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The purpose of this study was to evaluate the effect of endovascular treatment with Guglielmi detachable coils (GDC) on the outcomes of subarachnoid haemorrhage (SAH) patients of poor grades and high ages for each location of aneurysms. Between 1990 and 2003, 529 SAH cases underwent angiograghy as candidates of early aggressive treatment in our hospital. For the 299 cases in 1990–96 (Group 1), treatment options were early and intensively delayed craniotomy surgery and conservative management, while for the 230 cases in 1997–2003 (Group 2), GDG embolization at acute stage was added to these three treatment options. We compared clinical courses and outcomes of the poor grade (Hunt & Kosnik Grade 4–5) patients and high age (> =70 years old) patients between two groups for each location of aneurysms. Introduction of GDC embolization expanded the indication for early treatment in the poor grade patients with anterior communicating artery aneurysm (A-Comm An), the high age patients with internal carotid artery aneurysm (IC An) and all patients with Basilar bifurcation aneurysm (BA-Top An), and has contributed to improvement of their outcomes. To the poor grade patients with middle cerebral artery aneurysm (MCA An), GDC embolization was hardly indicated, because haematoma evacuation concomitantly performed with aneurysm occlusion would be necessary for those patients. In conclusion, results of treatment with GDC embolization at an acute stage are desirable for poor grade patients with A-Comm An, aged patients with IC An and all patients with BA-Top An. The indication of GDC embolization for the patients with MCA An is limited.

Ruptured vertebral artery dissecting aneurysms (VADA) re-bleed frequently especially during first 24 hours, which makes the prognosis of the patients with this disease poor. Recently endovascular trapping with detachable platinum coils at an acute stage has been done for preventing re-bleeding. However, for the cases with dissecting aneurysm involving the origin of the posterior inferior cerebellar artery (PICA), these methods are hardly indicated because of the risk of ischemic complication in the PICA territory. We proposed a simple and effective therapeutic method for these cases. We occluded the affected vertebral artery (VA) near its root intending to introduce collateral blood flow from the deep cervical artery into the VA trunk. The controlled antegrade VA flow and retrograde flow from the contralateral VA make a watershed at the dissecting aneurysm, which promotes thrombosis of pseudolumen with preserving the antegrade blood flow of PICA. We treated two cases with ruptured VADA involving PICA, and in both cases thrombosis of aneurysm was obtained without any ischemic complication. This method would be considered as a treatment of choice to the cases with VADA involving PICA.

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 = ¥ 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.

It is apparent that subarachnoid clots play an important role in the development of delayed vasospasm that is one of the major causes of mortality and morbidity in patients with acutely ruptured cerebral aneurysm. The purpose of this study is to compare the clearance of subarachnoid clots in the acute stage after the treatment with Guglielmi detachable coils (GDC) and after treatment with direct surgery. Forty-nine patients were treated by GDC embolization within four days of the ictus. After GDC embolization, adjunctive therapies, such as ventricular and/or spinal drainage (67%), intrathecal administration of urokinase (41%), continuous cisternal irrigation (16%), and external decompression (16%), were performed. Seventy-four surgically treated patients were subsequently treated by continuous cisternal irrigation with mock-CSF containing ascorbic acid for ten days. The clearance of subarachnoid clots was assessed by the Hounsfield number serial changes on the CT scans taken on days 0, 4, 7, 10 after subarachnoid hemorrhage. The incidence of symptomatic vasospasm was lower in the GDC group (6%) than in the surgery group (12%). The clearance of subarachnoid clots from both the basal cistern and the Sylvian fissure was more rapid in the GDC cases than in the surgery cases in the first four days. Intrathecal administration of urokinase accelerated the clearance significantly. GDC embolization followed by intrathecal administration of thrombolytic agents accelerates the reduction of subarachnoid clots and favorably acts to prevent delayed vasospasm.

The purpose of this study was to evaluate the effect of endovascular treatment with Guglielmi detachable coils (GDC) on the outcome of severe subarachnoid hemorrhage (SAH) caused by acute rupture of a cerebral aneurysm and on the incidence of symptomatic vasospasm. Thirty-five patients with aneurysmal SAH were treated in the acute stage using GDC. Fifteen out of 17 patients in Hunt & Kosnik grades I, II, and III showed good recovery (GR) at discharge, while one was moderately disabled (MD) and one was severely disabled (SD). Among 16 patients in poor neurological condition (GCS was ⩽ 9 on admission), the outcome was GR in 5 cases (31%), MD in 2 (13%), and SD in 9 (56%). These results were better than those for surgically treated patients with the same neurological status. The difference in outcome between endovascular treatment and surgery may have been related to the difference in the insult to the brain caused by each modality. The incidence of symptomatic vasospasm was lower in the GDC group (5.7%) than in the surgical group (12%). In the patients treated with GDC and intrathecal administration of urokinase, subarachnoid clots were cleared more rapidly than in those treated surgically with continuous cisternal irrigation. The accelerated clearance of subarachnoid clots in the GDC group might have helped to prevent delayed vasospasm. The long-term efficacy of GDC embolization in preventing subsequent bleeding has not yet been determined. However, this method seems to be less traumatic for the brain and may be suitable for treatment of patients with severe SAH.

Plasma and cerebrospinal fluid (CSF) levels of C4d and the circulating immune complex (CIC) to C1q were measured in 12 patients with chronic inflammatory demyelinating polyneuropathy and Guillain-Barre syndrome. CSF C4d values more than 2 SD from the mean of 8 cervical spongylosis cases were demonstrated in the patients with proximal demyelination. The CSF C4d probably originated from both intrathecal synthesis and the systemic circulation. CSF levels of C4d may serve as a sensitive indicator for the radicular involvement in demyelinating polyneuropathy.

Plasma and CSF levels of C4d and the circulating immune complex (CIC) to C1q were measured in 27 patients with progressive supranuclear palsy (PSP), Parkinson's disease (PD) and cervical spondylosis (CS). There was no significant difference among groups in plasma C4d or in plasma or CSF CIC to C1q. However, the PSP group had significantly higher CSF levels of C4d than the PD and CS groups. Higher CSF C4d index in the PSP group was also shown compared with PD and CS groups. These results suggest that augmented complement activation in the wide areas of the central nervous system occurs in PSP. CSF levels of C4d or C4d index may serve as a basis for differentiating PSP from PD.