Aneurysmal subarachnoid hemorrhage (SAH) poses an immediate threat to life. The accepted paradigm of treatment generally involves surgical intervention requiring craniotomy to allow neck clipping of the ruptured cerebral aneurysm, with the alternative approach of embolization of the aneurysm sac by the deposition of detachable coils delivered through the endovascular route. The selection of the treatment method depends on the establishment of clear guidelines for the attending neurosurgeon, but unfortunately no such definitive guidelines leading to a definitive treatment policy have been developed in Japan. Controlled comparison of the alternative treatment approaches of clipping and coil embolization is rendered difficult by the lack of reported series of interventions in patients using either clipping or coil embolization, and the methodological difficulties inherent in the retrospective comparison of the specific results achieved by unrelated institutes or individual surgeons. We describe our 5 years of experience of clipping and coil embolization to promote a consensus of decision-making for acute SAH.
Our therapeutic protocol emphasizes clipping, with coil embolization mainly considered for patients with poor neurological condition (Hunt & Kosnik Grades IV-V without hematoma), paraclinoid or basilar aneurysm, or serious systemic complications, and for elderly patients over 74 years old or older. We treated 198 patients, 55 males and 143 females aged from 31 to 91 years old (mean 61.3 years) with aneurysmal SAH between 2000 and 2005. Surgical clipping was performed in 164 cases, endovascular treatment in 25 cases, and conservative therapy for ruptured aneurysms in 9 cases. Overall, 95% of patients underwent radical treatment. On admission, 26% of patients were in poor neurological condition (Hunt & Kosnik Grades IV-V). Aneurysms arose from the anterior circle of Willis in 87% of cases. Eighty-seven percent of patients were treated with surgical clipping within 3 days of onset, and 84% were treated with coiling within 3 days.
Favorable outcome was defined as good recovery or moderately disabled classified by Glasgow Outcome Scale at discharge, which was achieved in 71% of all patients, 76% of patients treated by clipping, and 60% of patients treated by coil embolization. Symptomatic vasospasm occurred in 21% of patients after clipping but only in 3% after coil embolization (p<0.05). Computed tomography showed a low density area in 14% of patients after clipping but only in 3% after coil embolization. Administration of eicosapentaenoic acid significantly reduced the low density area in patients after clipping from 13.5% to 3.3% (p=0.035). Shunt surgery was required in 25% of patients after clipping, but only in 8% after coil embolization. Poor outcome occurred in patients with better preoperative neurological condition (Hunt & Kosnik Grades I-III) in 12% after clipping and in 14% after coil embolization, and preventable causes accounted for 75% and 50% of these cases, respectively.
Recently, the Ministry of Health, Labour and Welfare has required the collection and submission of accurate and complete information about treatment options, indications, and expected results for ruptured cerebral aneurysms. The availability of such an extensive database enabling rigorous analytical correlations will provide the required foundation to establish specific indications for the selection of the optimal methodology of clipping or coil embolization treatment for patients with acute SAH.

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Neurosurgery has now reached a mature stage in Japan, and the baby-boomer generation who initially established Japanese neurosurgery is leaving the operating theater. Therefore, effective education to pass techniques, knowledge, and experience on to the next generation is becoming more and more important year by year. Specific questions in the field of education such as “What should be taught?” “How much should it be taught?” and “What teaching methods are best?” must be answered in order to design a framework for educating and assigning neurovascular surgeons, neuro-endovascular surgeons, and so-called “two-swords surgeons” (trained as both neurovascular and neuro-endovascular surgeons) to satisfy future requirements for neurosurgical care in Japan. Here we give an overview of these problems.
Recently, surgical simulators based on physical virtual reality have been developed based on rapid advances in materials, technology, and IT knowledge, and laboratory training using such simulators has been widely accepted in medical education. However, many unsolved issues still remain in applying such laboratory training to the problems of actual neurosurgery. Surgical experience should be optimized for each trainee during residency, but the problems of individual needs have not yet been solved. For example, training may illustrate how to avoid serious bleeding from an aneurysm, but how to recover after this emergency by point aspiration, temporary clipping, or compression of the carotid artery at the neck portion is rather difficult to teach. Surgical manipulation during such a crisis by a clinical trainee sometimes results in a disaster even under direction of an experienced surgeon. Recently, awareness of patients’ rights has increased, so certification of surgeon’s skill has become an important issue. In this context, the clinical outcomes of the teaching hospital should be maintained to acceptable standards, and standardized education should be provided to each trainee.
Further, overall and long-term views are essential for resolving these issues because of the large discrepancies in the population density in Japan of physicians from clinical specialties related to stroke, such as strokology, emergency medicine, neurology, rehabilitation, neurovascular surgery, and neuroendovascular surgery. The prefectural discrepancy ratio for neuroendovascular surgery is the largest at 21.5, but is 4-6 in most other specialties. Therefore, no rigid framework can be established to educate residents and to assign neurovascular surgeons, neuroendovascular surgeons, and two-swords surgeons. However, we must decide how to resolve these issues in the near future despite the many problems.

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Indication of early treatment remains controversial for patients with poor-grade (WFNS grade IV and V) subarachnoid hemorrhage (SAH). Since 2006, we have tried endovascular treatment mainly using the Guglielmi detachable coil (GDC) as one treatment option for these patients. In this study, we compared clinical outcome and complications in patients treated in 2004–2005 with those treated in 2006–2007, and evaluated the changes in treatment strategy.
Between 2004 and 2007, we treated 81 patients with poor-grade SAH, and 61 underwent early aggressive treatment in our hospital. For 29 cases (10 males, 19 females, mean age 64.6 years) in 2004–2005 (Group 1), treatment options were early craniotomy (clipping) except for 1 case of intentionally delayed surgery, while for 32 cases (8 males, 24 females, mean age 66.2 years) in 2006–2007 (Group 2), endovascular coil embolization (mainly using GDC) at the acute stage was added to treatment options for cases of high age and/or poor general condition. We compared these 2 groups in terms of percentage of treatment option, clinical course and outcome, assessed with Glasgow Outcome Scale score (GOS) at discharge.
The percentage of patients treated by coil embolization increased from 0% in Group 1 to 20% in Group 2 for Grade IV and 6.7% to 50% for Grade V. The outcomes of patients in Grade IV were better in Group 2 than in Group 1. That is, for Grade IV cases, the percentage of good recovery (GR) significantly increased from 15.4% in Group 1 to 42.9% in Group 2. For Grade V cases, good outcome—GR and moderately disabled (MD)—increased from 13.3% in Group 1 to 26.3% in Group 2, otherwise dead also increased from 13.3% in Group 1 to 31.6% in Group 2 due to uncontrolled general complications. For Grade V cases, more than 50% patients in Group 2 were MD or severely disabled, or in a vegetative state. The incidence of symptomatic vasospasm and hydrocephalus did not differ between Group 1 and Group 2.
The introduction of coil embolization extended the indication of early treatment for poor-grade SAH patients and improved the outcome of those patients. On the contrary, over-indication of coil embolization revealed poor outcome of poor-grade SAH patients.
It is necessary for surgical indication in poor-grade SAH to objectively evaluate grade and familial and social aspects.

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