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Background: Long-term outcomes are unknown in patients with asymptomatic moyamoya disease. In this report, we aimed to clarify their 5-year risk of stroke and its predictors. Methods: We are conducting a multicenter, prospective cohort study (Asymptomatic Moyamoya Registry) in Japan. Participants were eligible if they were 20 to 70 years, had bilateral or unilateral moyamoya disease, experienced no episodes suggestive of TIA and stroke; and were functionally independent (modified Rankin Scale score 0–1). Demographic and radiological information was collected at enrollment. In this study, they are still followed up for 10 years. In this interim analysis, we defined the primary end point as a stroke occurring during a 5-year follow-up period. Independent predictors for stroke were also determined, using a stratification analysis method. Results: Between 2012 and 2015, we enrolled 109 patients, of whom 103 patients with 182 involved hemispheres completed the 5-year follow-up. According to the findings on DSA and MRA, 143 hemispheres were judged as moyamoya disease and 39 hemispheres as questionable manifestations (isolated middle cerebral artery stenosis). The patients with questionable hemispheres were significantly older, more often male, and more frequently had hypertension than those with moyamoya hemisphere. Moyamoya hemispheres developed 7 strokes, including 6 hemorrhagic and 1 ischemic stroke, during the first 5 years. The annual risk of stroke was 1.4% per person, 0.8% per hemisphere, and 1.0% per moyamoya hemisphere. Independent predictor for stroke was Grade-2 choroidal anastomosis (hazard ratio, 5.05 [95% CI, 1.24–20.6]; P =0.023). Furthermore, microbleeds (hazard ratio, 4.89 [95% CI, 1.13-21.3]; P =0.0342) and Grade-2 choroidal anastomosis (hazard ratio, 7.05 [95% CI, 1.62–30.7]; P =0.0093) significantly predicted hemorrhagic stroke. No questionable hemispheres developed any stroke. Conclusions: The hemispheres with asymptomatic moyamoya disease may carry a 1.0% annual risk of stroke during the first 5 years, the majority of which are hemorrhagic stroke. Grade-2 choroidal anastomosis may predict stroke, and the microbleeds and Grade-2 choroidal anastomosis may carry the risk for hemorrhagic stroke. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: UMIN000006640.

Endovascular recanalization is the primary strategy for the treatment of acute embolic stroke. However, atherosclerotic occlusions are often challenging to recanalize, and only medical therapy can be performed. In these cases, even the best medical treatment may not be effective, and the cerebral infarction progressively worsens. We believe that an emergency superficial temporal artery-middle cerebral artery(STA-MCA)bypass could be effective in these situations, after careful case selection. We use the following eligibility criteria: (1)atherosclerotic infarction; (2)cerebral ischemia with blood flow70% of the contralateral side; (3)progressively worsening symptoms or widening of the subcortical infarction despite medical treatment; and(4)surgery availability72 h from symptom onset. Among the 35 patients who underwent urgent STA-MCA bypass from 2014 to 2020, 27(77.1%)gained gait independence, and the National Institutes of Health Stroke Scale(NIHSS)scores improved from a preoperative median of 8 to 3 at discharge. The modified Rankin score(mRS)improved from a preoperative median of 5 to 2 at discharge. No intracerebral hemorrhages occurred due to hyper-perfusion syndrome. When we match it with other reports, this emergency surgery allows 76-90% of patients with progressive stroke to achieve gait independency.

ObjectivesTo examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan.DesignRetrospective study.SettingSix hundred and thirty-one primary care institutions in Japan.ParticipantsForty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database.Primary and secondary outcome measuresAnnual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3–6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1–25 points).ResultsIn the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality.ConclusionsThe 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.

Objective: In parent artery occlusion (PAO) for ruptured vertebral artery dissecting aneurysms (RVADA), target embolization using coils in a short segment to occlude only the vasodilated area containing the rupture point is selected as a first-choice procedure at our institute. We focused on RVADA involving the posterior inferior cerebellar artery (PICA) and evaluated the treatment results.Methods: This study consisted of eight cases with RVADA involving the PICA which were treated between October 2007 and January 2020. Based on radiological findings such as the bleb, the rupture points were located at the affected vertebral artery (VA) distal to PICA in all cases. Target embolization, by which only coiling at the dilated segment distal to the VA was performed. We aimed to preserve blood flow to the PICA. The incidence and extent of medullary infarctions, and neurological outcome were retrospectively assessed.Results: Regarding the diameter of bilateral VA, there were no differences in six cases while the affected VA with RVADA were larger in the remaining two cases. PICA was preserved in all cases but one in which occlusion of complementary PICA was observed. Postoperative medullary infarction was not noted. There was no rebleeding during the follow-up period. However, recanalization of the VA was observed in four cases and additional coil embolization was performed. All patients were discharged with a good outcome (modified Rankin Scale [mRS] 0; seven patients, mRS 2; one patient).Conclusion: Target embolization preserving the PICA in PICA-involved type RVADA was considered to be an effective treatment method for cases whose rupture point was located in the VA distal to PICA orifice.

Several basic experimental studies have demonstrated that statins have beneficial effects for intracranial aneurysm (IA). Clinical studies on unruptured IAs, however, remain limited to four retrospective studies that have reached different conclusions. This study was the first open-label, multicenter, randomized controlled trial to assess the preventive effects of atorvastatin. Patients with unruptured small saccular IAs were randomly assigned to statin and control groups. The primary endpoint was a composite of aneurysm growth of ≥0.5 mm, new bleb formation confirmed from magnetic resonance (MR) angiography, and rupture. Enrollment was prematurely terminated due to unexpectedly slow enrollment. Of 231 patients (275 target IAs), 110 patients (128 IAs) were randomly assigned to the statin group and 121 patients (147 IAs) to the control group. After excluding 22 dropout patients, 107 IAs in the 93 statin group patients and 140 IAs in the 116 control group patients were finally analyzed. No significant differences of basic characteristics were evident between groups, except for significantly higher systolic pressure in the statin group (P = 0.03). The primary endpoint occurred in 28 IAs (20.0%) in the control group and in 17 IAs (15.9%) in the statin group. No aneurysm rupture was confirmed in either group. Significant beneficial effects of statin for IAs were not demonstrated for the primary endpoint (log-rank P = 0.359). This randomized trial did not establish any preventive effects of atorvastatin for unruptured small IAs. Further studies of larger cohorts are required to clarify the efficacy of statins for patients with unruptured IAs. Clinical trial registration: UMIN000005135.

Background Skull bone tumor resection is sometimes difficult, when tumor is hidden under the bone surface or similar to the normal bone in appearance. Indocyanine green (ICG) fluorescence has been used in various surgical fields for visualizing vascular and tumor tissues. This is the first report to show that intraoperative ICG fluorescence is useful for skull bone tumor resection. Case description Four patients underwent skull bone tumor resection from June to December 2014. Two patients had Langerhans cell histiocytosis, and the others had hemangiomas. During surgical treatment, intraoperative ICG injection revealed the bone tumors hidden in normal bone tissue in real time. Three of the four tumors were identified as a high intensity area, and the other, a cavernous hemangioma, as an area lacking fluorescent enhancement. Each area was marked and then removed en bloc with an outside margin of 1 cm. On pathological examination, the surgical margin corresponded to the actual margin. In all cases, Postoperative course was uneventful, and there was no tumor recurrence. Conclusion Our experience illustrates that intraoperative ICG fluorescence examination might be a useful supplemental method for skull bone tumor resection, especially for tumors extending under the bone surface or similar to normal bone in appearance.

Background We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. Methods and results We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. Conclusions We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.

Hyperventilation is a well-known risk factor of ischemic events in pediatric patients with moyamoya disease. For young children, it is important to avoid crying to prevent ischemic events because of their unstable postoperative hemodynamics. To prevent crying in pediatric patients, we used dexmedetomidine(DEX)for sedation immediately after revascularization surgery.We investigated the effects of postoperative DEX use on hemodynamic changes and the avoidance of crying and hypocapnia in pediatric patients with moyamoya disease.Ten consecutive patients(5 boys and 5 girls)who underwent surgical revascularization were enrolled, and 16 hemispheres(8 boys and 8 girls)were sedated with DEX postoperatively between August 2011 and August 2016.During extubation after revascularization, DEX was started at 0.4μg/kg/hr under spontaneous breathing and its dose was increased depending on the degree of consciousness, to maintain sedation of at least 3 on the Ramsay scale. DEX administration was terminated the next morning.Sedation was maintained well in all patients without hypocapnia, and no ischemic complications were observed. One patient cried and needed additional intravenous DEX injections and was immediately re-sedated;no hypocapnia developed. Respiratory depression did not occur and changes in respiratory rate and decreases in SpODexmedetomidine is safe and useful for postoperative sedation in children with moyamoya disease.

Background: Improving the quality of stroke care is an urgent issue worldwide. To facilitate the measurement of quality of stroke care in Japan, we aimed to develop the Close The Gap-Stroke initiative in the J-ASPECT Study. Methods and Results: Quality indicators (QIs) were developed by a multidisciplinary board between 2015 and 2017. The process involved a systematic review of domestic and international studies related to primary and comprehensive stroke care. Adherence rates for the defined QIs were calculated for 8,826 patients with acute ischemic stroke from 227 hospitals between 2013 to 2015. Seventeen and 12 measures were identified as QIs for primary and comprehensive stroke care (PSC and CSC), respectively. We analyzed adherence rates of all 17 QIs for PSC and 8 QIs for CSC related with acute ischemic stroke. We found NIHSS documentation (91.0 %), CT/MRI performed within 25min and 24hr (80.9 % and 99.1 %), evaluation of extracranial vascular imaging (90.4 %), treated in stroke unit (57.4 %), tPA administration (89.5 %), tPA performed within 1hr (37.4 %), early and discharge antithrombotics medication (75.1 % and 49.0 %), discharge anticoagulation for atrial fibrillation patients (76.2 %), discharge statin medication (32.7 %), discharge antihypertensive agents (54.3 %), deep vein thrombosis prophylaxis (34.5 %), early rehabilitation (57.0 %), dysphagia screening (76.6 %), smoking cessation (59.8 %) and stroke education (71.4 %) for primary stroke care; and median time to multimodal CT or MR brain and vascular imaging (33 min), proper endovascular recanalization (81.7 %), tPA before endovascular recanalization (65.7 %), TICI grade 2b/3 after endovascular recanalization (73.0 %), median time of door to puncture (105 min), symptomatic intracranial hemorrhage after thrombolytic or endovascular therapy (7.45 %), 90 days mRS documentation after thrombolytic or endovascular therapy (60.8 %), occurrence of complication within 24 hours of diagnostic neuroangiography (7.27 %) for comprehensive stroke care. Conclusion: This is a promising first step to measure the QIs related to primary and comprehensive stroke care at a national level in Japan.

The number of patients receiving chronic dialysis treatment in Japan currently exceeds 300,000 people. Few reports have described carotid endarterectomy(CEA)for chronic renal failure patients because of the unacceptable rate of perioperative stroke and other morbidities. A strategy for and treatment results of CEA for chronic renal failure patients in our hospital are described herein.The present study included 6 patients who underwent CEA while receiving dialysis treatment between April 2011 and November 2014.Dialysis treatment was initiated due to diabetes in 4 patients and renal sclerosis in 2 patients. All the patients were men, with a mean age of 74.0 years. Two patients were symptomatic, and four were asymptomatic. In all the patients, heart vascular lesions and arteriosclerosis risk factors were present. Postoperatively, pneumonia transient cranial neuropathy, heart failure, and pneumonia in 1 case required extensive treatment. However, by the time of discharge from hospital, no cases had deteriorated compared with their pre-CEA state. The modified Rankin scale score on discharge was 0-2 for all the patients.CEA can be performed safely in patients receiving dialysis, but further operative procedures and careful postoperative management are likely to be needed for patients with CEA who are receiving dialysis.

Background: Hemorrhagic transformation (HT) following acute ischemic stroke is a major problem, especially for the indication of reperfusion therapy including intravenous administration of recombinant tissue plasminogen activator (IV rt-PA). The specific predictive factors of HT have not yet been established. The present study evaluated the findings of computed tomography perfusion (CTP) images as predictors of subsequent HT to identify patients with low HT risk for reperfusion therapy such as IV rt-PA. Methods: We retrospectively reviewed 68 consecutive stroke patients (41 males; mean age 72.9 years) with steno-occlusive lesions in the major trunk, including 10 patients who underwent IV rt-PA. Each HT was detected on a follow-up T2*-weighted magnetic resonance image until 2 weeks after stroke onset and categorized into four groups [hemorrhagic infarction (HI) type 1 and 2, and parenchymal hematoma (PH) type 1 and 2] according to the European Cooperative Acute Stroke Study (ECASS) classification. We assessed clinical features and radiological findings between the HT and non-HT groups or the PH2 and non-PH2 groups. The efficacy of initial time to peak (TTP) mapping of CTP for predicting HT or PH2 was evaluated. Results: Thirty-four patients (50%) developed subsequent HT: 18 (52.9%) had HI and 16 (47.1%) had PH, including 9 PH2 patients (13.2%). IV rt-PA was not significantly associated with HT or PH2 occurrence. Forty of the 68 patients (59%) revealed defect areas on the initial TTP mapping (TTP map-defect), and 34 of these 40 patients (85%) developed secondary HT and 9 patients (22.5%) developed PH2. Initial ‘TTP map-defect’ was significantly associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0070). Thirty of the 34 patients (88.2%) in the HT group experienced delayed recanalization of the occluded vessels, in contrast to only 8 of the 34 patients (23.6%) in the non-HT group. All patients of the PH2 group showed recanalization (p = 0.0042). In 40 ‘TTP map-defect’-positive patients, delayed recanalization was associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0491). All 28 patients without ‘TTP map-defect’ did not develop HT, including 8 patients (28.6%) with delayed recanalization. Conclusions: Initial ‘TTP map-defect’ of CTP could accurately predict HT risk including PH2 risk and identify low-risk patients even in the delayed period.

[123I]iomazenil (IMZ) is a specific radioligand for the central benzodiazepine (BZ) receptor that may be useful as a marker of cortical neuron loss after cerebral ischemia using single photon emission computed tomography (SPECT). This study used statistical imaging analysis for IMZ-SPECT to investigate the relationship between higher brain dysfunction and cortical neuron loss in the medial frontal lobes, to establish a confirmatory diagnosis of higher brain dysfunction in patients with adult moyamoya disease. IMZ-SPECT was estimated by three-dimensional stereotactic surface projections (3D-SSP). Cortical neuron loss was analyzed using the stereotactic extraction estimation (SEE) method (level 3: gyrus level) for 3D-SSP Z-score maps (Z-score >2). Extent of pixels with significant reduction of BZ receptor density within the target gyri (i.e. bilateral medial frontal gyri [MFGs] and anterior cingulate gyri [ACGs]) was calculated. In 6 patients with higher brain dysfunction, significant cortical neuron loss was observed in the bilateral MFGs in 4 patients, unilateral MFG in 1 patient, and bilateral ACGs in 2 patients. In 12 patients without higher brain dysfunction, no significant cortical neuron loss was observed in the bilateral MFGs or ACGs, and mild loss was observed in the bilateral MFGs in 2 patients, unilateral MFG in 4 patients, and unilateral ACG in 2 patients. Long-standing mild hemodynamic ischemia in the anterior circulation of patients with adult moyamoya disease could lead to incomplete brain infarction within the medial frontal lobes. Statistical imaging analysis using 3D-SSP and SEE methods for IMZ-SPECT could demonstrate significant cortical neuron loss in the bilateral frontal medial cortices involving MFG and/or ACG which correlate with higher brain dysfunction in patients with adult moyamoya disease.

We examined the operative findings of cerebral aneurysms that grew during follow-ups over the past 5 years. We defined aneurysmal growth as form change such as the bleb formation or more than 2-mm growth compared with past findings. In operation, we confirmed a very thin wall of cerebral aneurysm correspond to aneursymal growth during follow-up. Rupture rates appear to be high in aneurysms caused by a change such as the above. Clipping can prevent aneurysmal rupture in these cases.

We employ the 123I-IMP SPECT dual table ARG method and stereotactic extraction estimation (SEE) analysis 7 or 8 days after subarachnoid hemorrhage (SAH) onset to predict cerebral vasospasm. We report new findings of cerebral vasoparalysis during a period of cerebral vasospasm after SAH. From January 1, 2005 to April 30, 2008, we encountered 330 cases of aneurysmal SAH, and treated 285 cases. Of these, 65 were excluded as unsuitable for this study, for reasons such as lack of SPECT data, external decompression, admission over 7 days from SAH onset. We studied 220 cases treated by microsurgical clipping (n＝178) or endovascular coil embolization (n＝42). Vasoparalysis was defined as a rise in resting CBF and a loss of vascular reserve on SEE analysis of CBF-SPECT. Vasoparalysis occurred in 15 cases (6.8%). Of these, 9 cases (60.0%) had cerebral hematoma, temporary clips had been used in the operation for 8 cases (53.3%), 9 cases (60.0%) experienced postoperative cerebral infarction, and 3 cases (20.0%) had postoperative convulsions. Vasoparalysis occurs in relation to perioperative cerebral damage. In terms of the loss of vascular reserve following SAH, vasoparalysis resembles hemodynamic cerebral ischemia, although the conditions are quite different. Differentiating between these 2 conditions is important, as different forms of management are required. Dual table ARG and SEE analysis are very useful for the evaluating these 2 conditions.

Indocyanine green (ICG) angiography of cervical carotid artery stenosis was performed and the contrast patterns were analyzed. The subjects were 18 patients who had undergone carotid endarterectomy (CEA) since August 2009. Before arteriotomy, ICG angiography was performed and monitored. One patient who underwent ICG angiography of the cervical vessels during high-flow bypass of a ruptured cerebral aneurysm acted as a control. On ICG angiography of the control patient, the vascular lumen was first filled with ICG, after which the arterial component of the vasa vasorum was slowly contrast-enhanced, followed by contrast enhancement of the venous component, and finally uniform contrast enhancement of the arterial wall. The vasa vasorum were contrast-enhanced in an annular conformation along the short axis of the internal carotid artery. In CEA patients, the arterial component of the vasa vasorum was quickly contrast-enhanced after ICG filling of the vascular lumen, with a non-homogenous vascular network formed by branches of the vasa vasorum at the atheroma site, followed by contrast enhancement of the venous component and, finally, by patchy contrast enhancement of the entire arterial wall. The vasa vasorum were contrast-enhanced in a virtually radiating conformation along the long axis, mainly around the common carotid bifurcation. Similar results were also obtained from analysis of the time-intensity curve with Flow 800. ICG angiography findings in severe cervical carotid artery stenosis suggested that the vascular structure of the arterial wall had transformed from a normal condition to a pattern of nutrient supply to the atheroma.

Internal carotid artery (ICA) endovascular proximal occlusion and trapping with radial artery grafting is a favorable option in treating giant aneurysms in the cavernous portion of the ICA. Even if ischemic tolerance is proven with the balloon test occlusion (BTO) procedure, treatment strategies will likely vary depending on the individual case. Should other aneurysms exist in collateral vessels, hemodynamic stress will occur on the collateral vessels and the aneurysm after the endovascular proximal occlusion, likely causing the aneurysm to enlarge. In such cases, neck clipping of these peripheral aneurysms should be performed before ICA proximal occlusion or trapping and vascular bypass.

We report our experience in surgical clipping of 7 patients with a recurrent intracranial aneurysm previously treated by neck clipping. All were treated under deliberate mild hypothermia for protection from ischemia during intraoperative temporary vessel occlusion. Surgical approaches were the same as previous in 5, extended in 1 and different in the 7th, which made it possible to expose the entire length of the previous clip. Intraoperative temporary vessel occlusion was necessary in 5 cases and the maximum occlusion time of each case was 7 to 15 minutes. Clipping was successfully completed without surgical complications in all but 1 case, which suffered transient mild hemiparesis with small infarction in the territory of the perforating artery due to intraoperative temporary vessel occlusion. Adequate selection of surgical approach and sharp dissection around the aneurysm were essential. We emphasize the usefulness of intraoperative mild hypothermia for protection from ischemic insults during temporary vessel occlusion in territory supplied with the cortical artery.

We investigated surgical indication and factors relating to risks of rupture in 274 consecutive patients with unruptured cerebral aneurysms. Of the total, 114 (41.6%) patients were surgically treated: 96 were treated with craniotomy, and 18 were treated with coil embolization. The incidence of cases undergoing surgical intervention tended to expand with the increase of their aneurysm size except for cases with large or giant aneurysms. In cases with small aneurysms less than 4 mm, the presence of a familial history of subarachnoid hemorrhage, additional ruptured aneurysms, additional large aneurysms, posterior circulation aneurysms and intractable anxiety of patients were the reasons for surgical intervention. Nine of 17 (52.9%) cases with additional aneurysms suffering subarachnoid hemorrhage, 32 of 46 (69.6%) patients with a familial history of subarachnoid hemorrhage and 28 of 36 (77.8%) cases whose aneurysm had bleb formation underwent surgical intervention. Complete clipping was achieved in 94 of 96 (97.9%) cases treated with craniotomy, and a sufficient initial embolization rate of over 90% was obtained in all cases treated with coil embolization. Surgical complication affecting patients ADL was observed in only 1 of 119 (0.9%) treated cases, and consequent rupture of aneurysms occurred in 2 older patients during follow-up in 155 conservative cases. To decide surgical indication for unruptured cerebral aneurysms, it is important to consider factors related to risks of rupture.

We evaluated treatment results of 109 patients with ruptured cerebral aneurysms when we employed endosaccular coil embolization instead of surgical clipping if sufficient obliteration rate was predicted. Endosaccular coil embolization was applied to 14 (12.8%) and surgical clipping was used for the other 95 patients. The reasons why endosaccular coil embolization was not indicated were presence of intracranial mass lesions such as intracerebral, intraventricular or subdural hematoma in 15, renal failure in 1, uncertain ruptured site in multiple aneurysms in 13, possibility of dissection in 3, inaccessibility in 2 and inadequate size and configuration in 61. Eighty-three of 109 (76.1%) patients were assessed as modified Rankin scale better than 2 in 3 months. Sufficient obliteration rate such as complete or neck remnant was achieved in 12 of 14 (85.1%) patients treated with endosaccular coil embolization. Occurrence and severity of cerebral vasospasm, secondary hydrocephalus and hospital days were less in patients treated with coil embolization. When endosaccular coil embolization was used to treat ruptured aneurysms if a sufficient obliteration rate was predicted and surgical clipping was employed for others, indication of endosaccular coil embolization was still limited but treatment results were acceptable. Improvement of technique for complete obliteration in endosaccular coil embolization will expand the indication of coil embolization for patients with ruptured cerebral aneurysms, and it may help reduce cerebral vasospasm, secondary hydrocephalus and hospital days.

The Japanese Standard Stroke Registry Study (JSSRS) group (chief investigator: S. Kobayashi) developed new software for its acute stroke database. In our institute, this software was applied within a medical records database system that functioned in a local area network (LAN). From January 1, 2000, to January 31, 2002, 2,068 stroke patients were registered in the JSSRS database, and 1,731 patients' data were confirmed. About 70 patients were registered monthly, and cumulative cases with unconfirmed data were not increased but changed up to a mean 75 cases per month. The third section (medical record manager) should control continuous registration of stroke patients and confirmation of input data. The JSSRS database was useful for confirming classification of disease, patients' history, and clinical course for other forms in the medical records database. According to the confirmed stroke database, clinical categories of acute brain infarction were classified into cardiogenic embolism in 28.0%, atherothrombotic stroke in 27.4%, and lacunar stroke in 35.3%. Time from stroke onset to admission was within 3 hours in 36%, and within 6 hours in 48%. Accuracy of the stroke database could improve after the introduction of JSSRS database software. An acute stroke databank based on the JSSRS database could be valuable for establishing evidenced based medicine (EBM) for stroke management and planning of new strategy for acute stroke. In addition, input data for the JSSRS database is useful for confirming and establishing a medical records database.

Background and Purpose— About one half of those who develop adult-onset moyamoya disease experience intracranial hemorrhage. Despite the extremely high frequency of rebleeding attacks and poor prognosis, measures to prevent rebleeding have not been established. The purpose of this study is to determine whether extracranial–intracranial bypass can reduce incidence of rebleeding and improve patient prognosis. Methods— This study was a multicentered, prospective, randomized, controlled trial conducted by 22 institutes in Japan. Adult patients with moyamoya disease who had experienced intracranial hemorrhage within the preceding year were given either conservative care or bilateral extracranial–intracranial direct bypass and were observed for 5 years. Primary and secondary end points were defined as all adverse events and rebleeding attacks, respectively. Results— Eighty patients were enrolled (surgical, 42; nonsurgical, 38). Adverse events causing significant morbidity were observed in 6 patients in the surgical group (14.3%) and 13 patients in the nonsurgical group (34.2%). Kaplan–Meier survival analysis revealed significant differences between the 2 groups (3.2%/y versus 8.2%/y; P =0.048). The hazard ratio of the surgical group calculated by Cox regression analysis was 0.391 (95% confidence interval, 0.148–1.029). Rebleeding attacks were observed in 5 patients in the surgical group (11.9%) and 12 in the nonsurgical group (31.6%), significantly different in the Kaplan–Meier survival analysis (2.7%/y versus 7.6%/y; P =0.042). The hazard ratio of the surgical group was 0.355 (95% confidence interval, 0.125–1.009). Conclusions— Although statistically marginal, Kaplan–Meier analysis revealed the significant difference between surgical and nonsurgical group, suggesting the preventive effect of direct bypass against rebleeding. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr/index.htm . Unique identifier: C000000166.