The purpose of this study is to clarify significance of both induced mild hypercapnia and mild hypertension as preoperative tests predicting postoperative result of STA-MCA bypass on functional recovery of ischemic brain.
Cerebral ischemia was produced by occlusion of canine middle cerebral artery and changes of somatosensory evoked potentials (SEP, V₁) and regional cerebral blood flow (rCBF) were monitored for three hours following production of ischemia, under CO₂ inhalation or with a controlled intravenous infusion of Angiotensin II
From this study we obtained next results.:
1) In mild ischemia whose rCBF was decreased by 20 to 40% compared to control, rCBF and SEP (V₁) significantly recovered during artificially induced mild hypercapnia (PaCO₂ 43 to 55 mmHg). However, mild hypertension caused no or minimal changes on rCBF and SEP (V₁) in the ischemia of this degree.
2) In moderate ischemia, rCBF of which reduced by 40 to 60% compared to control. rCBF and SEP (V₁) were significantly restored by artificially induced mild hypertension. Conclusion:
Induced mild hypercapnia and mild hypertension methods are hopeful as preoperative tests predicting postoperative result of bypass surgery. However, care is needed on assessing the results of these tests, since response of cerebral arteries by two activation methods depends on degree of ischemia.

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The middle cerebral artery of dogs was occluded by a clip and the collateral blood supply was compromised by subjecting to hemorrhagic hypotension for 1 hour. Following restoration of the systemic blood pressure by infusion of the shed blood, the clip was permanent and removed at to different times. The first group represented animals which were kept MCA clipped for 24 hours (permanent occlusive group). In the second group, MCA clip was removed after 24 hours, then the involved area was recirculated. The third group was removed MCA clip after 4 hours and thereafter was recirculated for 20 hours in the involved area.
After 24 hours in the gray and white junction of ischemic area, hemorrhage from severe iscmemic damaged venules was observed in the three different groups. While in the iscmemic cortex, capillaries of the first two groups were packed with erythrocytes and platelets, but were not broken down. In the third group, hemorrhage cccured from the necrotic capillaries which were accompanied with the tapering and discontinuity of the endothelium and the destruction of the basement menbrane.
In our models, the last two groups as compared with permanent occlusive group were developed more severe ischemic damage by restoration of the blood flow. In the second group, strongly increased hemorrhage occured in the gray and white junction. The third group was increased brain edema and also occured hemorrhage in the ischemic cortex.

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Recently the STA-MCA anastomosis (STA... superficial temporal artery, MCA... middle cerebral artery) is often applied for the case of the stricture or occlusion of MCA trunk or the internal carotid artery. The purpose of this paper is to clarify the difference of the nature of the arteriosclerotic change of both arterial branches used for this anastomosis histologically comparing to other cerebral arteries.
Histological specimens were taken from surgical biopsy as well as fresh autopsy brain and were examined microscopically and electron-microscopically. As the biopsy material, specimens were taken; one from the arterial stump of MCA at the STA-MCA anastomosis and another small piece from the arteriole in the anterior portion of the temporal lobe. As the autpsy specimen, the brain was irrigated with glutal solution soon after death and cerebral arteries were examined systematically.
As the result, the following findings were confirmed. 1) The arterial wall of the STA was almost three times thicker than that of the cortical branch of MCA in ordinary condition. 2) The arteriosclerotic change of the cortical branch of the MCA was mostly slight and STA often showed characteristic thickening of intima which was composed of mature smooth muscle cells and massive collagen fiber. 3) The arteriosclerotic change was apparently more marked in the MCA trunk and the lenticulo-striate arteries than the cortical branch of MCA and STA.

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The purpose of this study is to consider the surgical indication for STA-MCA anastomosis from the preoperative angiographic point of view, and to find what kind of the preoperative angiographic findings bring a good blood flow through the anastomotic artery.
29 patent cases of STA-MCA anastomosis were used for the material of this study. The results were as follows
1. The large diameter of the STA brought a good anastomotic blood flow.
2. Delayed filling of the MCA via collateral circulation and/or back flow brought a good anastomosis blood flow too.
3. Although, it was thought the surgical indication was controversial in a case of completed stroke from the clinical point of view, the surgical indication might be accepted from the angiographic aspect even in a case of completed stroke.

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To evaluate a functional reversibility of ischemic brain and CT-findings, correlative studies for CT-scan and cerebral angiography or drug-induced EEG or somato-sensory evoked potential test (DEE-test) or clinical results has been performed on 65 cases of middle cerebral artery trunk occlusion.
Fifteen out of 52 cases with conservative treatment were confirmed as spontaneous recanalization of occluded artery by angiography.
External-Internal Arterial Bypass (EIAB) were carried out in 9 cases, EIAB with external decompression in 3 cases and external decompression in one case.
Based on the localization and extent of infarction, three cases were classified to four groups concerning CT-abnormalities such as total type (32 cases), cortical or subcortical type (14 cases), basal ganglionic type (18 cases) and normal type (1 case).
Angiographical findings such as occluded sites, collateral circulation via leptomeningeal anastomosis and filling of lenticulostriate arteries were roughly corresponded to the CT-abnormalities.
Clinical results of conservatively treated cases show that good functional recovery was gotten in the normal, cortical or subcortical and basal ganglionic type. Except 2 cases prognosis was very poor in the total type. Good effects after spontaneous recanalization of occluded artery were obtained in some cases of cortical or subcortical and basal ganglionic type infarction.
When the activation of SEP after induced hypertension was recognized, good surgical results has been led in both acute and chronic stage except total type infarction. If the SEP is activated by glycerol., external decompression will be recommended with or without EIAB in the acute stage.

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Using our model of unilateral complete infarction in the dog, we have undertaken a study of the sequential changes in CT findings during the acute period of brain infarction. It was found that low density areas first arise 3 hours after blood vessel occlusion. After 6 hours, these areas became more distinct. Significant differences in the CT values of the occluded and non-occluded hemisphere were seen 2 hours after vessel occlusion. Histological changes were also investigated.

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Thirty six cases with unilateral carotid artery occlusion were studied to elucidate the indication of surgical treatment by collateral circulation and CT findings.
There were three types of collateral pathway which were via Willis ring, via leptomeningeal anastomoses and transophthalmic collateral circulation. Classification of cerebral infarction by CT fiindings were IC territory type (17%), MC territory type (36%), perforators area (basal ganglionic region) type (8%), border zone type (33%) and no infarction type (6%). Angiographical fiindings of collateral circulation correlated well with the CT findings and clinical features. Transophthalmic and leptomeningeal anastomoses were insufficient and good collateral circulation through Willis ring was necessary to maintain the usefull life in many cases.
Eight cases (5 IC territory type and 3 MC territory type) developed severe brain swelling and neurological herniation signs. All conservatively treated cases died within a week after the onset due to secondary brain stem damage. In those cases, extensive surgical external decompression should be done not only for reducing mortality but also for improving morbidity. Decompression should be done until the early third nerve stage of downward transtentorial herniation.
Extra-intracranial arterial bypass (EIAB) was done in 14 cases (4 in acute stage and 10 in chronic stage). In 4 cases which were operated upon in acute stage, 2 cases of border zone type improved remarkably after bypass surgery. In 10 cases which the bypass operation was performed in chronic stage, 5 cases improved apparently and 3 cases were supposed to stop the deterioration of neuropsychological manifestations due to chronic low perfusion state. Border zone type by CT was good indication for bypass surgery. Perforators area type and no infarction type also have the indication for EIAB.
But in some cases, especially in acute stage, it is difficult to evaluate the effectiveness of collateral circulation and the functional reversibility after EIAB. Therefore, the analysis by the drug-induced EEG and somatosensory evoked potential (SEP)-tests which we have developed is important to decide the method of treatment.

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Radioisotope angiography following intravenous injection bolus of ^99mTc labelled red blood cells (Tc-RBCs) was performed pre- and post-operatively in seven patients of the superficial temporal artery-cortical branch of middle cerebral artery anastomosis (STA-MCA anastomosis). After setting the regions of interest in equal area over the left and right cerebral hemisphere on the sequential analog images, the radioisotope time-activity curve of each region of interest was obtained. The first derivative curve of its curve was calculated through Shimazu Scintipac 230, the interval between the first positive peak and the first minimum negative peak constitutes the mode of transit time. The mode of transit time of the operated hemisphere was decreased post-operatively less than pre-operatively in five patients that anastomosis was patent. On the other hand, the mode of transit time of the operated hemisphere was unchanged or increased post-operatively in two cases that anastomosis was not patent.
The vascular imaging with Tc-99m labelled red blood cells is qualitatively and quantitatively valuable for the detection of the patency of the STA-MCA anastomosis.

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Critical level of cerebral blood flow was estimated from 40 selected patients with ischemic cerebrovascular diseases (embolisms excluded) in comparative study with regional cerebral blood flow (rCBF) and computed tomography (CT). Regional CBF was performed by ¹³³Xe intracarotid injection method with 16 channel multidetectors, and the existence of low density area in cetrum semiovale was checked by CT scan. The results of extra-intracranial arterial anastomosis (EIAB) were also investigated in correlation to the rCBF study in 20 cases, based on the above study.
Mean rCBFs were ranged 13-26 ml/100g/min. in 13 patients with low density area in centrum semiovale on CT, and were ranged 25-49ml/100g/min. in 27 patients without low density in the area on CT. From these data, critical flow level was estimated 25-26ml/100g/min. (40-42% of normal) of mean flow.
In surgical group, the patients with preoperative mean rCBF between 25 and 30ml/100g/min. markedly improved after surgery.
These two results suggest that the EIAB operation should be done for the patients with critical flow level of ischemia as low as 25-30ml/100g/min. of mean flow.

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Reconstructive vascular surgery for TIA and RIND has been generally accepted. However the surgical indication of STA-MCA anastomosis for completed stroke is still controversial. In this report, we intended to evaluate an indication for extra-intra cranial anastomosis for completed stroke based on rCBF measurement and computed tomography. 38 patients with supratentorial ischemic cerecrovascular disease (TIA: 11, RIND: 11, completed stroke: 16) were investigated by angiography, CT scan and rCBF. rCBF was measured simultaneously over 16 regions of one hemisphere by non-invasive ¹³³Xe inhalation method. CT classification of supratentorial ischemic cerebrovascular disease are as follows. Ia: normal, Ib: brain atrophy, II: small size of focal low density, III: moderate size of focal low density, IVa: multi-focal low density, IVb: multi-lobar low density, IVc: diffuse low density.
It was revealed the small size of focal low density includes three clinical type (TIA: 4, RIND: 6, completed stroke: 6). It means those cases with three different clinical symptom had a same morphological lesion. All cases of this group shows relative small infarction localized in the basal ganglion or corona radiata on CT (so called“strategic infarction”). This result suggests that a boundary zone of reversibility of neurological symptom is found in this group. However, rCBF study in this group revealed various pattern, TIA showed slightly reduction of mean rCBF. In RIND the affected hemisphere showed moderately increased mean rCBF rather than unaffected side. Some number of these completed stroke were designated as minimal global reduction superimposed a relative focal ischemic area. The remainder had a severely generalized reduction of flow over the hemisphere.
In conclusion, cases showed small size of focal low density and minimal reduction of flow with relative focal ischemic area, even if they are clinically classified into complet stroke, are desirable candidates for STA-MCA anastomosis.

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In this presentation, a CBF study was performed by intracarotid infusion of Kr-81m in seven patients who underwent STA-MCA anastomosis for cerebral vascular occlusive disease.
In these patients, we studied especially the cerebral perfusion through extracranial-intracranial anastomosis by infusion of Kr-81m into the external carotid. We presented the procedure and results in these patients.
In each of the patients, the internal and external carotid were selectively cannulated by a teflon catheter which was connected to the output of the Kr-81m generator. The input of the generator was connected to a Harvard pump with 50ml syringe containing 5% glucose solution which was infused at the rate of 7. 5ml per minute. Infusion of the solution consequently milked Kr-81m from the generator into the carotid continuously at the same rate. The cerebral Kr-81m image which represented the perfusion, was depicted with the 5000-holes collimeter and gamma camera, and recorded on magnetic tapes. After completion of the CBF study, angiography was performed to confirm the patency of the anastomosis.
In these patients, the patency of the anastomosis and the degree of the extracranial-intracranial cross-perfusion were clearly observed by the external carotid infusion of Kr-81m.
Comparing with Xe-133 clearance method, this examination has a disadvantage that the absolute CBF values are not measured, but has an advantage that it is readily repeated immediately one after another because of its very shorthalf-life of 13 seconds. Thus this method has proven to be beneficial in studying the continuous CBF changes following hyperventilation or CO₂ inhalation.

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Pathophysiological study was made about the effect of ST-MC bypass surgery in the cases of“Moya-moya”disease and in the cases of ICA and/or MCA occlusion. Cerebral blood flow (CBF) was measured by use of Argon and medical masspectrometry (MEDSPECT II). CBF values were calculated according to Fick's principle. Cerebral oxygen consumption was calculated by arterial-jugular oxygen content difference and CBF.
In eleven cases of“Moyamoya”disease, marked decrease of cortical blood flow was characteristic. After bypass surgery increase of CBF was noted accompanied by increase of cerebral oxygen consumption.
In the cases with ICA and/or MCA occlusion, increase of CBF and cerebral oxygen consumption were also observed after ST-MC bypass surgery.
In the other three cases with ICA and/or MCA occlusion, the relation among CBF, mean arterial pressure and electroencephalogram was studied during drip infusion of trimethaphan. In all three cases, the widening of the range of autoregulation were noted after ST-MC bypass surgery.
From these evidences it was verified that ST-MC bypass surgery is effective to not only inprovement of CBF and cerebral metabolism, but also augumentation of cerebral circulatory reserve.

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Fifteen patients with occlusive lesion of major cerebral arteries underwent STA-MCA bypass operation.
Intraarterial pressure of the cortical artery of middle cerebral artery was measured by the canulation method. A 19 gauge tube is canulated into one STA and connected to a transducer. Antegrade middle cerebral artery pressure and retrograde middle cerebral artery pressure were recorded by the method of clipping of distal and proximal part of the middle cerebral artery.
As shown in Table 1, post operative improvement of neurological deficit was excellent in cases which showed the pressure above 40mmHg. In cases which did not improve after operation, even if the intra-arterial pressure over 40mmHg, occlusive lesion was at the origin of the middle cerebral artery or coexistent embolus was found on pre-operative angiogram.
The pattern and its degree of the collateral circulation are variable in cases by case, but, these pressure measurement revealed the expected functional capacity of the collateral circulation, the degree of development of the collaterals correlates with value of intraarterial pressure of middle cerebral artery.

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Intraarterial Pressure (IAP) of cortical MCA has been measured on 19 patients at the time of STA-MCA bypass for the treatment of cerebrovascular occlusive disease since 1973. The value of IAP has been considered to predict the degree of postoperative neurological improvement in stroke patients or to reflect the amplitude of N1-N2 component in the SEP. Clinically IAP was quite variable in the patients with ICA occlusion. IAP was lower in the patient with MCA stenosis (m=56mmHg) and MCA occlusion (m=44mmHg). Patients with Moyamoya disease had the lowest values of all (m=17mmHg). IAP seems to reflect mainly leptomeningeal anastomosis in the MCA occlusion and intraparenchymal anastomosis in Moyamoya disease. IAP in the patient with stroke revealed lower values (30.5±29.3mmHg) than the patients with TIA, or RIND (55±10mmHg, 56±18.5mmHg). Generally speaking, IAP reflected more or less the value of rCBF measured with Xe¹³³ clearance method.
Relationship between cortical IAP and CBF was investigated using hydrogen clearance method on experimental ischemia in dogs. MCA occlusion alone resulted in IAP drop only to 40% and occlusion of the ACA, ICA, PCom, MCA altogether to 35%. IAP of 60 mmHg seems to be critical; lCBF remains unchanged about 93 ml/100 gr./min above the value and drops parallel with IAP thereafter. Thus the same critical IAP might exist also in the clinical patient, below which rCBF would drop parallel with IAP and might lie between 45-50mmHg.

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In the performance of STA-MCA bypass operation for obstructive cerebrovascular disease, it is important to have knowledge of the hemodynamics at the time of surgery and to check the reactivity of anastomotic channel following operation. In EC-IC anastomosis, since an external carotid artery and the cerebral vessels which normally possess opposite reactivity to carbondioxide and other drugs, it is important to ascertain whether the flow through the anastomotic site is not governed by neurogenic control of an external carotid artery and determine the state of the anastomotic channel reactivity, but such means have not yet been fully developed. To elucidate these points, the authors performed the following studies. Experimental brain ischemia was mede and performed EC-IC anastomosis and subjected the anastomosed vessels to various load tests to detemine vascular reactivity.
Measured blood pressure and blood flow during STA-MCA anastomosis procedures in clinical cases and subjected patients to the same load test.
(1) Lingual-basilar anastomosis in dogs was performed after applying a clip to the proximal side of the basilar artery. Blood flow in lingual artery, basilar artery and anastomotic artery were measured respectively using an electromagnetic flow meter. The changes in blood flow following inhalation of CO₂ and administration of papaverine hydrochrolide, epinephrine and norepinephrine were recorded and the reactivity to apnea and elevation in blood pressure was also studied. The results revealed that the anastomosed vessels were controlled by the intracranial vesel reactivity.
(2) The mean blood pressure of the cortical branch of the middle cerebral artery in 13 cases measured during surgery prior to anastomosis was 38mmHg, which became 76mmHg after anastomosis. Those with value in excess of 30mmHg prior to surgery showed EP to he effective, while those with hypertension and completed stroke failed to show much clinical benefit. The STA mean blood flow volume as determined by electromagnetic flow meter immediately after anastomosis was 27.1ml/min.
(3) anastomosed channel reactivity was studied using a Doppler flow meter in 10 out of 32 cases who had undergone STA-MCA anastomosis. In cases with TIA and RIND who had shown definite improvement of neurological symptoms also showed good reaction to loads of CO₂inhalation, hyperventilation, but reactivity was decreased in completed stroke. The former is considered to reflect the reactivity of the anastomosed channel flow within intracranial small vessels, while in the latter as the vessels are supplying a territory which is in an irreversible state, although the state of blood flow in the STA is good, the reactivity of the small intracranial vessels was found to be poor.
It is considered that in the follow up patients who have undergone anastomosis, confirmation only by the fact that there is good blood via the STA by angiography is inadequate, and the study should be made to determine whether the bypass is functioning and reactive properly.

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A consecutive series of 60 cases of STA-MCA anastomosis were experienced in our service and the patency rate was 91.5% by angiographic proof. Namely, less than 10% cases had revealed poor patency. There are many factors which influence the shunt patency in bypass surgery. These are as follows: 1. Method of STA preparation, 2. Temporary clip, 3. Transient postoperative vascular occlusion, 4. Anastomotic angle between donor- and recipient artery, 5. Diameter of donor and recipient artery, 6. Intimal dissection of STA, 7. Duration of interception of blood supply with temporary clip and intraoperative perfusion pressure of the brain, 8. Formation of bony window, 9. Blood coagulability or other factors which exercise an important hydrodynamic effect to the blood stream.
Most of these factors have already been studied in some aspects, so it is reported chiefly about the item 4 in this paper.
The change of blood flow when a donor artery is anastomosed to a recipient artery with angle theta on forward blood flow, is shown, theoretically, in next three expressions.
(1)
(2)
(3)
Number one is the expression of balance in momentum. Number two is the equation of kinetic energy. Number three is the equation of continuity. From (1), (2), (3),
(4)
Consequently, one could assume that £13 is a function of the ratio of Q₂ to Q₃,
(5)
From another experimental model, if A₂=A and θ<45°, one could treat k as 0, therefore,
(6)
From expression six, it is easily understood that if theta is within 30°,Q₃ becomes a fairly large amount.
From the facts described above, it may be safely said that if one wishes to ensure the shunt patency of the bypass, one ought to anastomose the donor artery to the recipient artery with an angle within 30°of the adjacent artery which is responsible for the flood flow.

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In order to evaluate cerebral circulatory reserve, carotid artery compression of the contralateral side of main vascular lesion was performed under electroencephalographic and electrocardiographic control in 20 cases of STA-MCA anastomosis. Superficial temporal artery compression on the side of the operation was also carried out. EEG slowing was noted within 20 seconds on the compressed side in half of the cases when the carotid artery was compressed.
From the standpoint of cerebral circulatory reserve, these results were interpreted as follows: 1) Negative compression test gives no imminent decrease of the circulatory reserve. 2) Preoperatively positive responce indicates that the reserve through the collateral is not adequate and, therefore, good indication for the surgery. 3) In cases of significantly built-up collateral bypass by the anastomosis, slow wave activity was not provocated on the side of anastomosis (1 case), and time interval between digital compression and EEG changes delayed (2 cases). These evidences indicate that the reserve has been increased on the operated side in these cases. 4) If the evoked EEG abnormality is not altered postoperatively, blood flow via anastomosed bypass is suggested to be insufficient yet. 5) Focal EEG changes were evoked in 3 cases by the compression of the anastomosed STA, which suggests that effective blood flow in the area is dependent on the anastomosed STA.
These findings are well correlated with the results of angiographic study.

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It is generally accepted that some patients with cerebral ischemia have abnormal CBF dynamics, EEG findings or neurological findings not only in the ischemic regions but also in other regions of the ipsilateral and the contralateral hemisphere.
In nine patients with one-sided occlusion of the internal carotid artery, authers have observed abnormal findings of somatosensory evoked potentials (SEP) on the non-affected hemisphere in the resting state and/or in the induced hypertension.
The abnormal findings of SEPs were classified into three groups. In the group I, SEPs of the non-affected hemisphere were abnormal even in the resting state and not changed by the induced hypertension. In the group II, SEPs of the non-affected side were worsened under the induced hypertension. In the group III, SEPs of the non-affected side were activated by the induced hypertension.
In the group I and III, it is considered that ischemic regions and/or dysautoregulatory areas were completed by the interhemispheric steal or the transneural depression even in the non-affected hemisphere.
But, in the group III, reversible ischemic dysfunctions of the non-affected hemisphere were improved by the increase of the blood flow in the dysautoregulatory areas under the induced hypertension. In the group II, it is considered that, under the induced-hypertension, the interhemispheric steal from the non-affected hemisphere was occured by the increase of the blood flow on the dysautoregulatory areas of the ischemic regions.
In conclusion, it is necessary to improve the hemodynamics of the ischemic regions by the bypass surgery and except the disappearance of these abnormal phenomenon.

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Six cases of acute stroke which all showed severe neurological dificits were treated by emergency reconstructive surgery.
Embolectomy was performed on three cases within 6, 9. 5 and 18 hours respectively from the onset of stroke, and another three cases underwent STA-MCA anastomosis within 5.5, 9 and 21 hours respectively from the onset.
Hemorrhagic infarction followed all three embolectomy cases and two of them resulted in death. The rest of the cases showed transient exacerbation. Three STA-MCA anastomosis cases enjoyed complete remission and the rest of them resulted in favorable outcome. No hemorrhagic infarction was revealed in all three on CT examination.
The authors conclude that, as far reconstructive surgery for acute stroke, bypass susgery is not only safer but also more fruitful than embolectomy.

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From June 1979 to December 1979, 22 of STA-MCA anastomosis were performed successfully in this institution. Ten of these patients has the cerebrovascular lesion in their dominant side of hemisphere. Range of age of this group was from 37 to 69 (Average: 56. 5). Only one of these patients was female. Mode of the onset was follows: minor stroke; 3, progressing stroke; 1, major stroke; 6. Location of the lesion was classified as follows: extracranial occlusion of IC; 3, intracranial IC stenosis; 1, occlusion of MCA; 5, stenosis of MCA; 1. One week to 7 months after the initial onset, these patient had the surgical procedures. As a result, the good recovery of the moter function was observed on 6 patients. Three cases showed fair results and one unchanged. Concerning to improvement of aphasia, good results were revealed on 4 cases. Fair and unchanged cases were 5 and 1, respectively. These observation would be hopefully compared with a natural course of un-operated individuals in future.

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Thirteen aphasic patients with right hemiparesis due to cerebral vascular occlusions were treated with the superficial temporal arteries and middle cerebral arteries anastomoses (STA-MC anastomoses) and studied to determine the improvement in aphasias. The aphasic symptoms were evaluated by Standard Language Test of Aphasia (SLTA). In seven patients their aphasia regressed markedly following STA-MC anastomoses. CT scans of these patients revealed the good preservation in the cortical area and angiographies showed the good retrograde filling in the cortical branches of the left middle cerebral artery.
In six patients, the aphasia did not regress so well. Their CT scans showed the low density in the cortical region. And, retrograde fillings of cortical branches of the left middle cerebral artery were poor in their angiographies.

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The trial to establish the indication of the vascular reconstruction for the completed stroke was done by reviewing of 33 cases of completed stroke treated with STA-MCA anastomosis. 10 out of 33 cases made excellent and rapid recovery from severe neurological deficit immediate to four weeks after surgery. Preoperative studies of CT, cerebral angiogram, EEG, somatosensory evoked potentials (SEP) and timing of the surgery of these 10 cases were analyzed and the surgical indication was estimated through the results.
The results and estimated criteria of the surgery are as follows;
1) The ratio of CT number of affected brain to its intact brain is over 50%, mean value is 68. 5%.
2) Anatomical nature of preexisting collateral circulation must be sufficient in the ischemic brain.
3) The reduction ratio of V₁-amplitude of SEP in affected brain to intact brain is less than 53.4%.
4) Timing of the surgery is approximately four weeks after the onset.
EEG is useful study in postoperative follow-up, but is not of great value to predict the surgical indication.
If it is required to satisfy the above criteria, the indication of vascular reconstruction for the completed stroke will be subject to more restriction.

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The surgical indication of STA-MCA anastomosis for ischemic cerebrovascular disorder, especially completed stroke hasn't been determined. The authors researched 31 cases of completed stroke (mean of age was 56.4 years old) and discussed the indication of bypass surgery, evaluating their clinical symptoms bascd on a newly established rating scale “neurologic score”, and also evaluating the surgical effect by means of a newly defined “effect index”. The “neurologic score” contains eight symptoms as followings; state of consciousness, psychic state, motor function, sensory function, speech disturbance, visual field, agnosia and Gerstmann's syndrome and urinary and fecal incontinence, and it has three degrees. The“effect index” is defined as belows; (total neurologic score on the day before surgery-total neurologic score on 3 weeks after surgery)/total neurologic score on the day before surgery:_??_1.
The ratio of their patency was 93.8%. The number of symptomatically impoved cases after bypass surgery was 18 out of 31 cases (58%). The number of cases whose effect index was over 0.25 was 10 and over 0.5 was 3.
The effect index was over 0.25 in seven cases out of 12 cases of small size of focal low density, classified besed on CT firdings (I_a: normal, I_b: cerebral atrophy, II: small size of focal low density, III: moderate size of focal low density, IV_a: multifocal low density, IV_b: multilobar low density, IV,: diffuse low density). 2 out of 3 cases in III group and 3 out of 11 cases in IV group had symptomatical improvement. We also classified and studied the angiographical findings based on the affected pasition and its severity and there was no correlation between their affected types and clinical effect of bypass surgery in these 31 cases. It was concluded that even in completed stroke STA-MCA anastomosis was effective on those whose CT findings belonged. to“small size of focal low density”.

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The selection of proper patients for EC-IC bypass surgery has still remained difficult.
The authors have attempted a new approach to this problem, to determine indications of the operation according to a certain standard, that is, a scoring system.
Twenty-nine patients with ischemic cerebrovascular disease (TIA: 3, RIND: 2, slowly progressive stroke: 2, completed stroke: 22) who underwent STA-MCA anastomosis were studied.
In these patients, clinical, neuroradiological and operative factors were analysed. The clinical factors included age, medical risk factors, characteristics of the attack, interval between the last attack and operation. The neuroradiological factors were the conditions of major arteries, those of lenticulostriate arteries and the development of the collateral circulation which were studied angiographically, and CT findings.
Points were given to each factor according to its grade. The total score of each patient was calculated and compared with the operative result.
The averaged score for each of the operative results was as followed; Asymptomatic or Good (13 cases): +3.3(S.D.±.1.0), Fair (7 cases): -0.4(±1.3) and Unchanged (9 catet): -2.6(±0.9).
This scoring system seems to be useful in determining practically the candidates for EC-IC bypass surgery, and in anticipating prospectively the operative results.

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In the past decade, we had experienced over 100 cases with multiple steno-occlusive lesions, among 1264 cases which were diagnosed as cerebrovascular occlusive disease. Out of them, 71 cases with full angiographic studies undergone were selected to clarify some problems of surgical management. Twenty-one of these 71 patients were surgically treated, while the remaining 50 of them were done conservatively.
The definitive factors closely related with clinical results were as follows; the underlying general disorders, the mode of onset, the combination-pattern of steno-occlusive lesions and the degree of collateral circulation.
CT findings of those cases did not always reflect the clinical results so far as the location and the extent of low density area.
In cases with internal carotid occlusion (33 cases), the site of concomitant vascular lesions and collaterals were chiefly affected to their clinical results. On the other hand, in cases with middle cerebral artery occlusion (33 cases), their clinical results were determined by whether vascular supply to lenticulostriate arteries were preserved or not, and by the degree of leptomeingeal anastomoses corresponding to their proper vascular lesions.
Chronic low perfusion syndrome and recurrent stroke were frequently occurred due to multiple stenoocclusive cerebrovascular lesions. And the surgical cares such as Extra-Intracranial Arterial Bypass was beneficial to the improvement and the prevention of such pathological conditions.
The goals of patient's outcome strongly depends on the factors as previously described. Therefore, it is neccessary that the indication for bypass surgery should be decided considering those factors conscientiously.

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It has been latery reported that STA-MCA anastomosis has a protective effet against further cerebrovascular accidents in patients of TIA or RIND. The purpose of this study is to apply STA-MCA anastomosis to non ischemic diseases, namely the application of STA-MCA anastomosis.
Surgery of aneurysm has become safe and easy since microsurgery was developed. But IC ophthalmic aneurysm is still difficult to be clipped, especially if the patient has hypo- or aplastic A₁. Surgery was performed for these 9 cases to make STA-MCA anastomosis prior to clipping or trapping of the aneurysm or ligation of the internal carotid artery.
Vasospasm is one of the most important factors considering about the treatment of SAH. It has been recently known that there is a good correlation between hematoma of the cistern and vasospasm. STA-MCA anastomosis was performed following aneurysmal neck clipping to 11 cases of MCA or IC aneurysm from 3 to 14 days after SAH. Postoperative angiogram revealed dilated STA in 7 cases, which became narrow in follow up angiogram of more than 2 month afterward. There is no perplexed case due to vasospasm.
On the other hand there are 135 aneurysms in 129 cases, to which the STA-MCA anastomosis was not performed on clipping surgery. 19 cases (15%) had vasospasm, and 12 cases (9%) remained permanent deficit.
STA-MCA anastomosis must have preventive effect of brain ischemia due to vasospasm.

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The extracranial-intracraniat arterial anastomosis was performed on 11 patients of Moyamoya disease. Eight excellent results and 2 unchanged results were obtained. One patient died of postoperative intracerebral hematoma. The child case showed in general an improvement of neurological dificits, but all adult cases had some complications. It is, however, our impression that this revascularization surgery may be effective to Moyamoya disease by increasing blood flow to the ischemic brain tissue, though it is necessary to take the right measure to prevent complications.

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The authors report the results of eight STA-MCA anastomosis, two STA-MCA anastomosis with encephalo-myosynangiosis (EMS) and one EMS performed on six cases with so-called moyamoya disease. There were one child and five adults. The follow-up period after operation ranged from seven to 18 months. Four patients had excellent result, one good and one dead of subdural hematoma of non-operated side seven months after contralateral bypass procedure. Most possible cause of appearance of subdural hematoma in this case was aspirin ingestion. EMS is expected to be a replaceable surgical procedure for STA-MCA bypass under the absence of suitable recipient artery in the territory of middle cerebral artery.

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The authors experienced two cases of cerebellar infarction with excellent recovery by surgical treatment. The first case was 30-year-old female. She was transfered to our clinic after 48 hours unconsciousness following embolectomy of abdominal aorta. On admission, she was deeply comatose and had no spontaneous respiration. Neurological examination revealed miotic and fixed pupils with loss of reaction to light. Cerebellar infarction was immediately diagnosed by left brachial angiography and CT scan. A bilateral suboccipital craniectomy was performed and necrotic left cerebellar hemisphere was resected. Five months later, she was discharged only with left cerebellar ataxia.
The second case was 33-year-old male. He had sudden onset of headache, vomiting and dysarthria.Three weeks later, he was admitted to our clinic. Neurological examination revealed bilateral papilledema, mild right hemiparesis and right cerebellar dysfunction. CT Scan revealed low density area at the right cerebellar hemisphere. Righ suboccipital craniectomy with biopsy was carried out. Postoperatively, neuro-logical deficits gradually recovered and normal daily activity was gained at the time of discharge.
We reviewed 34 cases in the literature and our 2 cases and classified these cases into 3 types from clinical point of view. Type I, with development of disturbance of consciousness or brain stem compression sign within 3 days. Type II, within 2 weeks and Type III, more than 2 weeks. No differential neurological deficit was found among 3 types. Operations were performed on 28 cases out of 36 cases. Nine cases were excellent, 12 were fair, 4 ware poor and 3 died. We proposed surgical decomoression as soon as possible when the diagnosis was properly made.

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The authors present their experience with two cases of hemorrhagic infarction of the dominant sided cerebral hemisphere with fulminating clinical course. On the basis of the operative results of two cases, the method and indication of decompressive surgery are discussed in the treatment of severe hemorrhagic infarction of the dominant sided cerebral hemisphere.
The first case was operated on successfully by the extensive, internal, and external surgical decompression; hematoma removal, necrotomy, temporal lobectomy, incision of tentoreal hiatus, and removal of large craniotomy flap. The other case was treated only by external decompression, resulting in death.
The authors' experience suggested that extensive decompressive surgery should be considered even in the cases of hemorrhagic infarction of the dominant sided cerebral hemisphere with fulminating clinical course as early as possible.

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A Clinical analysis has been made in 9 cases of cerebellar infarction in whom both of massive edema of cerebellar hemisphere and internal hydrocephalus were observed on CT scans and/or angiograms. Five cases of them underwent decompressive suboccipital craniectomy and survived except for one case who died of perforation of duodenal ulcer after remarkable postoperative improvement. The other four cases were treated conservatively and deid soon. Consequently, surgical treatment is apparently effective in cases of massive cerebellar infarction. However, survivor's outcomes were quite different according to the mode of onset. One patient who became comatous rapidly after the onset remained totally disabled postoperatively. On the other hand, satisfactory recovery was obtained in the patients who were almost alert in the early stage and became gradually comatous, i. e. lucid interval. Then, surgical treatment is indicated for the cases who have lucid interval.
There were five cases who had lucid interval. The speed of deterioration was more rapid in the two cases of hemorrhagic infarction than in the three cases of anemic infarction. One of the former deteriorated too rapidly to be operated upon. In the other four cases, the shorter the time between the initiation of loss of consciousness and surgery, the sooner the recovery. Consequently, operation is recommended to start as soon as possible if the consciousness is disturbed, although the cases of hemorrhagic infarction might be operated upon before the consciousness is disturbed.

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The authors presented a case of atrial fibrillation who developed a complete hemiparalysis due to embolic occlusion of the middle cerebral artery and were successfully treated with a middle cerebral artery embolectomy. Reconstruction of the blood flow was accomplished approximately 10 hours after the onset of the hemiparalysis. Postoperative course of the patient was uneventful and the neurological deficits were rapidly improving until 5th postoperative day when the patient developed hypertension followed by a sudden fall of the blood pressure. At the same time, an irregularity of the pulse increased. This was treated with manitol and digitalis since the CT scan indicated swelling of the ischemic area of the brain and ECG showed an increase in atrial fibrillation. The patient became able to walk on discharge but the arm was not strong enough to hold things.
The authors discussed feasibility and effectiveness of the embolectomy for embolic occlusion of the main trunk of the cerebral artery from the findings of serial CT scans, taken pre- and postoperatively. The authors concluded that the operative indication of the embolectomy should be divided in two; an indication for the purpose of improvement of neurological dificits and the other indication for prevention of hemorrhagic infarction by removing the embolus in time, which otherwise recanalizes later and causes hemorrhagic infarction.
The optimal time of the surgery for the first purpose should be limited within 6 hours after the onset of the neurological deficits. For the second purpose, a surgery up to 10 hours after the onset still provides a safe and effective prevention of the hemorrhagic infarction if the patient is treated vigourously with hypertonic solution for postoperative brain edema and with an adequate cardiac protection.

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The author have had an experience of 13 cases of carotid thrombectomy or thromboendarterectomy for totally occluded internal carotid artery, 8 in Toronto and 5 in Japan. Retrospective analysis was done angiographically and clinically.
Angiographically there were 2 types of occlusion: lower type (8 patients) and upper type (5 patients).Of 8 patients with lower type of occlusion, all of 3 days after onset were restored in blood flow, but 3 of 5 patients operated after 4 days of onset were restored in blood flow. Of 5 patients with upper type of occlusion, 2 of 3 patients operated within 3 days after onset were restored in blood flow and one of 2 patients operated after 4 days of onset was restored in blood flow.
Postoperative angiography at 6 months time after operation was performed on 6 patients with flow restoration and all had patency. 9 patients with restoration of carotid blood flow have been excellent.
Unfortunately, 3 of 13 patients were died postoperatively. The cause of death in 2 patients was hemorrhagic infarction, one in Toront after thrombectomy and the other in Japan after STA-MCA anastomosis for MCA occlusion, and the other was hypertensive intracerebral hemorrhage during STA-MCA anastomosis for failed flow restration of internal carotid artery. One more hemorrhagic infarction was encountered after thrombectomy, however he was treated conservatively and has been excellent.
After STA-MCA anastomosis was developed carotid thrombectomy and/or thromboendarterectomy for the carotid occlusion have been forgotten because of high mortality and unreliability of revascularization. However, there are several reports with good results in carotid surgery for occlusion. From the retrospective point of view our selection of patients was not strict and further strict selection of patients for carotid thrombectomy and/or thromboendarterectomy should be necessary.
We believe when we can see the lower type of totally occluded internal carotid artery within 3 days after onset carotid surgery should be attempted before STA-MCA anastomosis for the patients with minor neurological risk factor.

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Recently carotid endarterectomy is increasing but postoperative myocardial infarction is frequently observed. It has been reported in foreign countries that the atherosclerotic coronary artery diseases were frequent in patients with carotid artery lesion(s). In Japanese, however, the relationship between the atherosclerotic changes of the carotid artery and the coronary artery were not well known. We studied this point here. The subjects were 136 consecutive patients of hemispheric cerebral infarction and they were divided into five groups according with their carotid angiographic findings as I) severe and II) mild lesion(s) at the carotid bifurcation, III) severe and IV) mild lesion(s) at the other portion(s) than carotid bifurcation and V) no carotid lesion. The ischemic changes of ECGs in their neurologically stable stage were analysed by Minnesota code. And the angiographic findings and the ECG manifestations were compared. In each group, half of the ECG abnormalities were the changes of ST-T. Myocardial infarction was recognized about 5% in all groups, but no statistical differences were observed. Though the percentage of abnormal ECGs was not so different in each group, almost all ECG-changes were severe in group I (12/13 cases). On the other hand, 50-70% were severe in other groups. So it was suggested that there is some relationship between the severe atherosclerotic changes at the carotid bifurcation and the coronary artery disease in the Japanese as well, but it is not sodistinctive as in white and negro. Careful management for cardiovascular system is important in pre-and post-operative medical care on the carotid endarterectomy.

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Fifty-two cases of occlusive cerebrovascular disease of the extracranial carotid artery were treated surgically in our service for last four and a half years. CEA was performed on 31 cases with one bilateral case, EIAB on 15 cases with one bilateral case and reconstruction of the internal carotid artery on 4 cases. Thirteen of 52 cases were either TIA or PRND and 24 cases of minor completed stroke. Repeated episodes of ischemic attack had occured in 27 of the 52 cases, the remainders had only once. Shifting patterns of the repeated episodes were examined in Table 3. Repeated TIAs were noted in 7 cases. In 8 cases TIAs shifted to a minor ccompleted stroke. Repeated number of TIAs were demonstrated in Table 3. The mean number of episodes of the TIA was 2.87±1.8 SD.
The follow up periodes of 48 cases were ranged from three months to four and a half years with a mean duration of 2.1 years. Two patients died from myocardial infarction, one was 2 years after the opration and the other six months. One of them had shown AF on the preoperative EKG but, the other patient showed a normal EKG. Recurrent attacks of ischemic CVD had occured in two cases.
A fifty six year old female, who had several TIAs with 60%stenosis of the internal carotid artery preoperatively, had two short episodes less than 10 minutes of disarthria two years after CEA. CT scan and carotid angiogram were examined after each episode but no abnormal findings were revealed. Stenosis of the left ICA had disappeared completely and the inner wall of ICA was smooth. Only the EEG showed a questionable paroxysmal abnormality.
In another case a fifty year old male had an attack of the monoparesis of the right upper extremity one and a half years after the EIAB. His preoperative diagnosis was progressing stroke with left ICA occlusion. Postoperative patency of the bypass was good. There was no change in the CT scan and the angiogram after the episode. No further attack had occured. We could not explain the pathogenesis of these recurrent cases.
It has been reported by us concerning procedures preventing against the operative complication of CEA. In this paper, it was also discussed the necessity of the postreconstruction angiography during the surgery, which is a convenient and reliable method for confirmation whether CEA is performed satisfactorily or not.

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The authors studied 18 cases of occlusive cerebrovascular disease with a tandem lesion, in order to evaluated results of different treatment modality and the surgical indication for carotid emdarterectomy (CEA). The tandem lesion was defined as a combination of angiographic pathologies both in the accessible cervical carotid (stenosis of light, moderate the severe degree; ulcer of small and large size) and in the ipsilateral main branch of the intracranial artery (stenosis; occlusion). The treatment for these patients consists of carotid endarterectomy for 10 patients and medical treatment for 8 patients Three of the 10 CEA cases were treated with middle cerebral artery thromboendarterectomy (2 cases) and with embolectomy and endarterectomy (1 case) simultaneously with the CEA. Results of the treatment were evaluated by the recurrence rate of neurological deficits before the treatment and by the survival rate in the long term follow-up study. The recurrence of the neurological deficits occured only in 2 cases of non-surgically treated patients with a carotid ulcer of the large size associated with distal lesions. In 6 cases of CEA patients, however, the distal lesions were left unoperated because of spontaneous recanalization (1 case), disappearance of preoperatively frequent TIAs after CEA (1 case) and a significant increase in the cerebral blood flow after the CEA (4 cases). The authors concluded that the present surgical indication of CEA for the tandem lesion is well accepted in terms of results of treatment except in the treatment for the distal lesions. The distal lesions should be treated after the CEA with extra-intracranial arterial bypass procedure if the postoperative increase in CBF is not significant.

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S. C. S. C. has been indicated for 309 cases of ischemic cerebrovascular disease and judged as good results. In order to perform this operation with safety and certainty, we need the micro-surgical anatomy of the superior cervical ganglion and its surroundings.
1) Superior cervical ganglion.
i) Type; a) spindle shaped 200/309
b) broad bean shaped 108/309
c) bottle gourd shaped 1/309
ii) Size; max. min. mean.
Length 6.0cm 1.3cm 2.8cm
Width 3.5cm 0.3cm 1.5cm
Thickness 1.3cm 0.2cm 0.8cm iii) Situation;
They are situated in the superior area of the posterior aspect of the bifurcation of the internal and external carotid artery.
iv) Branching;
Anatomical variations are often noted in the superior portion of the ganglion.
2) Surroundings of the superior cervical ganglion.
Take care for the glossopharyngeal nerve on the superior portion of the ganglion and the vagus nerve on the lateral aspect of the ganglion.

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Experimental studies were performed to research into the possibility of clinical application of arterial grafts transplantation irradiated with high voltage cathode ray.
Homologous and heterologous arterial segments were implanted in Fisher rat back subcutaneously. Antibody titer of Fisher rat after implantation was measured with immune-adherence hemagglutination method. Antibody titer after implantation of homologous and heterologous grafts decreased to 1/8 by 2 millions rads irradiation. Antibody titer of irradiated heterologous graft was still higher than that of nonirradiated homologous one.
To assess whether the postmortem change of arterial graft may affect its patency rate, homologous grafts taken from the corpses 3 or 6 hours after sacrifice, which were irradiated with 2 millions rads were transplanted in carotid artery in dogs using end-to-end anastomosis. Angiography 1 or 2 weeks after transplantation revealed the patency of all grafts of 14 dogs. On histological examination, 6 months after transplantation the structures of the graft, especially elastic fibers were well preserved. Complete reendothelialization was found on scanning electron microscope.
It is concluded that homologous grafts obtained within 6 hours after death are useful and tolerate to construct extracranial-intracranial bypass by use of high voltage cathode ray irradiation.

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Carotid thrombo-endarterectomy was carried out on 11 patients with stenosis or occlusion of the extracranial carotid artery due to atherosclerosis.
In this paper, we discussed the operative procedure of the thrombo-endarterectomy, especially effectiveness of the interlacing vascular suture. The interlacing vascular suture did not cause narrowing of the diameter or shortening of the axial length of the vessel, and could close the arteriotomied wound water-tightly and rapidly. We succeed shortening the time of the temporary occlusion of the internal carotid artery as a result of using interlacing suture and removing thrombus as en bloc, the shortest is within 15 minutes.
We had excellent results in all 4 cases combined superior cervical ganglionectomy, perivascular sympathectomy and thrombo-endarterectomy. We proposed the combined operation in usually manner.

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In the last three years, we have experienced four cases of occlusive disorder of the vertebral and common carotid arteries that showed cerebral ischemic attacks: RIND (one case), TIA (two cases) and minor stroke (one case). In all cases, transcervical approach was used to manipulate either the subclavian artery or the vertebral artery. In the first and the fourth case, saphenous vein graft was interposed between the subclavian artery and either the external or internal carotid artery in order to reconstruct the obstructed carotid blood flow. In the second case, a stenosed orifice of the right vertebral artery was corrected by patching with using a vein graft. In the third case, the coiling of the vertebral artery at it's origin was straightened by stretching. The operative result in every case was successful and the patient have not suffered from the further ischemic attack or stroke. The only operative complication which was observed in the case 3 was a transient Horner's syndrome. If the vascular graft is propery interposed, a highly risky thoracotomy can be avoided and substituted by a simple transcervical approach in the reconstructive sugery of the branches of the aortic arch.

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A case, 62 year old male, of brain infarction due to the right internal carotid artery occlusion was reported. Cerebral angiographies revealed severe arteriosclerosis, so anticoagulant (Warfarin) therapy combined with platelet antiagglutinating agent (Aspirin) was started prophylactically on the 10th day after the onset. The thrombotest values, measured by the method of Owren, were in the upper region (10-15%) of the therapeutic range (5-15%). On the 25th day his consciousness level suddenly deteriorated. CT scan revealed large thalamic hemorrhage near the infarcted brain tissue. On the next day the patient died.
According to other reports the anticoagulant therapy should be started at least 10 days after the occurrence of the brain infarction. The complication of cerebral hemorrhage in anticoagulant therapy was rare. However the majority of hemorrhage in these patients arise when bleeding occurs in previously infarcted brain. Therefore prophylactic anticoagulant therapy after the brain infarction should be started at least four weeks or more after the onset when hemorrhagic infarction does not occur.

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Fifty five patients with recanalized infarction were studied to clarify the mechanism of hemorrhagic infarction (HI) after revascularization. Hemorrhagic infarction appeared in 25 patients (46%) from 2nd to 30th day of stroke. There were two types of HI; the acute type with brain edema (12 cases), and the subacute type with positive contrast enhancement (CE) on CT (14 cases). Positive CE usually preceeded to the appearance of HI, which suggests the close correlation between the mechanism of positive CE and HI.
In 95 patients who were performed extra-intracranial arterial bypass (EIAB) surgery, HI was presented in three patients postoperatively. In these cases, the timing of operation was 2nd day, 8th day and 29th day of stroke respecively. Hypertensive treatment was also performed before or after surgery in two of those cases. One of these three cases with HI had a fatal course.
This fact gives a warning for reconstructive surgery in the cases with a large low density area on CT in acute and subacute stage (stage of positive CE on CT, namely within 5 weeks after the onset). Induced hypertention after surgery seems to be contraindicated in these cases.

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EC-IC anastomosis and CEA are now an established procedure for occlusive cerebrovascular diseases. EC-IC anastomosis is generally considered to be a relative low risk for intracranial operative procedure, but its procedure is associated with significant mortality and morbidity.
59 cases of the occlusive cerebrovascular diseases were managed surgically during last 2 years. EC-IC anastomosis in 46 cases (STA-MCA anast. 45, OA-PICA anast. 1) and CEA in 13 cases.
We have experienced postanastomotic complications, such as acute subdural hematoma, intracerebral hematoma, subdural hydroma, angiospasm, occlusion, migrane like headache and skin flap necrosis.
Acute subdural hematoma was complicated in 2 cases, which was recovered from motor weakness completely after the removal of hematoma but the other case remained neurogical deficit. Intracerebral hematoma complicated in 3 cases. First case developed subcortical intracerebral hematoma in the posterior site of the anastomosed region 2 days after operation but was recognized no neurological deficit and was treated conservatively. Second case, which was the progressive stroke, developed the intracerebral hematoma in the temporal L.D.A. of the preoperative CT for 2 weeks after operation. This cases died of DIC on 18 th day after operation following hemorrhagic infarction mentioned above. Third case, which was ICA occlusion, developed the thalamic hemorrhage in 1 year after operation. Subdural hydroma was recognized in cases. This complication was developed no neurological deficits but its course should be observed. Other complications, angiospam in one, occlusion of anastomosed vassels in one, headache after operation in 2 cases and scalp necrosis in 3 cases, were recognized. Postoperative occlusion of ICA after CEA was recognized in one case. In this case, emergency thrombectomy by the Fogarty catheter was carried out.
We reported and discussed postoperative complications of surgical revascularization for occlusive cerebrovascular diseases.

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