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Many asymptomatic non-ruptured intracranial aneurysms are detected by non-invasive radiological examinations. On the other hand, the question has arisen whether surgical treatment of them is justifiable or not because their natural history is not clear. Therefore, we should discuss with patients the possible risk of surgical treatment when they decide to undergo surgery. We retrospectively investigated treatment results and surgical complications involving asymptomatic non-ruptured intracranial aneurysms. From Jan. 1998 to Dec. 1999, we treated 151 patients (56 male, 95 female) aged 22-77 (mean 58.4), with 201 non-ruptured asymptomatic intracranial saccular aneurysms, excluding multiple aneurysms combined with subarachnoidal hemorrhage, within 6 months of onset. Our policy was that surgical treatment was indicated if the aneurismal size was over 3-4 mm, the patient’s age was under 70, and their general condition was satisfactory. Neck clipping was the first choice of the surgical treatment. Direct surgery was difficult for such aneurysms as internal carotid artery aneurysm arising near the dural ring, those involving posterior circulation and those of a large-size. Such aneurysms were treated with intravascular embolization if possible. We evaluated the surgical risk by the number of the operations (169 cases). Permanent morbidity resulted in 7 cases of the 112 direct surgery (6.3%) and 3 cases of the 56 cases of intravascular embolization (5.6%). No deaths resulted. The causes for the morbidity were brain damage or cranial nerve injury at the approach, a perforating artery injury or occlusion of the parent artery at the clipping in the direct surgery, and distal embolism and perforating artery occlusion in the intravascular embolization. The risk factor of the patients with postoperative neurological deficits was the aneurismal size (>10 mm, p The prognosis of severe subarachnoidal hemorrhage caused by the rupture of the aneurysm is poor, and surgical therapy for non-ruptured aneurysm over 10 mm in size is difficult. We have, therefore, decided not to change our treatment policy. However, even for transient or minor complications, surgical risk is accompanied with the treatment of cerebral aneurysm. We should seek to reduce such surgical complications by analyzing their causes.

A 13-year-old boy presented with a very unusual ependymoma extending extra-axially. Computed tomography demonstrated a tumor with a cyst and calcification adjacent to the dura and extending over the right occipital and parietal lobes. The cyst wall and solid tumor were enhanced postcontrast. Magnetic resonance imaging revealed that the solid tumor was isointense on T1-weighted images and a mixed iso- and high-intensity on T2-weighted images. The solid tumor and tissue surrounding the cyst were enhanced markedly by gadolinium-diethylenetriaminepenta-acetic acid. Sagittal and coronal images demonstrated a multilocular tumor shadow. Cerebral angiography demonstrated a tumor fed by a posterior branch of the right middle meningeal artery but no feeders from the internal carotid and vertebral arteries. The tumor was removed en bloc. The histological diagnosis was clear cell-type ependymoma.

A rare case of ganglioglioma associated with intracerebral and intraventricular hemorrhage is reported. A 55-year-old male, who suddenly developed headache, nausea, left hemiparesis, and left hemihypesthesia, was admitted. Plain skull X-ray showed a floccular calcification in the right parieto-occipital region. Computed tomography scan disclosed a calcified mass lesion, not enhanced by the contrast medium, in the right parieto-occipital region, and associated with intracerebral and intraventricular hemorrhages. A right carotid angiogram revealed an avascular mass. A right parieto-occipital craniotomy, subtotal removal of the tumor, and evacuation of the hematoma were performed. The calcified area of the tumor was removed piece by piece, and a reddish soft tumor, not calcified, was found, infiltrating the wall of the right lateral ventricle and intraventricular space. Histologically, the tumor was composed of mature ganglion cells and glial cells. In the calcified area of the tumor, thin-walled angiomatous vessels and calcification in the thick wall of the vessels were observed. The postoperative course was uneventful except for left homonymous hemianopsia. The clinical aspects of ganglioglioma and the relation between this tumor and intracerebral hemorrhage are discussed, reviewing the previously reported cases.