Kosnik Grade Research Articles

Medico-Financial Environment on Treatment for Acutely Ruptured Cerebral Aneurysms

We have been using the Guglielmi detachable coils (GDC) since 1997 as one choice of cerebral aneurysm treatment.We have, at the present time, two effective radical treatment methods for acutely ruptured cerebral aneurysms, GDC embolization and conventional surgical aneurysmal neck clipping. There ensued questions about the cost and efficacy of the two strategies. Retrospective analysis was done on a GDC group and a clipping group, with each twenty consecutive patients. The features of the GDC group patients were higher age, and poorer Hunt and Kosnik grades than the other group. All MCA aneurysms were treated with surgical neck clipping, while all the posterior circulation aneurysms were embolized with GDC. Based on the Japanese Medical Insurance and Payment System, 477,890 points (1 point = yen 10) as a mean was required with the GDC group, and 456,084 points with the neck clipping group, showing no significant difference between the two groups. In the GDC group, the cost of the implanted medical device seemed to raise the total medical expense. At present, the GDC embolization is the preferred choice of strategies in acutely ruptured cerebral aneurysms, and its preference increases in the surgically difficult cases, very old, or poor grade patients, and in various complicated cases. And, the GDC embolization seems to be satisfactory from the medico-financial viewpoint.

Surgical outcomes in elderly patients with aneurysmal subarachnoid hemorrhage

The optimum management for elderly patients with aneurysmal subarachnoid hemorrhage (SAH) remains controversial. The surgical indications for aneurysmal SAH in elderly patients were investigated. Materials and methods: This study retrospectively reviewed 148 elderly patients over 70 years old among 1019 patients surgically treated for SAH. The patients were divided into three groups: group A, 93 patients aged 70–74 years; group B, 33 patients aged 75–79 years; and group C, 22 patients aged over 80 years. The outcomes were evaluated using the Glasgow Outcome Scale, with good recovery and moderate disability considered as favorable. The surgical outcome was analyzed compared with the preoperative Hunt and Kosnik grade, location of the aneurysm and causes of complication. Results: A favorable outcome for patients in preoperative Hunt and Kosnik grades I and II was achieved in 84.8% of group A, 63.8% of group B and 57.1% of group C, and for patients in grades III–V, 40.4% of group A, 15.4% of group B and 12.5% of group C. The rate of favorable outcome decreased with age and worse preoperative clinical grade. In patients remaining conscious before operation, the differences in recovery rates were not statistically significant by advancing age. For those patients with disturbance of consciousness, however, the recovery rate was significantly worse in groups B and C as compared with group A. The causes of poor outcome were primary brain damage, vasospasm and muscle weakness due to extended bed rest. In addition, more than half of the patients in a severely disabled or vegetative state at the time of discharge resulted in death within 5 years. Conclusion: Surgery should be considered for elderly patients with aneurysmal SAH leading a normal life before onset and without severe systemic disease, even in those over 80 years, but not in patients with disturbance of consciousness due to primary brain damage.

Causes and evaluation of postoperative deterioration due to surgical procedure in patients with ruptured cerebral aneurysms

Poor outcomes may be caused by the surgical procedure for ruptured cerebral aneurysm. This study reviewed 1025 patients who underwent surgery for ruptured cerebral aneurysms and found 28 patients (2.7%) with poor outcomes due to the surgical procedure. Classification of these 28 cases according to the site of aneurysm showed 9/285 (3.2%) cases were located in the internal carotid artery, 5/185 (2.7%) in the middle cerebral artery, and 14/189 (7.4%) in the vertebrobasilar artery (VBA). Classification according to preoperative Hunt and Kosnik grading showed 7/399 (1.8%) cases were in grade I, 1/85 (1.2%) in grade Ia, 7/181 (3.9%) in grade II, 12/212 (5.7%) in grade III, and 1/133 (0.8%) in grade IV. Classification by age showed 19/879 (2.2%) patients were under 70 years old, and 9/146 (6.2%) were 70 years or over. Causes of deterioration were perforator injury, postoperative intracerebral hemorrhage, postoperative re-bleeding, parent artery occlusion, etc. Poor outcomes were often seen in patients with VBA aneurysms, Hunt and Kosnik grade III, and age 70 years old or over. Perforator injuries and postoperative re-bleeding due to incomplete clipping were particularly present in cases located on the VBA. Complete clipping should be achieved by appropriate dissection of the aneurysm, with temporary occlusion of the parent artery if necessary, to obtain good outcome.

水分，ナトリウム管理はスパスムを改善したのか？―当院におけるくも膜下出血管理の変遷―

Water and sodium balance is very important in patients with subarachnoid hemorrhage (SAH). We reviewed surgical outcomes with regard to cerebral vasospasm in 92 patients with SAH whose water and sodium balance was differently managed. All patients underwent surgery within 96 hours of the SAH. Water balance was controlled only by fluid in Group 1 (1998.1-1999.4), vasopressin was used to control urine output in Group 2 (1999.5-2000.5), and mineralocorticoids were also used to prevent sodium diuresis in Group 3 (2000.6-2001.12). Anti-inflammatory neuroprotective therapy using indomethacin was also employed in Groups 2 and 3. In Group 2, vasopressin effectively controlled urine volume, but also caused hyponatremia, and the incidence of vasospasm increased especially in patients with Hunt & Kosnik Grade 2. In Group 3, although mineralocorticoids prevented sodium diuresis, and reduced the incidence of hyponatremia and vasospasm in patients with Hunt & Kosnik Grade 2, there was no significant improvement on the Glasgow outcome scale or in the incidence of vasospasm in patients with Hunt & Kosnik Grades 3 and 4. Indomethacin reduced the number of high fever cases, but did not improve surgical outcome. Intravascular infusion of vasodilators or systemic hypothermia may be more effective in improving overall outcomes after SAH, especially in severe cases.

くも膜下出血の急性期治療 くも膜下出血重症例に対する急性期治療−ＧＤＣ塞栓術導入による変化−

Indication of early treatment remains controversial for patients in poor clinical condition (Hunt & Kosnik Grade 4 or 5) after subarachnoid hemorrhage (SAH). Since 1997, we have adopted endovascular treatment using Guglielmi detachable coil (GDC) as a treatment option for these patients. In this study, we compared clinical courses of the cases treated in 1990-1996 to those treated in 1997-2002 to evaluate the efficacy of changes in treatment strategy. Between 1990 and 2002, 130 cases with SAH in Grade 4 and 5 underwent angiography as candidates of early aggressive treatment in our hospital. For the 63 cases in 1990-96 (Group 1), treatment options were early and intensively delayed craniotomy surgery and conservative management, while for the 67 cases in 1997-2002 (Group 2), GDC embolization at acute stage was added to these 3 treatment options. We compared the 2 groups of patients in terms of clinical courses and outcomes, assessed with Glasgow Outcome Scale Score (GOS) at discharge. The percentage of the patients in which aneurysm was occluded at acute stage increased from 67% in Group 1 to 87% in Group 2 for Grade 4 and from 33% to 52% for Grade 5. In Group 2, 44% of Grade 4 and 83% of Grade 5 patients were treated by GDC embolization. The outcomes of the cases in both Grade 4 and 5 were better in Group 2 than in Group 1. That is, for Grade 4 cases, the percentage of Good Recovery (GR) significantly increased from 7% in Group 1 to 27% in Group 2. And for Grade 5 cases, good outcome (GR or MD) increased from 5% in Group 1 to 18% in Group 2. Two patients recovered completely from Grade 5 in Group 2, both of which were treated with GDC while none in Group 1 recovered completely from Grade 5. The incidence of symptomatic vasospasm was not changed between Group 1 (20%) and Group 2 (16%). The introduction of GDC embolization extended the indication of early treatment for severe SAH patients because it was less invasive and, as a consequence, improved the outcome of those patients.

脳動脈りゅう再破裂における関連因子の検討

To assess the predictor of rerupture, we statistically studied the related factors for 121 subarachnoid hemorrhage (SAH) cases during a recent 5-year period. Rerupture was classified into severe and mild ones; severe is defined as patients whose Hunt & Kosnik grade worsened after rerupture; mild is defined as patients who experienced severe headache or vomiting due to rerupture without a worsening of Hunt & Kosnik grade. Twenty-eight rerupture cases (23%) comprised 15 severe and 13 mild ones. Two had rerupture (one was mild, and the another was severe) after admission in spite of their compliance with our protocol for the prevention of rerupture. In all the rerupture cases, there was no factor that significantly affected aneurysmal rerupture. However, its incidence increased in the cases of vertebrobasilar artery aneurysm, bleb, and multiple aneurysms. On the other hand, in severe rerupture cases, vertebrobasilar artery aneurysm and multiple aneurysms significantly affected aneurysmal rerupture (p=0.049, 0.037, respectively) in comparison with the no-rerupture cases. Furthermore, when comparison was made between severe rerupture cases and mild ones, there was no factor that significantly affected aneurysmal severe rerupture. However, the incidence of severe rerupture was higher in the cases of vertebrobasilar aneurysm and multiple aneurysms, while the incidence of mild rerupture was the same in the cases of internal carotid artery aneurysm and bleb. Rerupture, especially severe ones, occurred mainly within 6 hours before hospitalization after the initial SAH. Glasgow outcome scales (GOS) of mild rerupture cases were almost similar to no-rerupture ones; however, severe rerupture cases showed significantly worse results than the others (p=0.038). To improve the outcome of SAH, we should be especially careful and plan an adequate management even in the period before hospitalization.

離島で発症し急性期にヘリコプター搬送を受けたくも膜下出血患者の転帰

To determine the risk and benefit of emergency helicopter transport of island patients for treatment of subarachnoid hemorrhage (SAH), we retrospectively analyzed 96 consecutive patients with SAH treated in our institution over the last 2 years. The island group consisted of 55 island patients who received emergency helicopter transport, the mean distance and duration of which were 140 km and 40 minutes, respectively. The land group consisted of 41 land patients transported by ambulance. Only one rerupture during flight was confirmed among the island group. Age, sex, and the time interval between onset and admission did not significantly differ between the 2 groups. At admission, there were 3 patients with Hunt & Kosnik (H & K) Grade 5 in the island group, and 7 with H & K Grade 5 in the land group, and the poor-grade patients were fewer in the former (p=0.09). Fifty-two of 55 patients in the island group, and 29 of 41 patients in the land group were treated operatively or interventionally, and 2 of the former and 12 of the latter were conservatively treated mainly because of poor grade, which was significantly different (p=0.003). At discharge, the number of patients with modified Rankin Scale Grade 0, 1, and 2 were 27 in the island group, and 12 in the land group, and the outcome of patients in the former tended to be better (p=0.09). The emergency helicopter medical transport of the patients with SAH was thought to be safe and effective.

The use of mild hypothermia for patients with severe vasospasm: a preliminary report

The purpose of this study was to determine the effect of mild hypothermia on cerebral ischaemia due to severe vasospasm, which was refractory to medical and intravascular treatments and to assess the brain protection of this treatment in patients who underwent delayed aneurysm clipping after presenting with ischaemic neurological deficits. Mild hypothermia (32–34 °C of brain temperature) was employed in two groups: (1) Patients (Hunt and Kosnik grades I to II) who showed progressive neurological deficits due to vasospasm and did not respond to conventional therapy (Group 1) and (2) Patients who received delayed aneurysm clipping after presenting with ischaemic neurological deficits due to vasospasm (Group 2). Seven of 8 patients in both Groups showed a favorable outcome with mild hypothermia (good recovery in 5 and moderate disability in two patients). Mild hypothermia is considered to be effective on critical cerebral ischaemia due to vasospasm even after failure to response the conventional therapies and to provide brain protection in delayed aneurysm clipping.

一山間地域におけるくも膜下出血の診療

From January 1997 to December 2001, patients with subarachnoid hemorrhage (SAH) among 14,008 residents in an isolated mountainous area; Oguni and Minamioguni towns in Kumamoto Prefecture, were evaluated. The subjects were patients being treated at Oguni Municipal Hospital. Over a period of 5 years, 19 patients were found to be suffering from SAH in this area, 3 of whom were visitors (residing outside this area). The annual incidence rate of SAH in this area was calculated as 22.9 per 100,000. The sex ratio (men:women) was 4:12. The average age was 67.9 years; 65.0 years for men and 68.8 years for women. Eleven patients were older than 65, and constituted 68.8% of the subjects. The risk factors of SAH were recognized, and both hypertension and smoking constituted 31.6%. Alcohol was 21.1% and hyperlipemia was 15.8%. In 13 clipping operated cases excluding 1 test craniotomy, Hunt & Kosnik's Grades at admission were G.I: 2, G.II: 5, G.III: 3, G.IV: 2 and G.V: 1, and Fisher's Groups were G.I: 0, G.II: 8, G.III: 3 and G.IV: 2. The sites of 16 operated aneurysms were internal carotid-posterior communicating artery (IC-PC): 2, anterior communicating artery (A Co.A): 4, middle cerebral artery (MCA): 10 and vertebral artery-basilan artery (VA-BA): 0. The aneurysmal size were < 5 mm: 5, 6-10 mm: 9 and 11 mm < :2 (average 7.6 mm, 2-15 mm). The results were evaluated at discharge, excluding 1 SAH of unknown etiology. 9 were good, 2 were dependent and 7 including 5 non-operative cases had died. We were satisfied with these results, because we were treating older patients. Although we attempted the clipping operation using only a three dimensional computed tomographic angiograply (3D-CTA; X-Vision GX (TOSHIBA) & X-Tension), we had no problem, except for 1 test craniotomy. 3D-CTA was useful during the clipping operation in the small hospital, especially, in regard to cost.

８０歳以上の破裂脳動脈りゅう患者の臨床的特徴と治療成績

We investigated the clinical features of 54 elderly patients aged over 80 years with ruptured intracranial aneurysms admitted to our hospital between May 1968 and December 2001. The changes in patient number, age, male/female ratio, site of cerebral aneurysm and preoperative Hunt & Kosnik grade were studied. The patients were divided into 2 groups (surgically treated group and conservatively treated group). Outcome was evaluated according to the Glasgow Outcome Scale, and the causes of poor results were analyzed.The number of patients calculated for 5-year periods is rising steadily, and reached 25 patients for the last 5 years (1997-2001), accounting for 46% of all. The mean age of the patients was 82.4 ± 2.5 (range 80-92 years), and 44 patients (81%) were under 84 years. The male/female ratio was 1:5. The location of 50 ruptured cerebral aneurysms (4 cases were excluded because cerebral angiography was not performed) were the internal carotid artery in 24 cases (48%), the middle cerebral artery in 12 cases (24%), the anterior communicating artery in 11 cases (22%), the anterior cerebral artery in 2 cases (4%), and the basilar artery in 1 case (2%). Their preoperative neurological grades, according to the classification of Hunt & Kosnik, were II in 11 cases (20%), III in 17 cases (31%), IV in 14 cases (26%) and V in 12 cases (22%).Of 54 cases, 26 were treated surgically: neck clipping of cerebral aneurysms was performed in 21 cases, wrapping of cerebral aneurysms in 2 cases, transarterial embolization of cerebral aneurysms in 3 cases and the remaining 28 cases were treated conservatively. The clinical outcome of the surgically treated group was GR in 4 cases (15%), MD in 5 cases (19%), SD in 6 cases (23%), VS in 2 cases (8%) and D in 9 cases (35%). The preoperative Hunt & Kosnik grades of the 4 GR cases were II in 1 case, III in 2 cases, and IV in 1 case. Cerebral infarction caused by cerebral vasospasm was revealed in 10 (38%) of 26 surgically treated cases. The preoperative Hunt & Kosnik grades of these 10 cases were II in 4 cases and III in 6 cases. The clinical outcome was MD in 1 case, SD in 1 case, VS in 1 case and D in 7 cases. Cerebral infarction caused by cerebral vasospasm during the last 5 years (1997-2001) was revealed in 3 (23%) of 13 surgically treated cases, although it was 7 (54%) of 13 cases before 1996. Twenty-two of 28 (79%) conservatively treated cases were serious (Hunt & Kosnik grade IV, V). The clinical outcome was GR in 1 case, SD in 2 cases, VS in 3 cases and D in 22 cases. Causes of death were primary brain damage in 14 cases, re-rupture in 4 cases, cerebral vasospasm in 3 cases and pneumonia in 1 case. It is necessary for determination of surgical indication to evaluate primary brain damage more strictly. And it is indispensable for improvement of operative outcome to take measures for cerebral vasospasm and general complications.

Clinical outcome following ultra-early operation for patients with intracerebral hematoma from aneurysm rupture--focussing on the massive intra-sylvian type of subarachnoid hemorrhage.

Of 250 patients admitted with aneurysmal subarachnoid hemorrhage (SAH) from 1994 to 2000, 16 had massive intra-sylvian hematomas. To predict the useful determinants of the clinical outcome for such patients we analyzed our last 16 cases. The study was performed in 2 parts. Part 1 covered the period from 1994 to 1996 and included 5 patients who underwent early surgery. Immediately before operation, Hunt & Kosnik grade (H&K) III was observed in 1, IV in 3 and V in 1 patient. Part 2, from 1997 to 2000, included 11 patients who underwent ultra-early surgery (within 3 hours after admission) with ventriculostomy and with 2 weeks' postoperative management in the ICU. Preoperatively, there were 2 patients with H&K III, 7 with IV, and 2 with V. The results in part 1 showed that 3 out of the 5 patients had poor outcome with symptomatic vasospasm. While in Part 2, seven returned to work, 2 had minimal and 1 had severe neurological deficits with symptomatic vasospasm, and 1 died. We therefore suggest that ultra-early surgery with ventriculostomy and postoperative management in the ICU is the most useful determinant to improve the clinical outcome in the treatment of SAH patients with massive intra-sylvian hematoma.

８０歳以上の超高齢者破裂脳動脈りゅうに対するＧＤＣ塞栓術

Endovascular treatment of intracranial aneurysms using Guglielmi detachable coils (GDCs) was performed on 10 patients aged 80-89. Preoperative Hunt and Kosnik grading revealed that 4 patients were in Grade II, 4 in Grade III, and 2 in Grade IV. The aneurysms were located in the internal carotid artery in 5 patients, in the anterior communicating aneurysm in 2, in the posterior inferior cerebellar artery in 2, and in the basilar artery in 1. The approach was transfemoral in 8 patients and transcarotid in 2. Intra-aneurysmal occlusion was performed in 10 patients with total occlusion in 4, subtotal occlusion in 5 and partial occlusion in 1. Procedure-related morbidity or mortality was not observed. All patients who were successfully treated, 4 patients in Grade II and 1 in Grade III had a good outcome (GR, MD), but the other 3 patients in Grade III and 2 patients in Grade IV had a poor outcome (SD, Dead). The follow-up period ranged from 6 to 22 months. No evidence of recurrent hemorrhage was noted during follow-up.Endovascular coil embolization, done without craniotomy, may offer particular advantages in managing ruptured intracranial aneurysms in patients over 80 years of age, especially those in Hunt and Kosnik Grade II.

破裂前交通動脈りゅうクリッピング術後長期経過した社会復帰例の高次脳機能の検討

This study demonstrated cognitive impairment among a group of patients undergoing open surgery for ruptured anterior communicating artery (Acom) aneurysms. We used the Wechsler Adult Intelligence Scale-Revised (WAIS-R), Wechsler Memory Scale-Revised (WMS-R), and Wisconsin Card Sorting Test (WCST) for the neuropsychological assessment. WAIS-R is one of the most famous assessment tools for cognitive impairment and is widely used because it has become the published norm and was evaluated by intelligence quotient.The subjects comprised 51 of 241 patients who recovered social life with the rupture of Acom aneurysms that had been clipped neurosurgically between April 1, 1982, and July 31, 2000. The WAIS-R score showed impairment in 12 patients (24%), the WMS-R score showed impairment in 20 patients (39%) and the WCST score showed impairment in 33 patients (65%), the highest impairment rate in these tests. None of these patients showed impairment only in the WAIS-R. There was no significant correlation between the various clinical factors such as the age, Hunt & Kosnik grading, Fisher group, approach side, infarction, shunt, removal of gyrus rectus and the neuropsychological impairment. However, there was a significant correlation between the age and the WCST score.Although it was difficult to detect the cause of cognitive impairment, some causes are associated with SAH itself whereas others are due to medial frontal lobe disorder for general effects of neurosurgery or other factors such as the disturbance of the perforating arteries.

この１例から学ぶ 塞栓療法後に再増大，再治療を繰り返した破裂脳底動脈りゅうの１例

A 58-year-old male suffered from diffuse and symmetric subarachnoid hemorrhage with Hunt and Kosnik Grade II. Angiography demonstrated 3 aneurysms. The largest was located at the basilar artery (BA) tip with a size of 18 mm ×15 mm ×14 mm and thought to have a small bleb. The 2nd largest was located at the left middle cerebral artery (MCA) bifurcation and showed an irregular shape with a maximum diameter of 5 mm. The smallest was at the right MCA bifurcation and showed a round shape with a maximum diameter of 3 mm. One of first 2 was thought to be ruptured, and we first treated the left MCA aneurysm by surgical clipping and confirmed it was unruptured. Immediately after clipping, we performed intraaneurysmal embolization of BA tip aneurysm using GDC.The result of embolization was a neck remnant with a volume embolization rate of 19.3%. The patient was discharged without any neurological deficit and continued oral anti-platelet drug for 6 months. Follow-up angiography 6 months later demonstrated enlargement of the remnant neck. Re-embolization was performed 8 months after initial embolization. At that time we planned the embolization with the help of neck plasty technique using two the balloons, but we could introduce the balloon microcatheter only into the right posterior cerebral artery (PCA). The result was again a neck remnant. Follow-up angiography was performed 6 months, 12 months, and 24 months after re-embolization, and the neck remnant was enlarged every time. Because re-embolization was technically difficult, we hesitated to perform a third embolization. Follow-up angiography at 36 months, however, showed large ballooning of the aneurysmal body, which made us decide to perform the third embolization. At the third embolization, immediately after introduction of balloon microcatheter into the left PCA, the BA was suddenly occluded. The BA was not recanalized any more in spite of fibrinolysis using tissue-type plasminogen activator. The patient died 5 days later.Appropriate case selection, including size of aneurysm, timing of embolization and probability of complete obliteration is essential for coil embolization. Performing embolization on inappropriate patients may result in poor control of the aneurysm complicate further treatment.

重症クモ膜下出血例Hunt&amp;Kosnik grade IV, Vに対するわれわれの治療戦略

重症クモ膜下出血例Hunt&amp;Kosnik grade IV, Vに対するわれわれの治療戦略

Surgical management of aneurysms of the bifurcation of the internal carotid artery

Internal carotid artery (ICA) bifurcation aneurysms are rare and easily bleed in younger patients, but are difficult to treat surgically, due to perforators surrounding and adherent to the aneurysm. A series of 25 patients treated by clipping under the operating microscope are analyzed and compared with previous cases. Twenty-five patients, 11 men and 14 women (mean age 51 years), were treated by the same neurosurgeon. Seventeen patients presented with subarachnoid hemorrhage (Hunt & Kosnik Grade I in three, II in five, III in two, IV in seven), five with unruptured ICA bifurcation aneurysms, and three with unruptured ICA bifurcation aneurysms but another ruptured aneurysm. There were 23 small, one large, and one giant ICA bifurcation aneurysms. The projection was superior in 12, anterior in seven, and posterior in six cases. Pterional approach was employed for all cases. Outcomes were evaluated at discharge with the Glasgow Outcome Scale. Favorable outcomes (good recovery (GR) and moderate disability (MD)) were obtained in ten of 17 patients with ruptured ICA bifurcation aneurysm. Favorable outcomes were significantly greater in Grades I and II (three in I, four in II) than in Grades III and IV (one in III, two in IV; P=0.0498). Seven of eight patients with unruptured ICA bifurcation aneurysm had favorable outcomes. Temporary clipping and projection of the aneurysm did not affect the outcome. Causative factors of unfavorable outcomes were primary brain damage in cases of small and large aneurysms and perforator damage in the case of giant aneurysm. Poor clinical grade and vasospasm are the causative factors of poor outcome in patients with ruptured ICA bifurcation aneurysm. Preservation of perforators is crucial in cases of giant aneurysm. Clipping of unruptured ICA bifurcation aneurysms is recommended since they tend to bleed at a lower age than other aneurysms.

Guglielmi detachable coil embolization for ruptured lower-midbasilar trunk aneurysms--a report of five cases.

Detachable coil embolization currently plays an essential role for patients with ruptured basilar artery aneurysms, even though it may have an unfavorable outcome and there may be some technical problems of embolization. We describe Guglielmi detachable coil (GDC) embolization for five ruptured lower-mid basilar trunk aneurysms, using a variety of techniques. The patients' ages ranged from 61 to 78 years; Hunt and Kosnik grade was distributed from 2 to 4, and three patients were found to have fenestrations of the lower basilar arteries. All patients underwent aneurysmal embolization at the subacute or chronic stage. The transfemoral route was used in three patients--one of whom, with a wide-necked aneurysm, was treated by the balloon remodeling technique. The transbrachial approach was chosen for the fourth patient, while vertebral artery origin exposure followed by a direct puncture was achieved in the fifth. All patients were assessed with 80-100% aneurysmal obliteration. No patient re-bled after the embolization. Small cerebellar infarction, possibly due to embolism from the obliterated aneurysmal sac, occurred 11 days after the treatment. Of the five patients, four achieved a good recovery, and one became severely disabled. Ruptured basilar trunk aneurysms can be successfully treated with GDC embolization. In addition to the routine transfemoral route, the transbrachial route, direct vertebral artery puncture, and balloon remodeling technique are also useful for the embolization of this location of aneurysm.

Results of direct surgery for aneurysmal subarachnoid haemorrhage: outcome of 2055 patients who underwent direct aneurysm surgery and profile of ruptured intracranial aneurysms.

The purpose of this study is to evaluate the therapeutic value of our surgical treatment of subarachnoid haemorrhage in a large series with standardized surgical principles. Results of 2055 direct operations on ruptured intracranial aneurysms, treated in our institutions, where surgical indications, instruments and techniques were standardized, between 1988 and 1998, were retrospectively evaluated and outcome of the patients was discussed; cases treated by intravascular procedures were excluded. According to the evaluation at discharge, 1083 (52.7%) patients were excellent, 324 (15.8%) good and 223 (10.9%) fair. There were 160 (7.8%) patients of poor outcome and the remaining 265 (12.9%) died. There were no differences in the outcome between pre-operative Hunt & Kosnik grade I and II, Fisher Scale 1 and 2, anterior circulation aneurysms and posterior circulation aneurysms except those at and around the basilar bifurcation, men and women, and those clipped and not clipped. The factors related to poor outcomes were, age of 60 years or over, pre-operative Hunt & Kosnik grade II or more, Fisher Scale 3 or more, aneurysm size over 15 mm in diameter, and location at and around the basilar artery bifurcation. The results presented in this study show the status of our direct surgical management of subarachnoid haemorrhage in a large series with standardized surgical principles and procedures.

高齢者破裂脳動脈りゅうに対するＧＤＣ塞栓術

We performed endovascular treatment of ruptured intracranial aneurysms with GDC in 11 patients over 70 years of age (ranging from 70 to 89 years old). Hunt & Kosnik grading was II in 2 patients, III in 4, IV in 2, and V in 3, respectively. The aneurysms were located in the internal carotid artery in 4 patients, in the anterior communicating artery in 4, in the posterior inferior cerebellar artery in 2, and in the basilar artery in 1. The approach was transfemoral in 8, transcarotid in 2 and transbrachial in 1. In 1 patient, GDC placement could not be done due to difficulty of catheter placement. Complete occlusion of the aneurysmal body was accomplished in 6 although a small neck remnant was observed in 2. Body filling was observed in 4. Procedure-related morbidity or mortality was not observed. The follow-up period ranged from 2 to 22 months. Recurrent hemorrhage was not observed. In the 7 patients with Grade II, III, and IV, 5 patients showed good recovery or moderate disability. All 3 patients with Grade V died. Cause of death was severe subarachnoid hemorrhage in 3, acute myocardial infarction in 1, and cerebral vasospasm in 1. GDC embolization is a useful therapeutic alternative for treatment of ruptured intracranial aneurysm in elderly patients.

Successful Treatment of a Ruptured Enlarged Infundibular Widening of the Posterior Communicating Artery. Case Report.

A 67-year-old female with a history of hypertension and cerebral infarction presented with subarachnoid hemorrhage (SAH) (Hunt and Kosnik grade 4). Brain computed tomography (CT) revealed a clot dominantly on the right (Fisher's classification Group 4). Cerebral angiography showed funnel-shaped widenings at the origins of the bilateral posterior communicating arteries. The maximum diameter of the widening was greater than 3 mm, so this widening was called an enlarged infundibular widening. Angiography showed a small bulge protruding posterolaterally from the wall of the right enlarged infundibular widening, and the right posterior communicating artery arose from the apex of the enlarged infundibular widening. Based on the findings of the brain CT and cerebral angiography, the diagnosis was SAH due to rupture of the right enlarged infundibular widening. Approximately 12 hours after the onset, the clot was evacuated through the right pterional approach. Bleeding from the small bulge of the right enlarged infundibular widening occurred intraoperatively, so a right-angled ring clip was applied parallel to the right internal carotid artery to obliterate the rupture point. Postoperatively, she was discharged without neurological deficit, and follow-up CT showed no other new infarction. We recommend clipping rather than wrapping or coating for similar cases of ruptured enlarged infundibular widening.