or verbal stimuli, and
(30) 3. is barely arousen with repeated mechanical stimuli,
(20) 2. is arousen with loud voice or shaking shoulders, or
(10) 1. is arousen easily with usual voice.
Grade I. The patient is awake without any stimulus, and
(3) 3. is quite senseless and cannot tell even his own name or date of birth,
(2) 2. is disorientated to time, place, and person, or
(1) 1. is seemingly alert but not fully so. “R” and“Inc” are added to the grading in case of restlessness and incontinence.

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破裂脳動脈瘤によるくも膜下出血の意識障害は, 出血, 血腫のための直接の脳傷害, 頭蓋内圧亢進, 脳血管攣縮のための脳血流低下, 脳浮腫等, 多くの原因が複雑に関与し合っている。 破裂脳動脈瘤再出血防止と同時に又, それ以前から, これらくも膜下出血の病態の改善に努めることが, 意識障害の回復と予後の向上を図る上には必要である。 pool & PottsはじめMcKisock,Hunt等は破裂脳動脈瘤の手術時期について, 術前のgradeの悪いものは手術予後も悪く, むしろ手術時期を遅らせるべきとの考えをもち, 一般にdown hill courseをとる例には手術を遅らせるとするのが現在の傾向かと思われる。
出血のための直接の脳傷害はその程度によって, くも膜下出血患者の予後をその初期で決定ずけるものであり, 重篤なものは保存的・手術的治療の範囲を超えるものもある。 しかしくも膜下出血では脳動脈瘤破裂のためのくも膜下腔への出血が, くも膜下腔での髄液の通過障害, 吸収障害, 更には脳室内血性髄液の髄液産生促進等のことからも, 急性の頭蓋内圧亢進を来たすことが知られている。 我々はくも膜下出血に限らず外傷性, 非外傷性頭蓋内出血では, 出血, 血腫による直接の脳傷害のための意識障害もさることながら, それに加えて髄液の循環障害, 吸収障害のための急性, 慢性の頭蓋内圧亢進による意識障害が更にオーバーラップし, 一層意識障害を増悪させていると考え, 脳室ドレナージを併用し, 脳室内圧をコントロールし, 頭蓋内圧亢進を低下させることによって良好な結果を得ているので報告する。

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