Patients who suffer a severe aneurysmal subarachnoid hemorrhage(SAH) and who have arrived in the emergency room with devastated neurological or medical condition by this event are categorized as poor grade(Grade IV or V) aneurysm patients. As the poor grade patients are more prone to develop rebleeding, acute hydrocephalus, intracerebral and intraventricular hematoma, and delayed ischemic neurological deficits, the management of these patients remains challenging and controversial. However, it is now becoming evident that a significant number of the poor grade patients can be salvaged with an aggressive management from the moment of patient's arrival to the hospital. Initial management for the poor grade patients should be directed to the life threatening conditions such as cardiopulmonary depression, seizure, acute intracranial hypertension and rebleeding. The authors suggest that: 1) the Grade IV patients should be treated aggressively with direct clipping for patients with non-complex aneurysms, acute hydrocephalus, or significant amount of intracerebral hematoma; 2) The Grade V patients who show neurological improvement with supportive care could be the patients for an aggressive management; 3) Intra-aneurysmal treatment with Guglielmi Detachable Coil would be an alternative therapeutic option in the poor grade patients with advanced age, poor general physical condition, or complex aneurysm such as aneurysm of the posterior circulation or paraclinoid segment of the internal carotid artery.
Aneurysm* ; Carotid Artery, Internal ; Depression ; Embolization, Therapeutic ; Emergency Service, Hospital ; Hematoma ; Humans ; Hydrocephalus ; Intracranial Hypertension ; Seizures ; Subarachnoid Hemorrhage

Intracranial giant aneurysms(GANs), approximately 5% of all intracranial aneurysms, represent a subgroup of diverse intracranial artery aneurysms(ANs) with a maximum sac diameter reaching or exceeding 25 mm. This size has been used arbitrarily to define this clinicopathological entity because smaller lesions have been shown to differ significantly with regard to the rate of rupture, the incidence of presentation with mass effect, and, most importantly, the difficulty of surgical treatment. And GANs also are a unique biological entity. The goals of therapy may include protection from hemorrhage, prevention and treatment of thromboembolic complications and relief of symptomatic mass effect. The treatment of all GANs has benefited from advances in angiography and imaging, endovascular techniques, intraoperative angiography, and collaborative advances in anesthetic technique, brain resuscitation and protection, critical care and rehabilitation. GANs present formidable surgical challenges due to their size, management strategies, brain protection and proximal control. Therefore dynamic and multidisciplinary strategy of therapy is optimally executed by a clinical team dedicated to interaction and collaboration, these clinical team should include diagnostic and interventional neuroradiology expertise and a technical competence geared toward realistic and individualized therapeutic options. The author reviewed the literature for clinical manifestation, diagnostic evaluation, therapeutic stategies including the method of brain protection of GANs.
Aneurysm* ; Angiography ; Arteries ; Brain ; Cooperative Behavior ; Critical Care ; Endovascular Procedures ; Hemorrhage ; Incidence ; Intracranial Aneurysm ; Mental Competency ; Rehabilitation ; Resuscitation ; Rupture

In many countries, the percentage of seninor citizens is expanding. Direct operation for ruptured aneurysm should be the choice of treatment in elderly patients of Hunt-Hess grade I through III, but should not be performed in cases of grade V. To evaluate the risk of early operation of elderly patients with ruptured cerebral aneurysm, conducted a retrospective analysis 464 elderly patients with ruptured aneurysms who were over aged 60 years between Jan 1980 to June 1999. Of these, 334 cases were performed early operation in which the direct intracranial operation was carried out within 3 days after last subarachnoid hemorrhage. The female: male ratio is 4.87: 1. The location of aneurysms are 144 anterior communicating artery aneurysms, 139 internal carotid artery aneurysms, 117 middle cerebral artery aneurysms, 35 multiple aneurysms, etc. Associated conditions are hypertension, diabetes mellitus, pulmonary problem, etc. Operation methods are 404 clippings, 53 coatings, 1 endovascular treatment, etc. Problems during operation are 29 broad aneurysms, 22 giant aneurysms, 21 tight brains, etc. In early operative group(within 3 days), 79% had favorable outcome, 11% unfavorable outcome and 10% died. The early operation is an effective and reliable method to reduce the occurrence of rebleeding, vasospasm, ischemic complication, medical complication and to shorten lengths of hospitalization.
Aged* ; Aneurysm ; Aneurysm, Ruptured ; Brain ; Carotid Artery, Internal ; Diabetes Mellitus ; Female ; Hospitalization ; Humans ; Hypertension ; Intracranial Aneurysm* ; Male ; Retrospective Studies ; Subarachnoid Hemorrhage

There are so many differences between the elderly patients and the younger patients in the aspects of a causes and the clinical course of spontaneous intracerebral hemorrage (ICH). As the mean life-time of a general population goes longer, the incidence of spontaneous ICH increases but the aggressive support in ICH is withdrawn more commonly and a prognosis of ICH becomes poor. Therefore, a prevention of ICH and a strict control of hypertension is very very important.
Aged ; Cerebral Hemorrhage* ; Humans ; Hypertension ; Incidence ; Mortality ; Prognosis

As the number of elderly people increases, the incidence of stroke, especially the hemorrhagic stroke, is increasing. A large-scale survey of the entire country pertaining to the incidence and demographic characteristics of hemorrhagic stroke in elderly is necessary. Through information garnered from a basic survey and clinical study, we must design a treatment program to reduce the mortality of elderly people through elucidating the specific properties of stroke pathophysiology.
Aged* ; Humans ; Incidence* ; Mortality ; Stroke*

Hypertension is a very common disorder in the aged persons. There exist several hemodynamic characteristics associated with hypertension in the geriatric population, - decreased elasticity of arterioles due to fibrosis, decreased renin activity, and decreased cardiac output and renal blood flow. Clinically, isolated systolic hypertension, blood pressure variation within a day, and white coat hypertension, are more common in the aged population. Furthermore, aged persons have more chances to suffer other diseases, diabetes, COPD, and renal dysfunction, for example. These characteristics need tailored approaches in diagnosing and managing hypertension in the aged. In the current literature, detailed characteristics of 'geriatric hypertension', are described, including definition, grade of hypertension, importance of treatment of hypertension, complications of hypertension, drug or non-drug treatment, and principles of drug treatment especially in the specific age group.
Arterioles ; Blood Pressure ; Cardiac Output ; Elasticity ; Fibrosis ; Geriatrics* ; Hemodynamics ; Humans ; Hypertension* ; Pulmonary Disease, Chronic Obstructive ; Renal Circulation ; Renin ; White Coat Hypertension

The stereotactic radiosurgery for arteriovenous malformation (AVM) began in the early 1970s. Nowadays, by 2000 world-wide, more than 27,500 patients have undergone Gamma Knife radiosurgery for cerebrovascular disease (CVD). New concepts, consisting of obliteration rate, postradiosurgical hemorrhagic risk, dose selection for treatment, and radiosurgery for pediatric AVM, medium-to-large sized AVM, cavernous malformation, venous angioma, so on, have been established. Gamma Knife radiosurgery has been considered as an effective management stratege with relatively few side effects for AVM. However, recently delayed radiation-induced complications were reported in 3.2 to 12.5% in range. Therefore, the long-term follow-up is thought to be mandatory even after treatment goal, complete obliteration, is confirmed.
Arteriovenous Malformations ; Follow-Up Studies ; Hemangioma ; Humans ; Patient Selection ; Radiosurgery*

These days, a less invasive surgery is stressed. One current thought is that the endovascular surgery itself is the less invasive and safer surgery for a cerebral aneurysm, and not the microsurgery. Is this true? We have evaluated the merits and demerits of each method. Our conclusion is as follows. Endovascular Surgery should be considered as an alternative, only for the specific patients. Microsurgery itself retains its position of the first treatment of choice for a cerebral aneurysm. "Less invasive" cannot be equated with "less dangerous". We will show the above reasons using slides and videotapes of several patients.
Humans ; Intracranial Aneurysm ; Microsurgery ; Videotape Recording

Dural arteriovenous malformations(DAVM) or Dural Arteriovenous fistulas(DAVF) consists of multiple arteriovenous shunt between arteries and a dural venous sinuses or a meningeal vein, constitute 10% to 15% of all intracranial arteriovenous malformations Most commonly they involve the transverse, the sigmoid and the cavernous sinuses. Other locations include the tentorial incisure, the superior sagittal sinus, the torcular Herophili, anterior cranial fossa, the convexity dura mater, and the foramen magnum. In angiographic features, leptomeningeal retrograde venous drainage, variceal or aneurysmal venous structure, and galenic venous drainage are significantly associated with aggressive neurological course caused by intracranial hemorrhage(ICH or SAH). Lesion at tentorial incisura and anterior cranial fossa has a tendency to have aggressive neurological course. Dural AVM located at cavernous sinus are classified as 4 types according to arterial distribution. Treatment of Dural AVF or CCF includes conservative monitoring, manual compression, arterial embolization, transvenous occlusion, surgical excision and radiation therapy. Surgical therapy with or without preparatory embolization remains the most versatile and effective therapeutic option. It is usually aimed at resecting the dural leaflets harboring the AVM(and adjacent sinus) and at disconnecting leptmeningeal draining pathways which are typically the source of serious neurological sequelae. In Tentorial AVF or anterior cranial fossa AVF the first choice of treatment is surgery because of difficulty in accessibility through transarterial or transvenous embolization.
Aneurysm ; Arteries ; Arteriovenous Malformations* ; Cavernous Sinus ; Colon, Sigmoid ; Cranial Fossa, Anterior ; Drainage ; Dura Mater ; Fistula* ; Foramen Magnum ; Intracranial Arteriovenous Malformations ; Superior Sagittal Sinus ; Veins

The application of stereotactic radiosurgery for cerebrovascular malformations began in the early 1970s. Despite pooly documented response of vascular malformations to externally fractionated radiotherapy, single fraction, high dose, small-field, focused irradiation of small vascular malformations were found to be effective and non-invasive method to obliterate vascular malformations. During last thirty years, overall role of stereotactic radiosurgery has been established in the management of carefully selected vascular malformations. By 1998 world-wide, more than 20,000 patients had undergone Gamma Knife radiosurgery for arteriovenous malformations. In comparison to other forms of nonsurgical management or surgical excision, stereotactic radiosurgery has number of advantages. In properly selected, small volume AVMs, the total obliteration rate at two years appears to be acceptably high(more than 80%), and is associated with low morbidity(less than 2-3%). In contrast to open surgical removal, radiosurgery is associated with none of the risk of microsurgical resection such as blood loss, infection, acute neurological deficits and operative mortality. And yet, major problem of radiosurgery is that it is still exposed to any potential risk of bleeding during latent period before complete obliteration of arteriovenous malformations. Continuous study and researches are recommended for radiobiological clearance. To solve this problem and to enhance the effectiveness of treatment, new energy source should be developed to reduce latent period until complete obliteration would be secured, while reducing the chance of risk by irradiation. Presently, radiosurgery is applied to other vascular malformations such as cavernous angioma or venous angioma, yet, the result is still subject to controversy. Thus, more rigorous research, clinical experience, and enhanced treatment plan should be sought.
Arteriovenous Malformations ; Hemangioma ; Hemangioma, Cavernous ; Hemorrhage ; Humans ; Mortality ; Radiosurgery ; Radiotherapy ; Vascular Malformations