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Background Adequate bypass harvesting of the superficial temporal artery (STA) is a standard procedure for every neurosurgeon, so mastery of techniques for its management and care is mandatory. Methods Here, we report the effectiveness of using the bipolar forceps as a novel procedure. Results This procedure improves safety, efficiency, and bleeding compared to the usual dissection. Conclusions In cases requiring an STA donor, this technique may be as useful as the traditional method and could become part of the neurosurgeon's armamentarium.

Item does not contain fulltext IMPORTANCE: Unruptured intracranial aneurysms not undergoing preventive endovascular or neurosurgical treatment are often monitored radiologically to detect aneurysm growth, which is associated with an increase in risk of rupture. However, the absolute risk of aneurysm rupture after detection of growth remains unclear. OBJECTIVE: To determine the absolute risk of rupture of an aneurysm after detection of growth during follow-up and to develop a prediction model for rupture. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data were obtained from 15 international cohorts. Patients 18 years and older who had follow-up imaging for at least 1 untreated unruptured intracranial aneurysm with growth detected at follow-up imaging and with 1 day or longer of follow-up after growth were included. Fusiform or arteriovenous malformation-related aneurysms were excluded. Of the 5166 eligible patients who had follow-up imaging for intracranial aneurysms, 4827 were excluded because no aneurysm growth was detected, and 27 were excluded because they had less than 1 day follow-up after detection of growth. EXPOSURES: All included aneurysms had growth, defined as 1 mm or greater increase in 1 direction at follow-up imaging. MAIN OUTCOMES AND MEASURES: The primary outcome was aneurysm rupture. The absolute risk of rupture was measured with the Kaplan-Meier estimate at 3 time points (6 months, 1 year, and 2 years) after initial growth. Cox proportional hazards regression was used to identify predictors of rupture after growth detection. RESULTS: A total of 312 patients were included (223 [71%] were women; mean [SD] age, 61 [12] years) with 329 aneurysms with growth. During 864 aneurysm-years of follow-up, 25 (7.6%) of these aneurysms ruptured. The absolute risk of rupture after growth was 2.9% (95% CI, 0.9-4.9) at 6 months, 4.3% (95% CI, 1.9-6.7) at 1 year, and 6.0% (95% CI, 2.9-9.1) at 2 years. In multivariable analyses, predictors of rupture were size (7 mm or larger hazard ratio, 3.1; 95% CI, 1.4-7.2), shape (irregular hazard ratio, 2.9; 95% CI, 1.3-6.5), and site (middle cerebral artery hazard ratio, 3.6; 95% CI, 0.8-16.3; anterior cerebral artery, posterior communicating artery, or posterior circulation hazard ratio, 2.8; 95% CI, 0.6-13.0). In the triple-S (size, site, shape) prediction model, the 1-year risk of rupture ranged from 2.1% to 10.6%. CONCLUSION AND RELEVANCE: Within 1 year after growth detection, rupture occurred in approximately 1 of 25 aneurysms. The triple-S risk prediction model can be used to estimate absolute risk of rupture for the initial period after detection of growth.

Background: Wall enhancement of intracranial saccular aneurysms in high-resolution magnetic resonance vessel wall imaging (MR-VWI) might indicate a ruptured aneurysm. Therefore, this study aimed to determine the diagnostic ability of wall enhancement to detect the ruptured aneurysms among multiple aneurysms. Methods: Patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms who underwent MR-VWI before craniotomy and clipping were included in the study. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after gadolinium injection. Aneurysm rupture was estimated based on the subarachnoid clot distribution, aneurysmal contours, and MR-VWI findings. We selectively performed surgical clipping and confirmed the rupture site intraoperatively. Results: Thirteen patients with SAH with 13 ruptured and 17 unruptured aneurysms were treated at out facility. The accuracy rate of rupture site diagnosis using MR-VWI was 69.2% (9/13 cases). Each unruptured aneurysm was equally or more strongly enhanced in the other four cases than the ruptured aneurysms. In three of the four unruptured aneurysms with positive MR-VWI findings, atherosclerosis of the aneurysmal wall was observed during simultaneous or elective clipping surgery. Further, clipping surgery was performed without intraoperative rupture in two cases with the help of MR-VWI findings. Conclusion: Correct diagnosis of the rupture site using MR-VWI alone was unreliable due to false positives caused by the wall enhancement of unruptured aneurysms with atherosclerosis. Therefore, ruptured aneurysms should be detected using more information in addition to MR-VWI images. MR-VWI may be advantageous to determine surgical strategies when managing patients with SAH and multiple aneurysms.

BACKGROUND Recurrent aneurysms after initial clipping have been discussed as an important issue in the surgical management of aneurysm. OBJECTIVE To report our experience with recurrent cerebral aneurysms after neck clipping and to discuss classification and recommended management. METHODS Aneurysm treatments from a single institution over a 20-year period were retrospectively reviewed. Twenty-three recurrent aneurysms in 23 patients were managed during the study period. Recurrent aneurysms were classified using the concepts of closure line and closure plane, as follows. Type 1: neck situated in an almost different site from the previous clip. Type 2: existing closure plane and reconstructive closure plane are almost the same. Type 3: existing closure plane and reconstructive closure plane cross (type 3a); in rare cases, the existing closure line is sufficiently distant from the neck (type 3b). Type 4: no reconstructive closure line is identifiable. RESULTS Nine patients presented with subarachnoid hemorrhage at recurrence. The mean interval to recurrence was 15.0 years. Management comprised clipping with elective subsequent old-clip removal (n = 7), clipping with preceding old-clip removal (n = 2), bypass occlusion (n = 1), coating (n = 1), combined surgery (n = 1), endovascular surgery (n = 4), and observation (n = 3). Therapeutic intervention was not indicated in 4 patients. Types 3a and 4 required more complex surgical procedures or coil embolization. Procedural complications were observed in 2 patients. CONCLUSION A small but definite propensity toward recurrence after neck clipping exists, and most recurrent aneurysms require some form of retreatment. The novel classification scheme may provide conceptual clarity and therapeutic guidance for decision making.

Neurovascular interventional radiology (neuro-IR) procedures tend to require an extended fluoroscopic exposure time and repeated digital subtraction angiography. To evaluate the actual measurement of eye lens dose using a direct eye dosemeter in neuro-IR physicians is important. Direct dosimetry using the DOSIRIS™ (IRSN, France) [3 mm dose equivalent, Hp(3)] was performed on 86 cases. Additionally, a neck personal dosemeter (glass badge) [0.07 mm dose equivalent, Hp(0.07)] was worn outside the protective apron to the left of the neck. The average doses per case of neuro-IR physicians were 0.04 mSv/case and 0.02 mSv/case, outside and inside the radiation protection glasses, respectively. The protective effect of radiation protection glasses was approximately 60%. The physician eye lens dose tended to be overestimated by the neck glass badge measurements. A correct evaluation of the lens dose [Hp(3)] using an eye dosemeter such as DOSIRIS™ is needed for neuro-IR physicians.

This pilot study aimed to investigate the utility of near-infrared spectroscopy/indocyanine green (NIRS/ICG) for examining patients with occlusive cerebrovascular disease. Twenty-nine patients with chronic-stage atherosclerotic occlusive cerebrovascular disease were included. The patients were monitored using NIRS at the bedside. Using ICG time-intensity curves, the affected-to-unaffected side ratios were calculated for several parameters, including the maximum ICG concentration (ΔICGmax), time to peak (TTP), rise time (RT), and blood flow index (BFI = ΔICGmax/RT), and were compared to the affected-to-unaffected side ratios of the regional cerebral blood flow (rCBF) and regional oxygen extraction fraction (rOEF) obtained using positron emission tomography with 15O-labeled gas. The BFI ratio showed the best correlation with the rCBF ratio among these parameters (r = 0.618; P = 0.0004), and the RT ratio showed the best correlation with the rOEF ratio (r = 0.593; P = 0.0007). The patients were further divided into reduced rCBF or elevated rOEF groups, and the analysis revealed significant related differences. The present results advance the measurement of ICG kinetics using NIRS as a useful tool for the detection of severely impaired perfusion with reduced rCBF or elevated rOEF. This method may be applicable as a monitoring tool for patients with acute ischemic stroke.

Background Recently, non-vitamin K antagonist oral anticoagulants such as direct thrombin and direct factor Xa inhibitors have been prescribed for prevention of embolic stroke. While in Japan, argatroban, also a direct thrombin inhibitor, is available for the treatment of atherothrombotic stroke patients. This study aimed to explore whether there is any differences between direct thrombin and direct factor Xa inhibitors regarding the inhibiting effect against thrombogenesis in the clinical setting of acute ischemic stroke. Methods Acute ischemic stroke patients newly prescribed anti-thrombotic agents were consecutively screened, and 44 patients with single medicine were enrolled (median 72.0 years-old). Blood samples were obtained at 1 and 2 weeks after the medication started. The extent of anticoagulation activity, inflammatory markers and platelet aggregation were assessed. Patients with antiplatelets were used as control. Results Prescribed antithrombotics were dabigatran (group D: n = 12), apixaban (group A: n = 14) and antiplatelet agents (group P: n = 18). Prevalence of stroke risks and anticoagulation activity were not different between groups D and A. The alteration of inflammatory markers in a week in the group A showed similar trend to those in the group P. The group D presented relatively lower amount of high-sensitive C-reactive protein and higher amount of pentraxin-3 compared with groups A and P. While 88.9% of group P patients showed decreased platelet aggregation activity with adenosine diphosphate, 55.6% of group D and 40.0% of group A presented the inhibition of platelet aggregation activity. Conclusions Even in acute ischemic stroke patients, both apixaban and dabigatran equally showed the anticoagulation activity. The reduction of inflammatory response might be prominent in apixaban, whereas the inhibition of platelet aggregation activity might be evident in dabigatran.

Since non-vitamin K antagonist oral anticoagulants (NOACs) were released for clinical use, many studies have investigated its effectiveness in stroke prevention. In this study, to determine whether or not there is a difference in outcome in secondary stroke prevention between warfarin and NOACs, patients with embolic stroke with newly prescribed anticoagulants were prospectively analyzed.Patients with acute ischemic stroke, who newly started anticoagulant therapy, were consecutively asked to participate in this study. Enrolled patients (76.3 ± 11.0 years old) were classified into warfarin (n = 48), dabigatran (n = 73), rivaroxaban (n = 49), and apixaban (n = 65). The outcome in 1 year was prospectively investigated at outpatient clinic or telephone interview. Recurrence of stroke and death was considered as the critical incidence.The prevalence of risk factors was not different among all medicines. Patients with dabigatran showed significantly younger onset age (P .001: 72.2 years old) and milder neurologic deficits than patients on other medicines (P .001). Cumulative incident rates were 7.1%, 15.3%, 19.0%, and 29.7% for dabigatran, apixaban, rivaroxaban, and warfarin, respectively. Dabigatran showed relatively better outcome compared with warfarin (P = .069) and rivaroxaban (P = .055). All patients on NOACs presented lower cumulative stroke recurrence compared with warfarin.Even in the situation of secondary stroke prevention, noninferiority of NOACs to warfarin might be demonstrated.

Background Posterior communicating artery (PCoA) aneurysms are among the most common aneurysms. Because blockage of the PCoA and perforators can cause adverse outcomes, occlusion of these arteries by surgical clipping should be avoided. The impact of factors on PCoA perforator infarction when using a distal transsylvian approach for PCoA aneurysms was examined. Methods A total of 183 patients underwent PCoA aneurysm clipping, excluding application of fenestrated clips. Patients were divided into 2 groups: patients with PCoA perforator infarction (infarction group) and patients without infarction (noninfarction group). Multiple factors were analyzed in the 2 groups. Results Twenty-two of the 183 patients (12.0%) showed perforator infarction, mainly on magnetic resonance imaging evaluation, resulting in permanent deficits in 2 patients (1.1%). The proportion of right-sided operations (86.4% vs. 53.4%; P = 0.005) and surgery for rupture (90.9% vs. 55.9%; P = 0.002) were significantly higher in the infarction group than in the noninfarction group. Aneurysms were significantly larger in the infarction group (8.4 ± 3.8 mm) than in the noninfarction group (6.3 ± 3.0 mm; P = 0.02). Ruptured status (odds ratio [OR], 7.35; P = 0.01), right side (OR, 5.19; P = 0.01), and aneurysm size (OR, 1.18; P = 0.02) remained independent predictors of perforator infarction on multivariate logistic regression analysis. Conclusions Ruptured status, right side, and large PCoA aneurysm were independent predictors of PCoA perforator infarction. Symptoms due to PCoA perforating infarction were mostly transient and rarely affected outcomes.

A small part of the patients with subarachnoid hemorrhage (SAH) are not properly diagnosed until they suffer ischemic neurological deficits and/or rebleeding during vasospasm. We therefore investigated the clinical profile of such patients. We retrospectively analyzed 581 patients with aneurysmal SAH experienced in our institute between 2001 and 2009. Patient’s characteristics, presence and severity of headache before final diagnosis, imaging investigations they received, their World Federation of Neurological Surgeons (WFNS) grades at admission, the location of aneurysm, treatment, and outcome at discharge were investigated. Five patients were not correctly diagnosed until they presented neurological deficits due to vasospasm or experienced simultaneous rebleeding. Their mean age was 69.4, and all were female. Although all patients had a bad headache, they did not undergo any imaging examinations. Immediate coil embolization was performed for 2 patients, 1 died due to rupturing during embolization procedure. The other 3 were treated by open clipping surgery (2 delayed and 1 immediate). Four patients had some disability as a sequel, and their outcomes were significantly worse compared with 53 patients with SAH in WFNS Grade II. The patients with SAH who had not been properly diagnosed in the acute stage had a poor outcome. We should be very careful when we see patients complaining of severe headache.

Blood blister-like aneurysms are dangerous aneurysms with fragile walls arising from the supraclinoid internal carotid artery (ICA). Primary treatment of these aneurysms in the acute stage is challenging, due to the substantial risk of periprocedural bleeding. We describe a series of 4 patients who presented with ruptured blister-like aneurysm of the ICA and were treated with completion of extracranial-intracranial high-flow bypass followed by inspection and trapping of the aneurysm. All patients were treated in the acute stage, within 48 hours of bleeding. External carotid artery to proximal middle cerebral artery bypass with interposed radial artery (RA) graft was established followed by approach to the lesion and trapping of the parent vessels. The aneurysms in 3 patients ruptured during dissection of the lesion from the surrounding structures, but bleeding was easily controlled. RA grafts were patent in all patients and no postoperative symptomatic ischemic or hemorrhagic complications were encountered, resulting in excellent outcomes with modified Rankin scale scores of 0 at follow up after 3 months. Our present strategy for surgical treatment of blister-like aneurysms completely avoided the risk of devastating intraoperative hemorrhage, offering a most cautious strategy associated with minimal risk of intraoperative massive bleeding.

The concept of optimum closure line was applied to a series of 51 consecutive middle cerebral artery aneurysms (14 ruptured, 37 unruptured) in 41 patients, 16 men and 25 women aged 29-79 years (mean 59.1 years). Visual inspection through the operating microscope revealed 3 types of aneurysm based on the origin of the aneurysm: bifurcation type (n = 39), trunk type (n = 9), and combined type (n = 3). Clipping along the optimum closure line should restore the vascular structure to the original configuration. Combination clip techniques were useful to form a curved closure line. This technique requires adequate operative fields with dissection of the aneurysm and related arteries from the neighboring structures as far as possible. The closure line concept is helpful to decide how to apply clips for particular aneurysms to avoid risks of ischemic complication and future recurrence. Combination clip techniques are often necessary to match a curved closure line.

We provide intraoperative problems and their preventive measures during the pterional approach to the basilar top aneurysm. We focus on the surgical techniques to obtain a wider operative field through the pterional approach. The surgical difficulties depend on various factors, including the size, location, and direction of the basilar top aneurysm. In particular, the interrelationship between the location of the internal carotid artery and the basilar top aneurysm is an important factor to be fully assessed preoperatively.

In surgical procedures to dissect the sylvian fissure, the fissure is commonly unfolded by the attachment of all sylvian veins to the temporal lobe. During this procedure, cerebral edema and contusion in the frontal lobe are often caused by sacrificing bridging veins from the frontal lobe and excessive retraction on the frontal lobe. In this procedure, some sylvian veins must be kept on the side of the frontal lobe to preserve the bridging vein. In many cases, detachment of the sylvian vein from the surface of the temporal lobe is required. The sylvian vein can be detached from the temporal lobe using the space around the temporal artery right under the sylvian vein. For detachment of adhesions between the frontal and temporal lobes, a “paper knife technique” is available in which a surgical site is generated by cutting upwards from the subarachnoid space around M1. In a “denude technique,” a wide surgical field can be obtained with less retraction of the frontal lobe by detaching the arachnoid membrane from the sylvian vein and thus allowing venous extension. During dissection of the sylvian fissure, arteries and veins belonging to the temporal lobe spread while adhering to the frontal lobe. In this case, the site to dissect is the frontal-lobe side where the vessels are located, even if the sylvian fissure is widely unfolded. Conversely, when cerebral vessels belonging to the frontal lobe are attached to the temporal lobe, the site to dissect is on the temporal lobe side, where the vessels are located. Thus the concept of a “microvascular sylvian fissure” in which detailed vessel structures are captured at a microscopic level is important in terms of preventing damage to blood vessels, pia matter and brain tissue. It is crucial to obtain a large surgical field and confirm where blood vessels belong. To detach an aneurysm attached to arteries such as M2, A2 or perforating arteries and deep veins, without causing damage, using the tip of micro-forceps for microvascular anastomosis as a raspatory is useful. Other detailed technical ideas are introduced. These include: pulling the aneurysm into the surgical site by transposing the artery and aneurysm using brain spatulas, silk threads, and Aron alpha to confirm adjacent vascular structures such as perforating arteries; using a “double-clip technique” to confirm complete clipping with 2 clips; and deliberately shifting the bayonet clip to preserve perforating arteries.

初回症候性脳出血患者のMicrobleeds(MB)の有無で,臨床所見や画像所見の相違について検討した.174例中,MB陽性例は65.5%で,皮質・皮質下(39.6%)に最も多く認められた.MB陽性/陰性群の比較検討では,年齢,性差,高血圧,糖尿病,高脂血症,入院時血圧,入院時および退院時のJapan Stroke Scale,血腫量には有意差がなかった.MB陽性群では,抗血栓薬の内服,ラクナ梗塞数,Leuko-araiosis(LA)の重症度が有意に高値であった.ロジスティック解析では,LA重症度がオッズ比2.20でMBに対する独立した因子であった.今回の結果よりMBはラクナ梗塞,特にLAと関連が深いと考えられた.また,MB陽性群で抗血栓薬の内服が高率だったことから,抗血栓薬投与前にMBやLAを評価することで,抗血栓薬内服中の出血のリスクを軽減できる可能性が示唆された.

A frontotemporal craniotomy is usually performed using a “keyhole,” made at the union of the zygomatic arch and frontal bone. Consequently, skull depression may occur postoperatively, leading to temporal area deformities and poor cosmetic results. To prevent these complications, we describe our technique for frontotemporal craniotomy using an osteotome to prevent cosmetic deformities. After the temporal muscle is dissected and reflected with the scalp flap, a total of 3 burr holes are made in the frontal and temporal bones. In the lateral greater wing of the sphenoid, where a keyhole is usually made, a bone incision is made anteriorly-posteriorly with an osteotome. The bone flap is lifted upward, and the osteotome is inserted from behind to continue the incision. At craniotomy closure, the bone flap is fixed using a cranial bone flap fixation clamp. This procedure involves almost no removal of frontal or inferior temporal bone, resulting in virtually no bone defect. The absence of skull depression or deformity in the temples postoperatively leads to excellent cosmetic results. Our technique for frontotemporal craniotomy using an osteotome does not create bone defects, and use of titanium clamps for bone flap fixation provides normal skull bone alignment. This procedure provides excellent postoperative cosmetic results.

Aging is considered to cause atherosclerotic changes in the carotid artery, but few studies have evaluated this relationship. In this study, we used carotid plaques removed from patients with carotid artery stenosis and investigated how aging contributes to carotid plaque morphology and symptoms.A total of 60 patients(55 men, 5 women; mean age, 70.5 years; range, 53-85 years) treated at our hospital between January 2009 and April 2012 were enrolled in this study. All patients underwent carotid endarterectomy; their carotid plaques were stained with hematoxylin-eosin and/or Elastica-Masson stain and examined by a pathologist. Using these data, the carotid systolic velocity and plaque morphology were analyzed considering the age by decade as well as the symptomatology.Of the 60 patients, 29 were symptomatic(transient ischemic attack (TIA) in 8 patients; infarction in 20;and amaurosis in 1). Symptoms were less common as patient age increased. The incidence of TIA also tended to decrease with an increase in age, although the opposite trend was seen with infarction. In plaque morphology, the presence of active plaque, macrophage, inflammatory infiltration, and capillary angiogenesis decreased as age increased, while the presence of degenerative plaques, decrease in smooth muscle cell number, and calcification inversely increased. Active, degenerative, and combined (active/degenerative) lesions are statistically unrelated to symptoms as well as systolic velocity (cm/sec) at the carotid stenosis. The rates of hemorrhagic lesions were similar among decades, but the lesion statistically contributed to increasing symptoms (p=0.0045) and increasing systolic velocity (p=0.031).Increasing age contributes to morphological changes in carotid plaques and symptoms. When hemorrhagic lesions are suspected in carotid plaques, patients will be symptomatic and may require surgery.

Background: Intraoperative qualitative indocyanine green (ICG) angiography has been used in cerebrovascular surgery. Hyperperfusion may lead to neurological complications after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis. The purpose of this study is to quantitatively evaluate intraoperative cerebral perfusion using microscope-integrated dynamic ICG fluorescence analysis, and to assess whether this value predicts hyperperfusion syndrome (HPS) after STA-MCA anastomosis. Methods: Ten patients undergoing STA-MCA anastomosis due to unilateral major cerebral artery occlusive disease were included. Ten patients with normal cerebral perfusion served as controls. The ICG transit curve from six regions of interest (ROIs) on the cortex, corresponding to ROIs on positron emission tomography (PET) study, was recorded. Maximum intensity (IMAX), cerebral blood flow index (CBFi), rise time (RT), and time to peak (TTP) were evaluated. Results: RT/TTP, but not IMAX or CBFi, could differentiate between control and study subjects. RT/TTP correlated (|r| = 0.534-0.807; P < 0.01) with mean transit time (MTT)/MTT ratio in the ipsilateral to contralateral hemisphere by PET study. Bland–Altman analysis showed a wide limit of agreement between RT and MTT and between TTP and MTT. The ratio of RT before and after bypass procedures was significantly lower in patients with postoperative HPS than in patients without postoperative HPS (0.60 ± 0.032 and 0.80 ± 0.056, respectively; P = 0.017). The ratio of TTP was also significantly lower in patients with postoperative HPS than in patients without postoperative HPS (0.64 ± 0.081 and 0.85 ± 0.095, respectively; P = 0.017). Conclusions: Time-dependent intraoperative parameters from the ICG transit curve provide quantitative information regarding cerebral circulation time with quality and utility comparable to information obtained by PET. These parameters may help predict the occurrence of postoperative HPS.

Distal anterior inferior cerebellar artery(AICA)aneurysms are rare, so its pathogenesis and treatment remain controversial. Here, we report the unique pathogenesis of a ruptured aneurysm in this area that was based on anomalous components as well as partial dissection of the arterial wall. A 61-year-old woman presented to our hospital with sudden headache and nausea. On admission, neurological examination revealed slight consciousness disturbance. Computed tomography(CT)of the head showed a clotted subarachnoid hemorrhage(SAH)that was dominant in the right cerebellopontine and prepontine cistern. Three-dimensional CT angiography detected an irregular fusiform aneurysm 4.5×3.2mm in size in the distal portion of the AICA. The patient underwent trapping without distal vascular reconstruction by the lateral suboccipital approach. After surgery, she experienced right hearing disturbance and ipsilateral facial palsy that were considered to be caused by vasogenic edema at the cerebellar peduncle that resulted from the initial SAH damage. Pathology revealed an aneurysmal wall with anomalous components and arterial dissection in the arterial wall. To our knowledge, only one article has reported the histological findings of a distal AICA aneurysm. Based on the pathology of this case, these findings may suggest a useful treatment strategy for this rare aneurysm.

The transoral transclival approach for the treatment of intradural lesions of the clivus is often associated with serious complications such as cerebrospinal fluid (CSF) leakage and meningitis. CSF pulse energy may be the most significant factor in CSF leakage and meningitis, but a bone baffle can block such CSF pulse energy. A 64-year-old female presented with sudden onset of severe headache. She had subarachnoidal hemorrhage due to a rupture of the vertebral-posterior inferior cerebellar artery aneurysm. A 66-year-old female complaining of occipitalgia and numbness of the extremities had a foramen magnum meningioma. Both patients were treated via the transoral transclival route with a protective bone baffle, obtained from the iliac bone, securely fixed in the bone window to protect the repaired dura from injury by CSF pulse energy. Neither patient showed CSF leakage or meningitis, and the period of continuous lumbar CSF drainage was only 7 days. The transoral transclival approach with a bone baffle is still very effective in selected cases.

A 21-year-old male presented with temporal lobe epilepsy associated with a venous angioma in the ipsilateral frontal lobe, presenting as intractable complex partial seizures. Neuroimaging showed a cerebral venous angioma in the right dorsolateral and opercular frontal lobe, and atrophy of the right hippocampus. As the ictal electroencephalogram (EEG) obtained with subdural electrodes indicated spike discharges initiating from the right mesial temporal lobe, temporal lobectomy was performed. The patient was seizure-free after the operation. Patients with epilepsy who have a cerebral venous angioma require precise analysis of the seizure pattern and an ictal EEG because of cerebral venous angioma may be associated with an another epileptogenic lesion which is surgically treatable.

Background and Purpose— The present study examined the relationship between circulatory and metabolic reserve in patients with hemodynamic impairment. Methods— Positron emission tomography was used to investigate 40 patients with major cerebral artery occlusive disease. The ratio of cerebral blood volume to cerebral blood flow (CBV/CBF) and vasoreactivity in response to hypercapnia (%CBF hypercapnia ) and acetazolamide (ACZ) stress (%CBF ACZ ) were measured to evaluate circulatory reserve. Oxygen extraction fraction (OEF) was measured to evaluate metabolic reserve. To detect relationships between circulation reserve and OEF, cerebral hemispheres were grouped into 5 or 6 stepwise groups based on reduction of circulation reserve. Results— OEF was significantly elevated in hemispheres with CBV/CBF ≥0.11 minutes and in hemispheres with %CBF hypercapnia ACZ in hemispheres with %CBF ACZ Conclusions— Metabolic reserve consumption began at CBV/CBF ≥0.11 minutes, CBF hypercapnia ACZ

Background: Some patients require a second surgical intervention for recurrence of treated aneurysms, untreated aneurysms in patients with multiple lesions, or de novo aneurysm. This retrospective review of the data was undertaken to evaluate when retreatment is necessary after initial aneurysm treatment. Methods: Cerebral aneurysms in 1755 patients were treated via clipping or coiling between January 1995 and September 2012. Postoperative follow-up was performed at 6 months after treatment and was repeated every 12 months (or longer) after treatment using three-dimensional computed tomography angiography or magnetic resonance angiography. Results: A cumulative total of 156 patients (8.9%) (117 women, 39 men; mean age: 55.0 years; range: 25–79 years) needed retreatment for rupture or regrowth of aneurysm (n = 31; ruptured (R)/remaining unruptured (U), 26/5), formation of de novo aneurysm (n = 45; R/U, 23/22), known untreated aneurysm in patients with multiple lesions (n = 78; R/U, 5/73), and hemorrhage from undetected aneurysm (n = 2). The regrowth risk is higher after endovascular treatment than after craniotomy and clipping. Median time to retreatment was 187 months (range: 11–280 months) for regrowth, 165 months (range: 22–330 months) for de novo, and 24 months (range: 2.8–417 months) for known untreated aneurysm. Regrowth or known with subarachnoid hemorrhage were frequently treated within 2 years from initial treatment. Conclusions: Aneurysms with residua or untreated aneurysms in patients with multiple lesions carry a risk of bleeding during a relatively short period, whereas there is a small but significant risk of de novo formation and subsequent hemorrhage at over 10 years after previous treatment.

The supreme anterior communicating artery (SAcom) is a very rare anomaly that appears as a communicating artery between the anterior cerebral arteries (ACAs). This anomaly was first reported by Laitinen and Snellman in 1960. They described the SAcom as a connection between both pericallosal bifurcations. They also suggest that the SAcom may be an embryological remnant and a cause of aneurysm formation. A distal ACA aneurysm can be associated with the SAcom. In this case report, we describe a ruptured fusiform aneurysm originating from the SAcom. We treated the patient by trapping the SAcom along with the aneurysm. This is the first case report regarding a ruptured fusiform aneurysm originating from the SAcom itself.

Remote cerebellar hemorrhage is a usual complication after supratentorial craniotomy. Especially, only several cases have been reported regarding the occurrence of remote cerebellar hemorrhage after burr hole drainage for the treatment of chronic subdural hematoma (CSDH). In this paper, we present an elder patient with this rare postoperative complication. A 73-year-old man presented with dysarthria and right hemiparesis. Computed tomography (CT) demonstrated a left chronic subdural hematoma. Hematoma drainage through a single burr hole was perfomed. About 3 hours after the surgery, the patient became restless and presented nausea and dizziness with a relatively large amount of drainage of hematoma. CT revealed resolution of the subdural hematoma and bilateral cerebellar hemorrhage appearing as "zebra sign". Magnetic resonance angiography and 3D-CT angiography showed the normal structure of posterior circulation in both the arterial and venous phases. The remote cerebellar hemorrhage was suspected to have happened as a result of overdrainage of hematoma. Finally, he was discharged without any neurological deficits. Although remote cerebellar hemorrhage after drainage through a burr hole for the treatment of chronic subdural hematoma is a rare complication, it is necessary to be aware of the possibility of such a complication after supratentorial surgery.

BACKGROUND AND IMPORTANCE We report a rare case of pathologically confirmed cryptic vascular malformation as a cause of primary convexity subarachnoid hemorrhage (SAH) of unknown etiology. CLINICAL PRESENTATION A 48-year-old woman presented with sudden severe headache. Localized right convexity SAH was observed on computed tomography (CT) scan, but the origin could not be detected despite extensive workup covering the entire head by using 3.0-Tesla magnetic resonance (MR) imaging with MR angiography and CT angiography combined with venous-phase imaging with a 320-detector row CT scanner. Subsequent digital subtraction angiography (DSA) performed 2.5 hours after admission failed to reveal any cause of SAH; however, a right frontoparietal avascular region was suspected to be due to a newly developed intracerebral hematoma. The lesion was simultaneously confirmed by angiographic cone-beam CT imaging. Because she remained neurologically intact, we decided to perform a follow-up study later with medical management. However, she developed left hemiparesis 3 hours after DSA. CT scan demonstrated progression of the hematoma, and her symptoms gradually worsened. Emergent surgical exploration along the SAH superficial to the postcentral sulcus and hematoma evacuation were performed, with favorable functional outcome. Pathological examination confirmed cryptic vascular malformation with several abnormally dilated arterioles within the subarachnoid space surrounded by a thick SAH clot. CONCLUSION It is important to consider the possibility of ruptured cryptic vascular malformation as a cause of nontraumatic nonaneurysmal convexity SAH when recurrent hemorrhage occurs despite thorough diagnostic workup, because surgical resection may be the only curative treatment option to eliminate the risk of rebleeding and disabling symptoms.

We studied the incidence of postoperative infection related to CSF leakage and anosmia in basal interhemispheric approach (BIH). Between April, 1990 to March, 2009, 142 cases of anterior communicating (Acom) aneurysm including both unruptured and ruptured have been treated by clipping surgery using BIH. We retrospectively obtained clinical informations from medical records and video records about infectious complications, CSF leakage of cerebrospinal fluid (CSF), olfactory dysfunction and intraoperative findings of damage to the olfactory nerve. In most cases (139 patients, 97%), frontal sinus were opened at craniotomy. Of all, CSF rinorrhea occurred in 4 cases (2.8%), and meningitis in 6 cases. There was only one patient who sufferd from meningitis due to CSF rinorrhea. All that patients recovered completely without deficit. Anosmia occurred in 6 cases (4.2%), and intraoperative injuries in 4 cases (2.8%). There was only one patient in whom anosmia was consistent with nerve injury. In conclusion, BIH is an appropriate procedure for infection risk control in Acom aneurysm surgery. It is difficult to avoid olfactory dysfunction completely, even if olfactory nerves are preserved in form.

The present study aimed to evaluate the impact of early surgical evacuation of sylvian hematoma caused by ruptured middle cerebral artery (MCA) aneurysm on clinical outcome after subarachnoid hemorrhage. Hospital records and computed tomography scans for 26 patients with MCA aneurysm who underwent surgical clipping between June 2001 and January 2008 were retrospectively reviewed. All patients presented with sylvian hematoma associated with subarachnoid hemorrhage and received surgery at 7.9 +/- 3.6 (mean +/- standard deviation) hours of ictus. They were divided postoperatively into two groups, achievement (n = 16) and non-achievement (n = 10) of extensive hematoma evacuation, and their clinical course and functional outcomes were compared. The frequencies of delayed ischemic neurological deficit and vasospasm-related cerebral infarction were significantly less (p < 0.05) in the achievement group. Better functional outcomes were obtained in patients with successful evacuation (p < 0.05), as assessed by improvement of hemiparesis on manual muscle testing scale at postoperative 1-month follow up and by the modified Rankin scale at postoperative 3 and 6 months. Clinical outcomes were also better in the achievement group. These results suggest that better clinical course and outcome can be expected in patients who undergo early successful hematoma evacuation with surgical clipping of a ruptured MCA aneurysm.

We successfully performed endovascular coil embolization for 2 patients with unruptured saccular aneurysms. However, transient cortical blindness and generalized seizure associated with CNS neurotoxity of contrast medium were noted for each patient after the procedure. In the first case of a 62-year-old woman with a right BA-SCA aneurysm, she complained of blindness with restlessness one day after the intervention but no evidence of embolism on MRA. Abnormal EEG with slow, large amplitudes and 99mTc-HMPAO SPECT-evidenced hyperperfusion were observed in the occipital area. Accompanied by resolution of the edematous changes on MRI in conjunction with normalization of EEG and rCBF by anticonvulsant administration, her visual acuity completely recovered 8 days after the onset. According to these findings, we considered this case as transient cortical blindness. In the second case of a 68-year-old man with a left MCA aneurysm, he exhibited generalized seizure 8 hours after the procedure. CT scan revealed retention of the contrast medium over the left hemisphere. Postictal EEG one day after the seizure showed left frontal slowing but had no evidence of contrast medium retention or hyperperfusion. He recovered well with corticosteroid, anticonvulsant, and intravenous hydration. His follow-up DSA 2 years after the coiling was performed without trouble by reducing the amount/concentration of the contrast medium and by prophylactic steroid and hydration. Non-ionic contrast medium-related neurotoxity as represented by transient cortical blindness or generalized seizure should be recognized as a possible complication of endovascular surgery where patients' brain areas are locally vulnerable to contrast medium exposure.