kato yoko

Objective High blood pressure (HBP) is observed frequently in patients with spontaneous intracerebral haemorrhage (SICH). Although HBP at admission has been associated with poor outcomes, most studies from which such conclusions were derived had been carried out decades earlier, when aggressive BP management was not implemented. In our institution, SICH patients showing HBP undergo aggressive BP management by intravenous nicardipine with target systolic BP (SBP) less than 140mmHg. We investigated whether responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living 90 days after admission differed by the degree of admission SBP. Patients and methods A retrospective study was carried out by reviewing charts of 120 SICH patients admitted within 6 h of onset who were quadrichotomized on the basis of SBP: <140 mmHg (n=6), 140-184 mmHg (n=49), 185-219 mmHg (n=38) and >= 220 mmHg (n=27). The six patients with SBP less than 140 mmHg were excluded, and demographic and outcome variables of the latter three groups were compared. Whether plasma catecholamine levels differed among the three groups was also investigated. Results Optimal BP management (target SBP<140mmHg) within 2 h of arrival was achieved in 98%, haematoma expansion occurred in 7% and the 90-day mortality rate was 11%. Responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living were not significantly different. Furthermore, plasma catecholamine levels did not differ significantly. Conclusion The lack of difference in the demographic and outcome variables in SICH patients managed by aggressive treatment to normalize the BP indicates that the previously reported association between HBP at admission and poor outcomes needs to be re-evaluated. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved.

AimTherapeutic intervention to repair unruptured aneurysms (UA) has not been strongly recommended for the elderly, because of their limited life expectancy and low annual bleeding rate. However, physically and mentally healthy older adults with seemingly high risk of aneurysmal bleeding might benefit from having their UA repaired. MethodsA single-center retrospective study was carried out. Among 1078 patients admitted for treatment of UA between 2007 and 2011, the number of patients aged 75 years who underwent surgical and endovascular repair of UA was 30 and 31, respectively. The operative and mid-term outcomes were compared between the two groups. For evaluation of the operative outcomes, frequency and types of adverse events that occurred within 30 days of intervention (operative morbidity) were described. For assessment of the mid-term outcomes, activities of daily living (ADL) at 24 months after intervention were evaluated with the modified Rankin Scale (mRS). ResultsThe operative morbidity rate was 6.7% in the open surgery group and 6.5% in the endovascular surgery group, and they did not differ significantly. The frequency of patients with mRS 0-2 at 24 months after intervention was 85.7% in the open surgery group and 82.8% in the endovascular surgery group, and they did not differ significantly. The adverse event rate of patients with middle cerebral artery aneurysms treated endovascularly was high (80%). ConclusionsThe outcomes of individuals aged 75 years who underwent repair of UA were generally favorable in either treatment group, with more than 80% living an independent life at 24 months after intervention. Geriatr Gerontol Int 2014; 14: 858-863.

Our assumption that blood pressure (BP) in supratentorial hypertensive intracerebral hemorrhage patients does not differ significantly according to the hemispheric laterality has never been verified before. This study was carried out to explore the possibility of hemispheric BP differences and whether this might influence the outcomes. A review of the charts/radiographic images of 281 patients with putaminal/thalamic hemorrhages diagnosed within 6 h of symptom onset was performed. Immediately after arrival, they received a continuous intravenous nicardipine infusion to lower and maintain systolic BP (SBP) between 120 and 160 mmHg. They were quadrichotomized as follows: left putamen (LP, n=89), right putamen (RP, n=69), left thalamus (LT, n=68), and right thalamus (RT, n=55). Two-group or four-group comparisons were made on demographic variables, BPs, and outcomes. Patients with left-sided hemorrhages presented with significantly worse neurologic scores in both hemorrhage categories and tended to sustain larger hematomas than their right-sided counterparts. Significant differences in SBPs between LP and RP (205 +/- 31 vs. 189 +/- 29 mmHg, P<0.01) as well as in diastolic BPs between LT and RT (109 +/- 19 vs. 97 +/- 20 mmHg, P=0.03) were noted. Multivariate regression analysis showed that patients with SBPs of at least 220 mmHg were 2.9 times more likely to harbor left-sided hemorrhages. There were no significant intergroup differences in responsiveness to a continuous intravenous nicardipine infusion or 30-day mortality rates. Although the differences in BPs are unlikely to have influenced outcomes, future trials involving supratentorial hypertensive intracerebral hemorrhages may benefit from considering hemispheric differences in BP and other demographic variables. (C) 2014 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Background and Purpose Insular injuries are known to cause autonomic derangements. Patients with ruptured middle cerebral artery aneurysms frequently develop temporal hematomas (THs) in addition to subarachnoid hemorrhages, and those with TH may sustain autonomic derangements more frequently than those without TH. Hemispheric lateralization in autonomic derangements has been reported in patients with insular ischemic stroke, and this study was conducted to clarify whether such lateralization was also observed in patients with TH resulting from middle cerebral artery aneurysm rupture. Methods A retrospective analysis on the medical records of 79 patients with ruptured middle cerebral artery aneurysms was performed on the basis of lateralization and presence of TH. They were quadrichotomized as left TH+ (LTH+; n=17), right TH+ (n=25), left TH- (n=15), and right TH- (n=22). Comparisons, mainly between LTH+ and right TH+, were made on demographic variables, autonomic/cardiac parameters, plasma catecholamine and glucose levels, and outcomes. Results There were no significant differences in demographic or cardiac parameters between the 2 groups. Systolic blood pressures were lower in LTH+ (13934 versus 174 +/- 47 mm Hg; P=0.05). The LTH+ group also tended to be more bradycardiac (80 +/- 19 versus 101 +/- 22 bpm; P=0.13). The LTH+ group exhibited significantly lower plasma norepinephrine (1008 +/- 975 versus 2549 +/- 2133 pg/mL; P=0.03) and glucose levels (9.3 +/- 1.8 versus 12.2 +/- 4.5 mmol/L; P=0.04). However, in-hospital mortality did not differ significantly (41% versus 44%; P=1.00). Conclusions Lateralization of autonomic derangements observed might not have had a significant effect on the outcomes. Nevertheless, autonomic derangements associated with insular injury should be considered in the management of subarachnoid hemorrhage patients with TH.

Background: Malignant hemispheric infarction is a life-threatening condition with a high mortality rate. Decompressive hemicraniectomy (DHC) is frequently a life-saving procedure that has shown the highest grade of evidence for patients 18 to 60 years of age. However, the efficacy of DHC in patients >60 years of age has rarely been investigated. Methods: A retrospective study was conducted in a single academic institution. Surrogates of patients with clinical signs of impending brain herniation despite standard medical therapy were offered the option of DHC regardless of age or the side of the lesion. The clinical data from 18 patients >60 years of age who underwent DHC for malignant hemispheric infarction in our institution were analyzed. Patients were classified into the following 2 groups: 61-70 and >70 years of age, and their demographics and surgical outcomes were compared. The variables compared included the male: female ratio, side of the lesion, type of stroke, site of vascular occlusion, use of thrombolytic therapy, National Institutes of Health Stroke Scale score, stroke onset-to-DHC interval, duration of hospital stay, infectious complications, and 90-day mortality rate. Results: There were no significant intergroup differences in any of the demographic variables evaluated. However, the 30-day mortality rate was significantly higher in the group that was >70 years of age (0% v 60%; P = .01) than in the group that was 61 to 70 years of age. Conclusions: We suggest that the efficacy of DHC in malignant hemispheric stroke patients between 61 and 70 years of age be further investigated in future randomized trials. By contrast, it appears unlikely that patients >70 years of age would benefit from DHC.

Objective: We retrospectively analyzed thromboembolic complications for unruptured cerebral aneurysms treated with stent assisted coil embolization (SAC).<br>Patients and methods: Between 2010 September and 2012 March, 36 unruptured broad neck aneurysms in 35 patients were treated by SAC following dual antiplatelet medication with aspirin and clopidogrel. Aspirin and clopidogrel were started 1–14 days before the procedure. After the procedure, diffusion weighted MR imaging (DWI) was performed within seven days. DWI findings were graded into A to D depending on the number and the size of bright spots: A, no bright lesions; B, 1–5 small (＜10 mm) lesions; C, six or more small lesions; D, any large (≧10 mm) lesions.<br>Results: Angiography showed complete occlusion was achieved in 13 aneurysms (36%), neck remnant in nine (25%), and body filling in 14 (39%). Symptomatic thromboembolic complications occurred in six cases (17%). The symptoms were transient in four of the six patients, and two patients had persisting minor symptoms (modified Rankin Scale 1 and 2). The DWI grade of SAC cases was A in two patients, B in six, C in 16, and D in eight. Among SAC cases, there was a tendency of higher incidence of Grade D when clopidogrel was started earlier than three days before the procedure.<br>Conclusions: SAC is a feasible and effective technique for treating broad neck aneurysms. Starting clopidogrel three or more days before the procedure may half reduce thromboembolic complications. <br>

Patients with aneurysmal subarachnoid hemorrhage (SAH) are frequently complicated by acute cardiac dysfunctions, including cardiac wall motion abnormality (WMA). Massive release of catecholamine into the systemic circulation after aneurysmal rupture is believed to result in WMA, and poor-grade SAH seems to be the most important risk factor. However, plasma catecholamine levels have rarely been measured in SAH patients with WMA, and previous studies indicated that the elevated levels might not necessarily predict WMA. The objective of this study is (1) to evaluate relationship between WMA and plasma catecholamine levels in poor-grade SAH patients in the acute phase and (2) to clarify clinical characteristics of SAH patients with WMA. Among 142 poor-grade (World Federation of Neurosurgical Societies grades IV and V) SAH patients, 48 underwent both transthoracic ultrasound and measurement of plasma catecholamine levels within 24 h of SAH onset. They were divided into WMA+ (n = 23) and WMA- (n = 25) groups, and intergroup comparison was made on demographics, plasma catecholamine levels, and outcomes. Plasma norepinephrine levels were significantly higher in WMA+ group than in WMA- group (2,098.4 +/- 1,773.4 vs. 962.9 +/- 838.9 pg/mL, p = 0.02), and the former showed significantly worse outcomes 90 days after admission. There were no intergroup differences in the plasma levels of epinephrine. Plasma norepinephrine levels were inversely correlated with left ventricular ejection fraction. Multivariate logistic regression analysis revealed that increased plasma norepinephrine levels were predictive of WMA, although age, female sex, and grade V SAH were not. This retrospective study highlights the role of norepinephrine in pathogenesis of SAH-induced WMA.

BACKGROUND: For cardiac arrest (CA) victims, brain computed tomography (CT) may serve as a prognosticator. Loss of gray-white matter discrimination (GWMD) and sulcal edema/effacement are reliable CT signs of hypoxia, and a time window may exist for development of these signs. Most data are derived from CA victims of cardiac etiology, however, and CT signs have rarely been evaluated in victims of CA secondary to subarachnoid hemorrhage (SAH). METHODS: A retrospective study was conducted to clarify the incidence, temporal profile, and prognostic significance of early CT signs in resuscitated SAH-CA patients. RESULTS: During a 6-year period, 35 SAH-CA patients were identified. CT signs were observed in 94 %: loss of GWMD was observed in 94 %, whereas sulcal edema/effacement was observed in 77 %. In 29 patients, the interval between CA and the return of spontaneous circulation (ROSC) was estimated. CT signs developed almost invariably when the CA-ROSC interval exceeded 10 min. Loss of GWMD always preceded sulcal edema/effacement. None of the 35 patients achieved long-term survival, regardless of the presence of the CT signs. CONCLUSION: CT signs may develop earlier in patients with SAH-CA than CA of cardiac origin. Because of a poor prognosis, early CT signs are not useful prognosticators in that population.

Neurogenic pulmonary edema (NPE) occurs frequently after aneurysmal subarachnoid hemorrhage (SAH), and excessive release of catecholamines (epinephrine/norepinephrine) has been suggested as its principal cause. The objective of this retrospective study is to evaluate the relative contribution of each catecholamine in the pathogenesis of NPE associated with SAH. Records of 63 SAH patients (20 men/43 women) whose plasma catecholamine levels were measured within 48 h of SAH onset were reviewed, and the clinical characteristics and laboratory data of those who developed early-onset NPE were analyzed thoroughly. Seven patients (11 %) were diagnosed with NPE on admission. Demographic comparison revealed that the NPE+ group sustained more severe SAH than the NPE- group. Cardiac dysfunction was also significantly more profound in the former, and the great majority of the NPE+ group sustained concomitant cardiac wall motion abnormality. There was no significant difference in the plasma epinephrine levels between NPE+ and NPE- group (324.6 +/- 172.8 vs 163.1 +/- 257.2 pg/ml, p = 0.11). By contrast, plasma norepinephrine levels were significantly higher in the NPE+ group (2977.6 +/- 2034.5 vs 847.9 +/- 535.6 pg/ml, p &lt; 0.001). Multivariate regression analysis revealed that increased norepinephrine levels were associated with NPE (OR, 1.003; 95 % CI, 1.002-1.007). Plasma epinephrine and norepinephrine levels were positively correlated (R = 0.48, p &lt; 0.001). According to receiver operating characteristic curve analysis, the threshold value for plasma norepinephrine predictive of NPE was 2,000 pg/ml, with an area under the curve value of 0.85. Elevated plasma norepinephrine may have more active role in the pathogenesis of SAH-induced NPE compared with epinephrine, although both catecholamines may be involved via multiple signaling pathways.

Background and Purpose-The majority of patients with ventricular wall motion abnormality (WMA) associated with subarachnoid hemorrhage (SAH) are postmenopausal women. In addition to elevated catecholamine, the role of estrogen in the pathogenesis of WMA has recently been implicated. The objective of this study is to clarify the interrelation among catecholamine, estrogen, and WMA in patients with SAH. Methods-A retrospective analysis was performed on the medical records of 77 patients with SAH (23 men, 54 women) whose plasma levels of epinephrine, norepinephrine, and estradiol had been measured and echocardiograms had been obtained within 48 hours of SAH onset. Results-Twenty-four patients (31%) were found to sustain WMA on admission. Multivariate regression analysis revealed that decreased estradiol (P=0.018; OR, 0.902) and elevated norepinephrine levels (P=0.027; OR, 1.002) were associated with WMA. After quadrichotomization of 77 patients based on sex/WMA, plasma norepinephrine levels were markedly elevated in men with WMA, whereas estradiol levels were markedly decreased in women with WMA. Plasma norepinephrine and estradiol levels were not correlated. Fifty-four female patients with SAH were further quadrichotomized based on norepinephrine/estradiol levels with a threshold value of 1375 pg/mL for norepinephrine and 11 pg/mL for estradiol. The incidence of WMA in the high-norepinephrine/low-estradiol group was significantly higher than the low-norepinephrine/high-estradiol group. Conclusions-To our knowledge, this is the first study to evaluate the interrelation among catecholamine, estrogen, and SAH-induced WMA. Lack of estradiol in postmenopausal women may predispose them to develop WMA after poor-grade SAH. However, the precise role of multiple sex hormones in SAH-induced WMA should be evaluated in future prospective studies. (Stroke. 2012;43:1897-1903.)

After the introduction of Guglielmi Detachable Coils (GDC), endovascular management of ruptured and unruptured aneurysms became a viable alternative to surgical clipping as a "minimally invasive" option. Endovascular management of aneurysms became even more common after the International Subarachnoid Aneurysm Trial, which was one of the first prospective, randomized trials comparing clipping and coiling, showed reduced dependency and death in patients undergoing coiling after two months and one year. As the numbers of patients treated by endovascular therapy grow neurosurgeons are facing increasing challenges of clipping difficult aneurysms not suitable for coiling, including those that are wide-necked, thrombosed or involving many perforators. In addition, treatment failures (recurrent and residual aneurysms after coiling) pose difficult treatment scenarios fraught with complications due to surrounding adhesions, coil migration and involvement of adjacent neurovascular structures. Thus, we analyzed the recent literature dealing with the nuances of clipping after coiling and reviewed the current management principles involved in treating these difficult aneurysms. (C) 2011 Elsevier Ltd. All rights reserved.

After the introduction of Guglielmi Detachable Coils (GDC), endovascular management of ruptured and unruptured aneurysms became a viable alternative to surgical clipping as a "minimally invasive" option. Endovascular management of aneurysms became even more common after the International Subarachnoid Aneurysm Trial, which was one of the first prospective, randomized trials comparing clipping and coiling, showed reduced dependency and death in patients undergoing coiling after two months and one year. As the numbers of patients treated by endovascular therapy grow neurosurgeons are facing increasing challenges of clipping difficult aneurysms not suitable for coiling, including those that are wide-necked, thrombosed or involving many perforators. In addition, treatment failures (recurrent and residual aneurysms after coiling) pose difficult treatment scenarios fraught with complications due to surrounding adhesions, coil migration and involvement of adjacent neurovascular structures. Thus, we analyzed the recent literature dealing with the nuances of clipping after coiling and reviewed the current management principles involved in treating these difficult aneurysms. (C) 2011 Elsevier Ltd. All rights reserved.

Patients with poor-grade subarachnoid hemorrhage (SAH) are often complicated with acute cardiopulmonary dysfunctions, particularly neurogenic pulmonary edema (NPE) and takotsubo-like cardiomyopathy (TCM). This study retrospectively investigated the incidence, demographics, clinical characteristics, and outcomes of patients with SAH complicated with both NPE and TCM (NPE-TCM). The effects of aneurysm location and other clinical variables on the incidence of NPE-TCM were also investigated. Among 234 SAH patients treated during 5-year period, 16 (7%) presented with NPE, and transthoracic ultrasonography revealed that 14 of these 16 patients (88%) also had TCM. All 14 patients with NPE-TCM had poor-grade SAH (World Federation of Neurosurgical Societies grades IV and V). Ruptured posterior circulation aneurysm was predictive of NPE-TCM, but other clinical variables were not. Eight of the 14 patients with NPE-TCM could undergo treatment for ruptured aneurysm. Long-term outcomes were favorable in 5 of the 8 patients. Grade IV SAH patients had significantly better outcomes than grade V patients. TCM develops frequently in SAH patients presenting with NPE, and transthoracic ultrasonography should be conducted routinely in that population. Patients with ruptured posterior circulation aneurysm may have elevated risk of developing NPE-TCM. Endovascular obliteration of the aneurysm may be preferable to open surgery, but the optimal treatment modality needs to be evaluated further. Considering the limited number of SAH patients complicated with NPE-TCM, a multi-center cooperative study may be required.

There are many microtubules in axons and dendritic shafts, but it has been thought that there were fewer microtubules in spines. Recently, there have been four reports that observed the intraspinal microtubules. Because microtubules originate from the centrosome, these four reports strongly suggest a stimulation-dependent connection between the nucleus and the stimulated postsynaptic membrane by microtubules. In contrast, several pieces of evidence suggest that spine elongation may be caused by the polymerization of intraspinal microtubules. This structural mechanism for spine elongation suggests, conversely, that the synapse loss or spine loss observed in Alzheimer's disease may be caused by the depolymerization of intraspinal microtubules. Based on this evidence, it is suggested that the impairment of intraspinal microtubules may cause spinal structural change and block the translocation of plasticity-related molecules between the stimulated postsynaptic membranes and the nucleus, resulting in the cognitive deficits of Alzheimer's disease. Copyright © 2012 Fuyuki Mitsuyama et al.

BACKGROUND: In ruptured cerebral aneurysms (RCAs), identification of the rupture point of a cerebral aneurysm is useful for treatment planning. In unruptured cerebral aneurysms (URCAs), detection of the risk of aneurysmal rupture is also useful for patient management. OBJECTIVE: Electrocardiographic (ECG)-gated 3D-CT angiography was performed for patients with RCAs and URCAs using 320-row area detector CT (ADCT) to detect pulsation of the cerebral aneurysms. The clinical usefulness of this method was then evaluated. METHODS: Twelve patients had 12 RCAs, and 39 patients had 53 URCAs. A 320-row ADCT system was used to scan. ECG-gated reconstruction was then performed with the R-R interval divided into 20 phases. RESULTS: Pulsation was observed in 10 of the 12 RCAs. The bleeding site was considered to correspond to the area of pulsation. Pulsation was observed in 14 of 53 URCAs. Thirteen patients with 18 URCAs were followed. Of the 11 URCAs in which pulsation was not observed, 1 showed a change in shape. Of the 7 URCAs in which pulsation was observed, 3 showed a change in shape. URCAs in which pulsation was observed were more likely to show a change in shape (P = .082). CONCLUSION: The area of pulsation was found to correspond to the bleeding site in many RCAs. This information would be extremely useful for treatment planning. The detection of pulsation in an URCA is therefore considered to provide useful information for patient management.

Objective: The aim of this study was to present our experience with retrograde suction decompression in clipping of large and giant cerebral aneurysms and analyze its advantages and pitfalls. Methods: A retrospective analysis of 27 patients with large and giant intracranial aneurysms treated by suction decompression assisted clipping between November 2005 and February 2010 was done. The surgical technique and the outcome of patients were reviewed. Results: All aneurysms were successfully clipped, and postoperative 3-D CTA or DSA revealed no major branch occlusion or residual aneurysm. There was no surgical mortality in both giant and large aneurysm groups. Conclusion: Retrograde suction decompression is a successful adjunct to clipping of large and giant cerebral aneurysms.

Objective: The authors present a patient with acute ischemic stroke due to severe stenosis of the left internal carotid artery who was successfully treated with carotid artery stenting (CAS) in the acute stage.Case: A 76-year-old man presented with aphasia and right hemiparesis. Intravenous administration of rt-PA was not indicated because the patient was outside the time-window. As perfusion CT revealed a large ischemic penumbra in the territory of the left middle cerebral artery, we attempted neuroendovascular therapy to rescue the penumbra from infarction. The regional saturation of oxygen (rSO2) was monitored by near-infrared spectroscopy (NIRS) during the procedure. Before the procedure, rSO2 in the left frontal area was decreased by 10% compared with that on the right side. The self-expanding stent was deployed after predilation. Just after deployment, rSO2 on the left side increased by 10% and we intentionally did not perform postdilation to avoid hyperperfusion. The procedure was finished within 6 hours and 30 minutes after ischemic onset. The postoperative course was good and there were no hemorrhagic complications.Conclusion: NIRS monitoring allows observation of real time changes in cerebral perfusion during the dilatative procedure, which provides useful information for intraoperative decision-making on whether stenting should be added after angioplasty and then, whether postdilation should be performed during carotid artery stenting in the acute stage.

Giant aneurysms have a dismal natural history, thus necessitating early management. These pose a great challenge to the vascular neurosurgeon. The complexity of their anatomy, parent vessels or branches and perforators warrants additional measures for maintaining distal perfusion. Here we try to define the minimally invasive management of these aneurysms. This study compares reconstruction and bypass.<br> This study covers 40 large and 5 giant cases of aneurysms treated in our institute. Giant aneurysms are those with a dome diameter 25 mm or more. 3D CT scan and DSA were the primary investigative procedures, and 3D CT scan was especially useful in thrombosed aneurysms. Aneurysms that had involved a major portion of the parent wall were reconstructed, thus avoiding bypass.<br> Based on our experience, not only basic technique of trapping and evacuation and clipping of the aneurysm neck but also reconstruction of the artery bearing the aneurysm is vital for good postoperative results. Different clipping methods are also used to reconstruct the parent artery. Bypass techniques are also gaining importance in the management of giant aneurysms in difficult cases. However, we feel that bypass procedures are too extensive and are associated with attendant complications. Acute graft occlusion is one of the commonest complications. Aneurysmal rupture is one more complication of bypass procedures. Prolonged occlusion can also cause neurological deficits. <br> Considering the difficulties with bypass and our experience in parent vessel reconstruction with multiple clipping, we feel bypass should be considered only in exceptional cases.<br>

Giant aneurysms have a dismal natural history, thus necessitating early management. These pose a great challenge to the vascular neurosurgeon. The complexity of their anatomy, parent vessels or branches and perforators warrants additional measures for maintaining distal perfusion. Here we try to define the minimally invasive management of these aneurysms. This study compares reconstruction and bypass.<br> This study covers 40 large and 5 giant cases of aneurysms treated in our institute. Giant aneurysms are those with a dome diameter 25 mm or more. 3D CT scan and DSA were the primary investigative procedures, and 3D CT scan was especially useful in thrombosed aneurysms. Aneurysms that had involved a major portion of the parent wall were reconstructed, thus avoiding bypass.<br> Based on our experience, not only basic technique of trapping and evacuation and clipping of the aneurysm neck but also reconstruction of the artery bearing the aneurysm is vital for good postoperative results. Different clipping methods are also used to reconstruct the parent artery. Bypass techniques are also gaining importance in the management of giant aneurysms in difficult cases. However, we feel that bypass procedures are too extensive and are associated with attendant complications. Acute graft occlusion is one of the commonest complications. Aneurysmal rupture is one more complication of bypass procedures. Prolonged occlusion can also cause neurological deficits. <br> Considering the difficulties with bypass and our experience in parent vessel reconstruction with multiple clipping, we feel bypass should be considered only in exceptional cases.<br>