The efficacy and safety of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) have been established as standard treatments in acute ischemic stroke. Various trials are being conducted to further improve the efficacy. The introduction of tenecteplase is progressing. Randomized controlled trials (RCTs) on acute stroke patients with large ischemic regions and those with strokes caused by medium vessel occlusion are also being conducted. Furthermore, results relating to combination therapy with IVT and MT, adjunctive therapy using neuroprotective agents, and medical care systems for rapid treatment, are accumulating. Therefore, further development of acute reperfusion therapy is expected to progress.

  In this article, we present updates on intracranial artery stenosis. Intracranial artery stenosis is attributable to various pathophysiology. Outcomes of medical treatment for atherosclerotic intracranial artery stenosis have improved due to advancement of antithrombotic agents and anti-atherosclerotic treatment. It is important to quantitatively assess intracranial hemodynamics and to lower perioperative complication rate in bypass surgery for atherosclerotic intracranial artery stenosis and occlusion. In recent years, new findings of both ischemic and hemorrhagic moyamoya disease have been reported and more specific surgical indications for moyamoya disease are possibly established. Pediatric cerebrovascular disease is created as a new item in Japanese guidelines for the management of stroke 2021. Focal cerebral arteriopathy is published in the guidelines and it is one of the critical etiologies for acute ischemic stroke in children.

  The treatment of carotid artery stenosis has been proven in randomized controlled trials (RCTs). First, the superiority of carotid endarterectomy (CEA) over medical therapy and the non-inferiority of carotid artery stenting (CAS) in high-risk patients with CEA were demonstrated. More recently, an RCT on asymptomatic lesions has been underway. The therapeutic risks of carotid artery lesions include postoperative hyperperfusion syndrome in patients with severely impaired cerebral hemodynamic reserve, and postoperative thromboembolic complications in patients with vulnerable plaques. For the former, using shunt system reportedly shortens the ischemic time in CEA, and staged angioplasty demonstrably reduces the ischemic time in CAS. For the latter, the usefulness of various plaque imaging techniques, including MRI, CT, and US, has been reported. Recently, new plaque imaging techniques using optical coherence tomography and near-infrared spectroscopy have been reported. Furthermore, micromesh stents, which can reduce thromboembolic complications in CAS, have been introduced as a new device in Japan. Regarding medical treatment strategies, improvements in blood pressure and lifestyle factors, antithrombotic drugs, statins, and other medications are also evolving. In the future, strategies to reduce the complications of CEA and CAS, optimization of medical therapy, and further investigations into the best treatment option according to disease background including age, previous history, and the pathology of the lesion, are warranted.

  Repetitive facilitative exercise (RFE) is an exercise therapy developed to recover motor control and function in hemiparetic limbs or fingers after a stroke. The neuroscientific basis of RFE focuses on reconstructing and strengthening motor-descending pathways by “realizing the intended movement by facilitation technique” (Hebb's law) and its “concentrated repetition” (use-dependent neuroplasticity). The benefits of RFE have been verified in clinical trials including randomized controlled trials. To further functional recovery, we have also developed several combination therapies using various physical agents. If hemiplegia is accompanied by spasticity,“direct application of vibratory stimuli (DAViS) or botulinum treatment may be applied to first control the spasticity, and then, RFE is performed. Conversely, when voluntary-motor control is weak, RFE targeting the agonist muscles, is performed under low-amplitude continuous neuromuscular electrical stimulation (NMES) or functional vibratory stimulus (FVS). Based on our experiences and knowledge, we developed a new rehabilitation robot through industry-academia and medical-engineering collaborations. The robot has been used for stroke rehabilitation clinically. This robot is expected to reduce the burden on therapists, and increase the amount of training for patients with stroke.

  Ventriculoperitoneal (VP) shunts are commonly used to treat hydrocephalus. Shunt malfunctions requiring revision surgery may occur due to various factors. Here, we report a rare case of shunt malfunction due to catheter kinking caused by severe calcification of the supraclavicular subcutaneous tissues.

  A 19-year-old man visited our department with complaints of headache and vomiting. A VP shunt had been placed for hydrocephalus due to intraventricular hemorrhage when he was 1-month-old. Head computed tomography (CT) revealed ventriculomegaly in comparison to CT images taken one year prior. We attempted to change the pressure setting of the shunt valve. However, this was not possible. The ventricular catheter and valve were revised, but the symptoms and CT findings did not improve. A shuntogram revealed omega-shaped kinking of the catheter in the supraclavicular region. During the reoperation, calcified tissue was identified around the catheter. The calcified tissue was removed, and the kinking was subsequently released.

  A fibrous sheath around the catheter could have led to the formation of calcified scar tissue and the subsequent catheter kinking. Pathological examination revealed inflammation in the surrounding tissue. The calcification could have been due to the elution of barium particles from the silicon component of the catheter. To our knowledge, this is the first case wherein a good outcome was achieved by simply removing the surrounding calcified soft tissue. Frequent sites of calcification must be considered when searching for the cause of shunt malfunction.

  A 77 years-old female patient presented with a three-year history of oral pain and thirst. Computed tomography (CT) of the head revealed a round mass compressing the surrounding bony structure located in the right pterygopalatine fossa. Magnetic resonance imaging revealed that the tumor was well-demarcated, with ring-like enhancements on T1-weighted imaging with gadolinium enhancement. The patient underwent endoscopic surgery via a combined transnasal and sublabial transmaxillary sinus approach. The pathological diagnosis was schwannoma and subtotal tumor removal was performed. Postoperatively, the patient's pain reduced, although the oral thirst persisted. The combined endoscopic approach may be a less invasive and more effective surgical alternative for pterygopalatine fossa tumors.