Reconstructive surgery may be the second best method in a such case, in which neck clipping of aneurysm seems to be impossible or difficult and it cannot help selecting proximal clipping or trapping of the parent artery. Many kinds of reconstructive surgical procedures have been reported. STA (superficial temporal artery)-MCA (middle cerebral artery) anastomosis is the most common procedure. But, this method is not useful in all cases. It is not suitable for the purpose of the reconstruction of anterior cerebral artery. In some case, the amount of blood flow through the STA is not enough to maintain the function of the brain. For these reasons, not only STA-MCA anastomosis but also various kinds of reconstructive procedures should be used according to the needs of each cases.
In the last five years, 46 reconstructions of the parent artery have been performed prior to or secondary to the aneurysm surgery. The reason why these procedures were needed were as follows,
1) 6 patients with incidental aneurysm was estimated to have cerebral ischemia due to the occlusion of internal carotid artery or middle cerebral artery.
2) In 10 cases, the aneurysm was so big or giant, which might be difficult to be clipped. So, STA-MCA anastomosis or A₃-A₃ side to side anastomosis was made prior to clipping of aneurysm for the purpose of prolongation of parent artery occlusion time.
3) 3 cases with intracavernous giant aneurysm were applied the STA-MCA anastomosis and 18 cases who had a giant aneurysm at the ophthalmic or intracavernous portion of ICA were treated with the anastomosis between the cervical external carotid artery and the middle cerebral artery using a radial artery graft.
4) 7 cases with dissecting aneurysms of the vertebral artery were applied various kinds of reconstructive procedures.
5) In 6 cases, some troubles had occurred during surgery and some reconstruction were made for countermeasures against the occlusion of parent artery.
In this paper, our techniques and methods of reconstructive procedures with some examples were reported, and the cause of deterioration was discussed. To summarize our interpretation of results, it should be noted that in aneurysm surgery it is advisable to prepare simultaneously various kinds of reconstructive procedures as well, not only for the patients with a giant aneurysm or an unusual aneurysm like as dissecting aneurysm but also with an usual aneurysm. High flow bypass with a radial artery graft and intracranial interarterial bypass like as A₃-A₃ side to side anastomosis and M₁-M₂ anastomosis should be used widely in the future.
Last, please excuse me if I overemphasized my opinion more subjectively than was necessary. And I will be glad if this paper is any help to young neurosurgeons.

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Casting hematoma and subarachnoid hemorrhage in acute subarachnoid hemorrhage causes serious consciousness disturbance and can be fatal. Severe subarachnoid hemorrhage with Fisher Group 3 or more causes symptomatic cerebral vasospasm, which greatly affects the prognosis in such serious cases. Here we report our procedure to remove intraventricular casting hematoma and subarachnoid clots to improve the prognosis in such serious cases.
Intraventricular casting hematoma: Intraventricular casting hematoma is often found in ruptured anterior communicating artery aneurysm, and anterior interhemispheric approach (AIH) is used to clip the aneurysm. Intraventricular casting hematoma complicated with anterior communicating artery aneurysm, in many cases, ranges from the anterior horn of the lateral ventricle, to the body, posterior horn, inferior horn, and third ventricle. Removal of casting hematoma is possible from the anterior horn of the lateral ventricle by frontal corticotomy after AIH. The contralateral intraventricular casting hematoma can be treated by breaking the septum pellucidum, and the third ventricle can be treated via the foramen of Monro. After removal of the hematoma, drainage tubes are placed in the trigone and third ventricle to control the intracranial pressure.
Subarachnoid clot: For subarachnoid hemorrhage in the acute stage, the irrigation suction system is applied with irrigation water, that is 500ml of saline mixed with 60,000 units of urokinase compressed to 400mmHg, to remove the subarachnoid clots as much as possible. In severe subarachnoid hemorrhage with Fisher Group 3 or more, the sylvian fissure is opened widely from the distal part to remove clots. In addition, clots are removed from the carotid cistern and prechiasmatic cistern, then the liequist membrane is opened, and clots are removed from the ambient cistern, interpeduncular cistern, and prepontine cistern not only in case of internal carotid aneurysm but also in case of middle cerebral aneurysm. Finally, the tip of the drainage tube should be placed in the opposite inlet of the ambient cistern. In case of anterior communicating aneurysm, removal of subarachnoid clots is basically limited to those in the anterior interhemispheric fissure and prechiasmatic cistern because the approach is made by AIH. Therefore, the frontal base should be opened with the bifrontobasal approach first, to allow the sylvian fissure to be easily opened by the frontobasal approach. Subarachnoid clots in the sylvian fissure can be removed by the frontobasal approach, and also from the interpeduncular cistern and prepontine cistern.
By this method, consciousness disturbance was improved in early postoperative stages in intraventricular casting hematoma cases. In addition, extensive removal of subarachnoid clots significantly reduced the occurrences of symptomatic vasospasm.

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Our prior studies revealed that favorable outcome occurred in 54% of WFNS Grade IV and 14% of Grade V patients with subarachnoid hemorrhage (SAH). To predict the outcome in patients with severe SAH, we assessed the outcome of the 192 poor-grade patients admitted to Asahikawa Red-Cross Hospital who suffered aneurysmal subarachnoid hemorrhage in the period of 1994 to 2001. Preoperative GCS with 3 and 6 presented approximately 20% of favorable outcome. None of the patients with preoperative GCS 4 or 5 presented favorable outcome.
Seventy-nine patients were rated as SD (severely disabled) in GOS (Glasgow outcome scale). Three of 79 patients were rated SD because of focal sigh, such as aphasia or hemiparesis. The remaining cases revealed variable degrees of post SAH dementia. Using multivariate analysis, we found that the age (p<0.001) and postoperative GCS (p<0.01) correlated with the outcome in SD patients.
We conclude that aggressive management can benefit patients with GCS 3 or 6 even in Grade V. The outcome of the Grade V can be rated as “acceptable” in 28% when we include SD patients with acceptable deficit. In elderly patients 75 years old and older, our preliminary data suggest preoperative GCS with 8 or better may be the borderline to expect favorable outcome.

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For surgery of giant or large cerebral aneurysm, we have used the intraoperative monitoring of cortical blood pressure to safely perform surgery and to get optimal clipping, when the risk of parent arteries stenosis caused by aneurysmal clipping may be higher. We report the merits and demerits of this method compared with usual methods for CBF monitoring such as ultrasonic Doppler flowmeter.
We studied 5 giant aneurysms and 3 large aneurysms by applying this method. In the 3 cases of giant aneurysm, high flow EC-IC bypass using radial artery (RA) free graft and ICA proximal ligation was performed. And in the other 2 cases, direct aneurysmal clipping under a temporary use of RA was employed. On the other hand, all 3 cases of large aneurysm had atheroscrelotic change in its wall. They were treated by direct clipping.
To monitor the cortical blood pressure, the following procedure was used. At first, we prepared two branches of superficial temporal artery (STA). After this, one of the branches was anastomosed to one of the branches of the middle cerebral artery (MCA) just distal to the aneurysm. Next, cannulation was performed into another branches of STA using a plastic needle, which was connected to a pressure transducer. By cutting off the blood flow from the main trunk of the STA, cortical blood pressure of the MCA was monitored through the bypass pathway.
Our study shows the differences between the two types of cases. In cases of direct clipping surgery, the change of cortical blood pressure indicated whether the parent artery was stenotic or not. And in cases of performing RA free graft bypass, it showed whether bypass flow could be used as a substitute for ICA flow or not. These results show it is easy to evaluate the direct blood pressure quantitively. In conclusion, this monitoring is considered a useful method to ensure safe surgery for patients with giant or large aneurysms.

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The case of 49-year-old woman with a ruptured dissecting aneurysm of the left vertebral artery is reported in this paper. She was admitted complaining of severe headache and became moribund after re-bleeding attacks. CT scan demonstrated massive subarachnoid hemorrhage, especially around the brainstem, and intraventricular hematoma. Vertebral angiography showed the so-called“string and pearl sign”in the left vertebral artery just distal of the origin of the posterior inferior cerebellar artery and no abnormality in the well-developed right vertebral artery. The aneurysm was located at midline, therefore and advanced lateral suboccipital approach was used. This can be done through the space made by drilling off the lateral part of the foramen magnum. The aneurysm was thus easily trapped without any retraction of the cerebellum. And then extensive clot evacuation was done around the brainstem and in the fourth ventricle. Fortunately, the patient gradually recovered after surgery, but with some mental incapacity. In conclusion, we would like to emphasize that a moribund patient can not be cured without immediately removing the aggravating factors as quickly as possible. And pre-operative diagnosis may be the most important factor in the therapy of dissecting aneurysms.

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The skills of skull-base drilling and cerebral revascularization are now essential in open surgery for cerebral aneurysms. For this purpose, achieving a bloodless operative field, and identifying and preserving the normal anatomical structures are imperative. We propose the effectiveness of creating a bloodless operative field and operating under a high magnetic field by presenting four common approaches for aneurysm surgery: the transsylvian approach; interhemispheric approach; extradural anterior clinoidectomy; and lateral suboccipital approach. Here we show how we achieve our preferred operative field and present our operative figures.
For safe, high-quality clipping of cerebral aneurysms, vascular surgeons should create a bloodless operative field, adjust to surgery under a high magnetic field and train hard for skull-base drilling by attending cadaver courses.

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We report intraoperative difficulties we have encountered during clipping surgery for unruptured cerebral aneurysms.
There is a low risk of intraoperative rupture, but when it occurs, it can be managed either by tentative clipping or proximal flow control. The risk of aneurysm rupture can be decreased by gentle manipulation of the aneurysm, as well as full mobilization of the aneurysm and its neighboring vessels. Adhesions of vascular structures, arteries, and/or veins can be separated from the aneurysm in almost all cases with careful and sharp dissection. Injuries to perforating vessels are the most common problems. The risk of permanent injury can be reduced by combining multiple monitoring methods, especially MEP (motor evoked potential) and micro-Doppler.
It is vitally important that we be aware of the difficulties that may occur during surgery and develop methods to avoid or manage them.

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We present a case of PICA-involving ruptured vertebral artery dissecting aneurysm (VA-DA) that was initially treated by endovascular proximal coil embolization. One month after the operation, recanalization was observed by angiography. Four years after the first operation, a neuroradiological examination revealed complete occlusion of the right VA. However, the surgical findings of continuous bleeding into the aneurysm was assumed to be occurring from the vasa vasorum. Based on this case, we suggest that careful observation is necessary when a VA-DA aneurysm is treated by endovascular proximal coil embolization, because of the risk of insufficient blockage of the vasa vasorum, which is difficult to detect by neuroradiological examination.

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Vascular reconstruction of intracranial lesions is sometimes required during various operations. A few examples are: A3-A3 side-to-side anastomosis for anterior communicating aneurysm in order to secure the blood flow to the distal anterior cerebral artery, STA-radial artery graft-A3 hemi-bonnet bypass for bilateral injury of the anterior cerebral artery, and direct stitching for aneurysmal neck laceration, etc. In this paper we describe the various techniques of vascular reconstruction for intracranial lesions and tumors. Some special microsurgical instruments, such as a micro-needle folder for stitching in a deep field, should be sterilized individually, and be ready for use at any time because injury to vessels in a deep operative field occurs suddenly. If the injured vessels are reconstructed quickly and completely, the neurological deficits after surgery can be limited and at times even prevented. Therefore veins or arteries that are or have been damaged should be reconstructed as much as possible.

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Aggressive surgical treatment, including intracerebral and/or intraventricular hematoma evacuation, cisternal clot irrigation, external decompression, unilateral temporal lobectomy with resection of herniated uncus and aneurysmal clipping, was carried out on poor-grade aneurysmal SAH patients (Hunt and Kosnik Grade 4 or 5). A protocol consisting of a reversibility test of dilated pupils and light reflex under a rapid infusion of 900-1200ml mannitol was utilized for selection of operative candidates. The patients who showed bilateral negative light reflex with dilated pupils even after the infusion of mannitol were excluded from active treatment and given supportive care only. During the period between April 1992 and December 1994 a total of 207 SAH patients were admitted to our department, with 88 (42.5%) patients arriving in Grade 4 or 5. Urgent operations were performed on all the 41 Grade 4 patients and on 12 of the 47 Grade 5 patients. Preoperative CT scans in Grade 4 patients showed Fisher Group 2 in one case, Group 3 in 23 and Group 4 in 17. Those in Grade 5 surgical group were Fisher Group 3 in 7 cases and Group 4 in 5 cases. The outcome at 3 months of the Grade 4 patients following Glasgow Outcome Scale was GR in 9 (22.0%), MD in 10 (24.4%), SD in 13 (31.7%), V in 1 (2.4%) and D in 8 (19.5%). More favorable outcomes (GR, MD) were obtained in Fisher Group 3 (14/23, 60.9%) than in Fisher Group 4 (5/17, 29.4%). In the 12 Grade 5 patients who were selected for active treatment, 5 patients survived with moderate to severe deficits and 7 died. Mortality in the Fisher Group 3 was 85.7% (6/7) and 20% (1/5) in the Fisher Group 4. In the 4 patients who survived in Grade 5 with Fisher 4, 3 were cases having casting intraventricular hematoma. In the 35 non-surgical group, all patients had died within 2 weeks.
We conclude that Grade 4 aneurysm patients can achieve a better outcome with active treatment based on immediate intracranial pressure decrease and brain stem decompression. Even in Grade 5, patients with Fisher 4, especially the cases with casting intraventricular hematoma, can survive with urgent and aggressive surgical treatment. On the other hand, the result in Grade 5 patients presenting Fisher Group 3 CT findings are poor, and we suggest that hypoxia caused by cardio-pulmonary dysfunction would have a greater effect on brain condition than intracranial hypertension.

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目的:過去5年間のWFNS grade別のクモ膜下出血(subarachnoid hemorrhage; SAH)の治療成績をまとめ,現時点での治療の到達点と限界について検討した。対象と方法:1996年1月から2000年12月に外科的直達手術を行った315例の動脈瘤破裂によるSAHを対象とした。年齢は19-89歳(平均61.0±13.1)。破裂動脈瘤の部位は前交通98,内頸95,中大脳77,前大脳19,椎骨脳底動脈系26。術前WFNS gradeはI: 112, II・III: 80, IV: 72, V: 51例。GCS 6点以上の症例は全例外科治療,5点以下の最重症例ではマニトールの急速点滴や時間経過により神経症状が改善した症例に手術を行った。手術はできるだけ早期に開頭clipping術を行い,クモ膜下血腫や脳内・脳室内血腫が存在すればその除去を積極的に行った。治療成績は発症3か月後の状態をGlasgow Outcome Scale (GOS)で評価した。結果:WFNS grade Iは98%で転帰良好(GR, MD)となった。Grade IIおよびIIIでは転帰良好例は84%。転帰不良の原因は手術合併症と脳血管攣縮であった。Grade IVでは転帰良好例は61%,死亡率11%。脳内血腫などのinitial brain damageによりSD以下の転帰不良にとどまる例が多いほか,脳血管攣縮が転帰を悪化させる要因になっていた。Grade Vでは転帰良好例は18%,死亡率31%。転帰不良の原因はinitial brain damageによるものが大多数であった。他に80歳以上の超高齢者で転帰が不良であった。結論:開頭直達手術で軽症SAHは問題なく治療できる。しかし脳血管攣縮の発生率や重症例および80歳以上の高齢者では治療成績の限界があり,血管内手術との適当な役割分担をしていくことで成績の向上が望みうる。

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Objective: Radial artery graft (RAG) for complex vascular lesions has been a well-established treatment option. In the last 20 years, our center has performed more than 120 RAGs, during which we have come across various experiences including complications. In this report, we present the surgical technique, and intraoperative monitoring for 10 of our recent cases, based on our experiences of the complications. The results of diffusion-weighted image (DWI) ischemic findings within 2 days after surgery are also reported.
Materials & Methods: Recent RAGs performed for unruptured internal carotid aneurysm, and spontaneous carotid-cavernous fistula (CCF) are included in this study. The basic procedure was external carotid artery-radial artery-M2 (ECA-RA-M2) graft bypass combined with superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. The highlights of this surgical technique are as follows.
1) Subcutaneous tunnel insertion using temporary clip to prevent kinking of the graft.
2) STA-MCA anastomosis is important for continuous cerebral perfusion pressure monitoring.
3) Selection of the recipient MCA for RA and STA anastomosis is confirmed by indocyanine green video angiography (ICGVAG), combined with temporary proximal MCA occlusion clip. The authors used monitoring bypass for select cases.
4) Antithrombotic agents are used before surgery for unruptured lesions as well, to prevent ischemic complications due to thrombosis and graft spasm. Additionally, DWI, 3DCTA perfusion CT, SPECT etc. are performed in the early postoperative period for the same reason.
Results: In this series with modified RAG technique, no symptomatic ischemic complications were experienced. Although the number of cases is small, the incidence of symptomatic ischemic complications with this surgical technique was lower than that reported in the past.
Conclusion: Since three surgical sites are involved, various parameters and possible complications need to be monitored during surgery, and in the postoperative period.

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During high flow bypass (HFB) surgery to make a submandibular route using a radial artery, the passage of a graft between an anastomosis site of the cervical external carotid artery to the temporal base is made blindly. This is also a frequent occlusion site of the graft in the surgery. In this study, we focused on complications that can occur during this procedure. Fourteen consecutive patients undergoing HFB for internal carotid artery aneurysms between 2012 and 2017 were evaluated. In all 14 patients, patency of HFB was confirmed with postoperative computed tomography angiograms. Major complications concerning the surgery to make the submandibular route were the following: 1) the use of a medial route to the stylohyoid muscle (SHM) resulted in no extra margin of the radial artery length in 5 patients; 2) a long styloid process obstructed the submandibular route in 2 patients; 3) the superior temporal artery, which was compressed by a route tube at the external carotid artery, was obstructed during the assist bypass procedure in 2 patients; 4) a radial arterial graft was occluded in the submandibular region during the procedure in one patient. Considering the limitation of the available graft length, a submandibular route lateral to the SHM was the most suitable for HFB using a radial artery graft. To obtain good patency of HFB using this route, preparation for possible complications occurring during surgery is essential in addition to sufficient knowledge on the anatomy of this region.

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In this paper we introduce a“high pressure irrigation and suction system”designed for acute stage surgery of ruptured intracranial aneurysms, and the new operative method using this equipment. The mechanism and the structure of this system are omitted here, but in use it can be handled in the same manner as a sucker, and clots in the subarachnoid space can be washed immediately.
Until now“dry field”and“blunt dissection”have been the routine in neurosurgery and general surgery. But a completely dry field raquires“sharp dissection”without any damage to vessels. Recent developements of microscopes and microsurgical instruments seem to bring“sharp dissection”into chronic stage operations. But, in acute stage operations this is not easy because of subarachnoid clots adhering to vessels and the arachnoid trabeculae. Complete“sharp dissection”can be accomplished with this irrigation and suction system, not only in chronic stage operations but also in acute stage operations.

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We have retrospectively analyzed outcome for poor-grade aneurysmal subarachnoid hemorrhage (WFNS Grade IV-V) among consecutive 24 and 36 patients in two periods: 1993.7-1994.6 and 1998.7-1999.6, respectively. In both periods, we aggressively treated them with early surgery, including extensive surgical removal of subarachnoid clot and intracerebral hematoma using a high-pressure irrigation-suction system. In the second period, hematoma removal could be achieved less invasively and more extensively with technical improvements and usage of urokinase in the irrigation fluid. More patients in their 70s and 80s were treated surgically in the second period.
When all patients were compared, the rate of favorable outcome increased in the second period but not significantly. However, among patients less than 80 years old, patients with 6-9 points in preoperative Glasgow Come Scale (GCS) and the WFNS Grade IV patients with Fisher 4 CT achieved a significantly better outcome in the second period. In both periods, patients in their 80s and patients with 3-5 points in preoperative GCS did not show any improvement in overall outcome. Extensive treatment, including extended removal of subarachnoid clot and intracerebral hematoma, helped improve the patients described above, but did not change the overall outcome because of the increased number of older patients and patients in worse grades in the second period.

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We experienced 5 cases of nonbranching site aneurysms arising from the internal carotid artery system in the past 5 years. Two cases were successfully treated with neck clipping and 2 cases were treated with trapping. Wrapping by gauze and fibrin glue was used in 1 unruptured case. The outcome was good in all cases (mRS 0-2).
However, non-branching site aneurysms have fragile walls, the neck is not clearly defined and postoperative rebleeding can easily occur. We believe the sacrifice of a normal parent artery is necessary to prevent re-bleeding. For this reason, we believe interception of the parent artery should always be considered to prevent postoperative rebleeding.
When parent artery interception is of concern regarding postoperative ischemic events, a high-flow EC-IC bypass may be needed. On the other hand, the issue of separation of the neck is possible at all sides and the possibility of clipping strangling part of the parent artery also exists.

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We report 4 cases of giant aneurysms in the basilar tip region, comprising 1 large and 3 giant aneurysms located in the basilar tip (2 cases), basilar-SCA (1 case), and PCA (1 case). One of the 4 was ruptured (basilar tip aneurysm). The symptoms were headache (3 cases) and oculomotor palsy (1 case; basilar-SCA). All aneurysms had unilateral internal carotid artery occlusion. In all cases the aneurysms were clipped following EC-RA-M2 bypass to prevent ischemia at the area of the occluded internal carotid artery and to reduce hemodynamic stress within the aneurysm. The clinical courses of 2 basilar tip aneurysms were good but 1 basilar-SCA aneurysm re-grew and ruptured 4 years later after incomplete clipping of the aneurysm. In 1 PCA aneurysm a new basilar tip aneurysm occurred that grew progressively. We consider that the cause of these aneurysms was hemodynamic stress due to internal carotid artery occlusion. It is suggested that the internal carotid artery should not be occluded without an EC-RA-M2 bypass.

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