OBJECTIVES: Recently, we reported a tendency toward spontaneous hemorrhage in both the preoperative and postoperative periods in patients with intracranial epidermoid cyst (EC). According to our experience, this tendency for spontaneous hemorrhage was partly caused by the pathologic blood vessels adjacent to the EC. This study was designed to testify this hypothesis. METHODS: Twenty-three removable pericystic or intracystic blood vessels from 17 patients with EC were collected during surgery and were then examined by transmission electron microscopy. The microvascular structure in gliomas was chosen as the control. RESULTS: Under electron microscopy, variant pathologic changes of vessels were found in all patients with EC. In the tunicae intima, we found vacuolization, apoptosis, necrosis, and intralumenal protrusion of endothelial cells, as well as swollen basement and highly flexed and discontinued elastic plate. In the tunicae media, vacuolization and swollen mitochondria were found in muscular cells. In the tunicae adventitia, extravascular erythrocytes, edema or apoptosis of pericytes, collagen predominance, and inflammatory cell infiltration and destruction were found. Neuron denature and necrosis were found in the peripheral brain tissue. In the microvascular structure of 5 glioma specimens, we found enlargement and hyperplasia of endothelial cells, swollen basement membrane, swollen pericytes, and astrocytic hyperplasia and neuron denature in adjacent brain tissues. CONCLUSIONS: Our findings provide strong evidence for the hypothesis that intracystic or pericystic vascular degeneration or destruction accounts for the spontaneous hemorrhage tendency before and after surgical resection of ECs.