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We compare outcomes of ruptured aneurysmal subarachnoid hemorrhage mainly treated by surgical clipping between 2000 and 2004 (early term) with outcomes of patients mainly treated by surgical clipping between 2005 and 2007 (late term) with first selection of endovascular coiling to poor-grade, posterior circulation, or elderly patients. Between January 2000 and September 2007, 287 patients were treated and 147 and 140 patients belonged to early and late terms, respectively. Poor grade patients (Hunt and Kosnik Grade IV, V) comprised 24.5% and 34.5% (NS), posterior circulation patients comprised 14.3% and 10.7% (NS), and, elderly patients (over 70 year-old) comprised 23.1% and 35.0% in early and late terms, respectively. The rate of elderly was significantly higher in late term than in early (p＜0.05). Endovascular coiling was performed on 10.9% and 29.8% of patients in early and late terms, respectively, and the rate was significantly higher in late term than in early (p＜0.01). Good outcomes were assessed with modified Rankin Scale of 0－2 at 6 months. Good outcomes were 61.2% and 62.1% in early and late terms, respectively (NS). In poor-grade patients, good outcomes were 13.9% and 27.7% (NS), in posterior circulation, 47.6% and 53.3% (NS), and in elderly, 26.5% and 53.5% in early and late terms, respectively, and the rate of good outcomes in elderly was significantly higher in late term than in early (p＜0.05). Outcomes of ruptured aneurysmal patients were significantly improved in elderly patients, but not in poor grade, nor in posterior circulation, due to first selection of endovascular coiling. Despite the significant increase of elderly patients, total outcomes of ruptured subarachnoid hemorrhage in late term were not inferior to those of early term.

The long-term outcomes of aneurysms occluded by clipping are unclear. The present study investigated 5 females aged from 45 to 72 years old (mean 63.6 years) admitted for treatment of recurrent subarachnoid hemorrhage (SAH) 7 to 19 years (mean 9.8 years) after clipping of internal carotid artery-posterior communicating artery (ICA-PCoA) aneurysms, which had caused SAH in 3 patients and were unruptured in 2 patients. Angiography delineated the well-developed PCoA in all patients. Clips had been applied to the aneurysm neck parallel to the ICA trunk at the initial surgery in 3 patients. An additional clip could be applied to the recurrent aneurysm without removal of the first clip in 2 patients, but the original clip had to be removed before reclipping in the other 3 patients. Adhesive materials and Bem-sheet used at the initial operation hindered dissection of the recurrent aneurysm from the surrounding arteries in 1 patient, resulting in infarction in the area of the PCoA perforating arteries. This study suggests that the method of clipping is very important for ICA-PCoA aneurysm, particularly the direction of clip application to the ICA trunk, and the avoidance of unnecessary or excessive wrapping of the residual neck. We recommend that neuroimaging follow-up of recurrent aneurysms in patients with a history of clipped aneurysm, especially ICA-PCoA aneurysm, be continued as long as possible.

Aneurysmal subarachnoid hemorrhage (SAH) poses an immediate threat to life. The accepted paradigm of treatment generally involves surgical intervention requiring craniotomy to allow neck clipping of the ruptured cerebral aneurysm, with the alternative approach of embolization of the aneurysm sac by the deposition of detachable coils delivered through the endovascular route. The selection of the treatment method depends on the establishment of clear guidelines for the attending neurosurgeon, but unfortunately no such definitive guidelines leading to a definitive treatment policy have been developed in Japan. Controlled comparison of the alternative treatment approaches of clipping and coil embolization is rendered difficult by the lack of reported series of interventions in patients using either clipping or coil embolization, and the methodological difficulties inherent in the retrospective comparison of the specific results achieved by unrelated institutes or individual surgeons. We describe our 5 years of experience of clipping and coil embolization to promote a consensus of decision-making for acute SAH. Our therapeutic protocol emphasizes clipping, with coil embolization mainly considered for patients with poor neurological condition (Hunt & Kosnik Grades IV-V without hematoma), paraclinoid or basilar aneurysm, or serious systemic complications, and for elderly patients over 74 years old or older. We treated 198 patients, 55 males and 143 females aged from 31 to 91 years old (mean 61.3 years) with aneurysmal SAH between 2000 and 2005. Surgical clipping was performed in 164 cases, endovascular treatment in 25 cases, and conservative therapy for ruptured aneurysms in 9 cases. Overall, 95% of patients underwent radical treatment. On admission, 26% of patients were in poor neurological condition (Hunt & Kosnik Grades IV-V). Aneurysms arose from the anterior circle of Willis in 87% of cases. Eighty-seven percent of patients were treated with surgical clipping within 3 days of onset, and 84% were treated with coiling within 3 days. Favorable outcome was defined as good recovery or moderately disabled classified by Glasgow Outcome Scale at discharge, which was achieved in 71% of all patients, 76% of patients treated by clipping, and 60% of patients treated by coil embolization. Symptomatic vasospasm occurred in 21% of patients after clipping but only in 3% after coil embolization (p Recently, the Ministry of Health, Labour and Welfare has required the collection and submission of accurate and complete information about treatment options, indications, and expected results for ruptured cerebral aneurysms. The availability of such an extensive database enabling rigorous analytical correlations will provide the required foundation to establish specific indications for the selection of the optimal methodology of clipping or coil embolization treatment for patients with acute SAH.

Low molecular dextran is often used in post-operative management of subarachnoid hemorrhage (SAH) to induce hypervolemia and hemodilution; however, its associated complications are not well-known. We retrospectively analyzed prothrombin time (PT%), activated partial thromboplastin time (APTT%), and fibrinogen level as coagulation markers in patients with subarachnoid hemorrhage who developed delayed intracranial hemorrhagic complications after undergoing craniotomy for clipping to examine the effect of long-term use of low molecular dextran on bleeding tendencies. Fifty-two patients with SAH who underwent craniotomy were divided into 2 groups: 26 without post-operative use of low molecular dextran (Group 1) and 26 to whom low molecular dextran was administered for more than 5 consecutive days (Group 2). Group 2 was further divided into 2 subgroups: those who developed hemorrhagic complications (Group 2A) and those without complications (Group 2B). The frequency of complications in Group 2A was 19% (5/26; 3 with subdural hematoma and epidural hematoma, 1 with epidural hematoma, and 1 with intracerebral hematoma). Complications appeared 7.6 days on average after starting low molecular dextran. Compared with Group 1, PT% and APTT% as well as pre-and post-low molecular dextran administration fibrinogen levels significantly decreased in Group 2A. Low molecular dextran is known to decrease fibrinogen levels, and patients' clinical conditions and changes in fibrinogen levels should be closely monitored to detect bleeding tendencies when low molecular dextran must be used for long periods.

Recently less invasive diagnostic tools for the brain have been developed rapidly at a time when the population of the elderly has become enormous. Likewise, the number of patients having uAN-associated ischemic complications has grown sharply. For this special category of uAN, risk-benefit analysis is extremely difficult. Higher morbidity/mortality is common but rupture rates are considered more frequent than incidental uAN. To prevent bleeding from uAN and to reduce complications triggered by precedent ischemic insult, we have performed radical surgery for such special uAN according to the following guidelines: 1) 70 years old and younger, without serious neurological deficits or general complications, capable of independent life, 2) significant interval (3-6 months) required between precedent ischemic insult and radical surgery, 3) meticulous examination for the etiology of ischemic condition and adequate treatment for the causes, 4) acceptance of prophylactic surgery such as CEA/stent (2 stage), and STA-MCA (concurrent with uAN surgery), 5) prevention of dehydration/hypotension and minimal washout of anti-platelet/thrombotic drug through perioperative period, 6) avoiding too much aspiration of CSF, long-time compression of the brain, temporarily occlusion of arteries, and sacrifice veins. We analyze the results of this series and evaluate the strategy in relation to the cause of complications. Surgical mortality was 0 and morbidity was observed in 3 patients (permanent: 1; 6.25%, transient: 1; 6.25%). Good results were obtained by our strategy. Precedent ischemic insult may not deeply influence the result. Concurrent bypass did not increase risk of ischemic complication during radical surgery for uAN. However, much attention must be paid to sclerotic perforating artery, brain atrophy, and craniocerebral disproportion in patient with uAN and precedent ischemic accident.