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Intracranial arterial microanastomosis remains an important neurosurgical technique. Intimal dissection of donor or recipient arteries can cause bypass failure. We used a silicone rubber stent while performing arterial microanastomoses, and achieved an excellent postoperative patency rate. In this study, we evaluated the efficacy of the stent in cases of extensive intimal dissection. In 5 cases involving extensive intimal dissection of vessels out of a total of 856 microanastomoses that were performed between November 2000 and August 2014, we placed a silicone rubber stent in the lumen of the recipient artery for donor to recipient suturing. Surgery was performed in 3 cases of cerebrovascular atherosclerotic disease and in 2 cases requiring cerebral revascularization for the treatment of aneurysm recurrence. In one of the 5 cases in which arterial microanastomosis was performed in the spasm period after subarachnoid hemorrhage, a patent anastomosis could not be confirmed. We observed the following advantages of silicone stent use: clear visualization of the orifice created in the vessel, avoidance of suturing or damaging the contralateral side vessel edges, and maintenance of the shape of the anastomosed vessel segment. These advantages made it easier to visualize the intima and to achieve fixation by using tacking sutures.

Delayed traumatic intracerebral hematoma (DTICH) is a rare complication of head injury that appears suddenly after an interval of several days or months. Here, we report a case of DTICH during antiplatelet therapy for vasospasm following surgeries for a ruptured left internal carotid-posterior communicating (ICPC) aneurysm and right acute epidural hematoma (EDH). A 77-year-old man with no medical history was diagnosed with a subarachnoid hemorrhage (SAH) due to rupturing of a left ICPC aneurysm and a right linear fracture of the right parietal bone due to a head injury following the rupture. On day 2, the patient underwent successful clipping of the left ICPC aneurysm. Computed tomography (CT) performed post-clipping revealed a right acute EDH below the linear fracture of the right parietal bone, which was removed immediately. A next-day CT revealed minor contusions in both temporal poles. Fasudil, ozagrel, and cilostazol were administered from Day 3 post-clipping and EDH evacuation to prevent vasospasm. The contusions did not enlarge until Day 10. On Day 11, the patient became comatose, and a huge hematoma was identified in the right temporal lobe to frontal lobe. Although the hematoma was removed immediately, the patient died on Day 13. The hematoma was considered to be a rare case of DTICH that developed from a minor contusion of the right temporal lobe during antiplatelet therapy for vasospasm. In cases of aneurysmal SAH with head injury and contusion, we must pay attention to DTICH and select more deliberate treatment for vasospasm.

Aneurysms located on the proximal portion of the posterior inferior cerebellar artery (PICA) are rare, and even rarer are fusiform aneurysms in this location. Therefore the principles of surgical management are poorly understood and still subject to debate. The management plan for these lesions is based on the proper understanding of the PICA anatomy, and particularly the origin of important perforating arteries. As many anatomic variations of PICA can be observed and the perforator's origin is sometimes in complex anatomical relations with the aneurysm, the management has to be individualized in each case. The objective of management is to exclude of the aneurysm from the circulation while preserving the perforator and distal flow. We report four cases of PICA fusiform aneurysms of the anterior or lateral medullary segments which were treated successfully with trapping of the abnormal arterial segment and distal revascularization of PICA. Trapping was adjusted to the specific anatomical circumstances in each case, preserving perforators to the maximum and revascularizing (OA-distal PICA) distal territory.

Cervical vertebral arteriovenous fistulas (AVFs) are very rare. The most frequent cause is trauma including iatrogenesis which result from vertebral artery penetration during central venous catheterization. Some endovascular techniques have been reported for this type of lesion. However, several potential problems exist, such as possibility of recurrence of AVFs and VA occlusion with endovascular treatment. In this article, we review two cases with iatrogenic vertebral AVFs which were successfully treated surgically and report the advantages of surgical treatment.

Background: Although some patients with moyamoya disease need revascularization in the anterior cerebral artery (ACA) territory, there are few reports on direct bypass in the ACA territory because of the difficult surgical technique., Objective: To report our technical strategy for superficial temporal artery (STA)-ACA bypass., Methods: We performed simultaneous STA-ACA and STA-middle cerebral artery direct bypasses in 7 patients with moyamoya disease using the following strategies: creating 2 separate craniotomies for the 2 bypasses, dissecting a long STA graft and securing a recipient ACA around the bregma for the STA-ACA bypass, and using loose stitches at the anastomoses. One branch of the STA was dissected for a length of approximately 10 cm. The graft coursed on the brain surface under the bone bridge and was directly anastomosed to the cortical branch of the ACA. At the anastomoses, the stitches were widely spaced and loose to facilitate expansion of the orifice., Results: This method prevented kinking of the graft. Postoperative angiograms revealed good patency of the STA-ACA bypass in all patients. After the bypasses, 5 patients no longer had transient ischemic attacks or stroke, 1 patient was almost completely free of transient ischemic attacks, and 1 patient had only residual contralateral symptoms. In all 7 patients, patency of the bypass was satisfactory during follow-up periods ranging from 9 to 23 months (mean 16.4 months)., Conclusion: This method of STA-ACA bypass provides successful and reliable direct revascularization of the ACA territory in patients with moyamoya disease. Further investigation of the possible merit of this surgery in improving cognitive function is warranted.

Objective: For patients with internal carotid artery occlusion with advanced narrowing of the ipsilateral external carotid artery (ECA), we performed preventive carotid endarterectomy (CEA) for the ECA stenosis before superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis for internal carotid artery occlusion., Methods: Between August 2002 and July 2005, we treated seven patients with such lesions, six men and one woman, ranging in age from 52 to 66 years (median, 60 yr). Before STA-MCA anastomosis, we performed preventive CEA for advanced ECA stenosis (>70%) to ensure sufficient blood flow to the STA. STA-MCA double anastomoses were performed more than 1 month after the CEA. Postoperative cerebrovascular complications and carotid restenosis were investigated., Results: All patients in the present series had an excellent postoperative course without cerebrovascular complications during either the CEA or STA-MCA anastomosis phase. Furthermore, no postoperative carotid restenosis occurred, and all STA-MCA anastomoses were patent during a mean follow-up period of 35.6 months., Conclusion: The present study suggests that surgical management by external CEA followed by STA-MCA anastomosis is safe and effective for patients with internal carotid artery occlusion and advanced stenosis of the ipsilateral ECA.

Objective: The extracranial-intracranial bypass may have the potential to improve hemodynamic cerebral ischemia caused by occlusive diseases of the main cerebral arteries. Intraoperative confirmation of effective distribution of blood flow via the donor arteries to the involved region will assure a successful bypass surgery., Methods: Infrared thermography was used to measure the temperature of the cortical surface at the operative field. Regional cerebral blood flow (rCBF) was measured with a laser Doppler flow meter. Changes in the cortical surface temperature before and after temporary occlusion of the bypass were compared with changes in rCBF values in the corresponding sites., Results: Thermographic examination demonstrated a heterogeneous increase of cortical surface temperature caused by the blood flow via the extracranial-intracranial bypass and was closely related to rCBF changes., Conclusion: Thermography is useful not only to demonstrate the distribution of blood flow through the extracranial-intracranial bypass but also to quantitatively evaluate the rCBF changes in the operative field.