Objectives: Some acute stroke patients with intracranial arterial occlusion have concomitant extracranial carotid artery occlusion or high-grade stenosis. Emergency carotid artery stenting (CAS) is a potentially effective treatment option to enhance intracranial reperfusion for these patients, yet selection of optimal candidates for this procedure remains elusive.Methods: We analyzed clinical data of patients who underwent emergency CAS in the setting of acute endovascular recanalization from 2005 to 2012. Reperfusion was graded with modified Thrombolysis in Cerebral Infarction (mTICI) scale. Clinical outcomes were assessed by modified Rankin Scale (mRS) at 90 days.Results: 23 patients were included with mean age of 64.2 years, median admission NIHSS score of 20. The median initial Alberta Stroke Program Early CT Score on diffusion-weighted imaging (DWI-ASPECTS) was 7. 18 patients (78.3%) had internal carotid artery occlusion at the origin. 19 patients (82.6%) had intracranial tandem arterial occlusions. All patients successfully underwent CAS and 14 patients (60.9%) underwent additional mechanical thrombectomy. Nine patients (39.1%) were mTICI grade ≥2b. Hemorrhagic transformation with parenchymal hematoma (PH) occurred in nine patients (39.1%). At follow-up, six patients (26.1%) had a favorable outcome (mRS 0-2). The multiple logistic model yielded age (OR 1.20, 95% CI [1.02, 1.41], P = 0.03) and initial DWI-ASPECTS (OR 0.25, 95% CI [0.07, 0.92], P = 0.04) independently associated with an unfavorable outcome (mRS 3-6) and additional mechanical thrombectomy (OR 2.5, P = 0.005) was associated with PH.Conclusions: Endovascular recanalization with emergency CAS is technically feasible. Further refinement of patient selection may reduce postprocedural hemorrhaghic transformation and optimize resultant clinical outcomes.

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Obejctive: This retrospective study aimed to compare the perioperative complications associated with treating carotid artery stenosis using either carotid endarterectomy (CEA) or carotid artery stenting (CAS) that were performed at a single Japanese institution from April 2011 to December 2014.Methods: CEA or CAS was selected to treat 222 lesions based on the patients’ individual risk factors. CEA was considered to be the first-line treatment in all cases (n = 104). The CEA group contained 55 symptomatic cases and 49 asymptomatic cases, and the CAS group contained 59 symptomatic cases and 59 asymptomatic cases. High-risk patients for CEA, which included, for example, those with angiographically poor collateral flows underwent CAS (n = 118).Results: The CEA and CAS groups were compared with respect to the perioperative clinical complications that occurred within 30 days of the procedures, which included any strokes, myocardial infarctions, or deaths. No significant differences were observed between the groups in relation to the perioperative complications.Conclusion: Selecting appropriate individualized treatment methods based on patients’ risk factors may contribute to improvements in the overall outcomes in patients with carotid artery stenoses.

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Objective: Antiplatelet therapy is essential in neuroendovascular therapy to avoid periprocedural thromboembolic events. The purpose of our study was to evaluate the relationship between platelet aggregation analysis by VerifyNow assay system (Accumetrics, San Diego, CA, USA) and thromboembolic complications.Methods: Seventy-two neuroendovascular procedures were performed between March 2013 and February 2015 in this institution. There were 41 males (56.9%) and their mean age was 69.9 years. Meanwhile, there were 31 females (43.0%) and their mean age was 62.7 years. In all cases, clopidogrel (CLP) was used as one of the periprocedural antiplatelet therapy. All patients were measured CLP response as P2Y12 Reaction Units (PRU) value using VerifyNow assay system (Accumetrics, San Diego, CA, USA) with the whole blood sample collected from the long sheath located at the femoral artery. All patients received diffusion-weighted image (DWI) on MRI at 1–4 days after the procedure. The occurrence of thromboembolic events was recorded and the relationship between CLP response and DWI hyper-intensity area (HIA) positive was analyzed. Appropriate cut-off value to predict thromboembolic events was examined. Results: Symptomatic thromboembolic complications occured in three patients (4.1%), and each PRU value was all over 226. CLP hypo-responder in our study recognized 46 patients (63.8%) as cut-off PRU value set 208. As the result of cut-off value defined as CLP hypo-responder, with regard to PRU more than 208, a significant difference appear in DWI HIA positive or negative, but with regard to PRU more than 230, a significant difference is not recognized.Conclusion: In our study, CLP response measured by VerifyNow assay system is well correlated with the periprocedural thromboembolic events in neuroendovascular procedure. The cut-off value of PRU in neuroendovascular therapy is not still defined, but CLP hypo-responder defined PRU value more than 208 might be meaningful in neuroendovascular therapy performed to Japanese. We should make the custom-made periprocedural anti-platelet therapy according to personal response.

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Objectives: Mechanical thrombectomy for acute ischemic stroke needs to be performed in the shortest possible workflow time and have a high recanalization rate. The steep learning curve for this procedure is essential for comprehensive as well as low-volume stroke centers, wherein the annual number of mechanical thrombectomy cases is less than 10. We retrospectively evaluated the workflow times and successful recanalization rates of three types of devices for mechanical thrombectomy: the Merci retriever, the Penumbra System, and the stent retriever. We concomitantly assessed the learning curves for each device in this procedure.Methods: We retrospectively reviewed 19 patients who were transferred to our stroke center and underwent mechanical thrombectomy between February 2012 and August 2014. Time intervals between the placement of a guiding catheter and recanalization or final angiography (guide to revascularization time; GRT) were calculated from time-stamped images during the procedure.Results: Three cases were treated with the Merci retriever, 11 with the Penumbra system, and five with the stent retriever. There was a significantly higher successful recanalization rate [as indicated by the Thrombolysis in Cerebral Infarction (TICI) scale grade 2B or 3] between the three devices (0% in the Merci retriever group, 36.3% in the Penumbra system group, and 100% in the stent retriever group; p = 0.009). The median GRT was 66, 81, and 22 min for the Merci retriever, the Penumbra system, and the stent retriever, respectively; a statistically significant difference was noted between these groups (p = 0.016).Conclusions: The use of the stent retriever in mechanical thrombectomy for acute ischemic stroke seems suitable in low-volume stroke centers given its high success rate and ease of use.

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Objective: We report a case of spontaneous dissection of the cervical internal carotid artery.Case Presentations: A 42-year-old man presented with dysarthria, dysphagia, lingual deviation to the left, left lingual atrophy and paralyzed left soft palate. He had no history of trauma. Although brain MRI showed no abnormal findings, brain MRA, cervical MRA and angiography revealed a dissection of the cervical internal carotid artery and a dissecting aneurysm. From these findings, we diagnosed the patient with peripheral lower cranial nerve palsy caused by a spontaneous dissection of the left cervical internal carotid artery. After 1 week of conservative management, angiography demonstrated enlargement of the dissecting aneurysm. The dissection of the dissecting aneurysm was then treated with carotid artery stenting to prevent the onset of stroke. After stenting, the patient’s symptoms improved gradually.Conclusion: Spontaneous cervical internal carotid artery dissection should be considered as a differential diagnosis of lower cranial nerve palsy and was successfully treated with endovascular therapy in our case.

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Objective: Posterior circulation perforating artery aneurysms are uncommon. Furthermore, a posterior thalamoperforating artery (pTPA) aneurysm arises from the P1 segment of the posterior cerebral artery (PCA) is rare. We report a case of de novo pTPA aneurysm treated by coil embolization.Case Presentations: A 51-year-old woman underwent clipping surgery for left P1 fusiform aneurysm 7 years before presentation. The left PCA (P1 segment) was unfortunately occluded, but the patient remained neurologically intact. A follow-up 3D-computed tomographic angiography (3D-CTA) 1 year after surgery showed no remnant aneurysm. 7 years after surgery, she experienced sudden stuporous condition and was transferred to our hospital (Hunt and Hess grade 4). A digital subtraction angiography (DSA) showed a small aneurysm arising from a perforator artery originating from the superior aspect of the left P1 and diagnosed as de novo pTPA aneurysm. Endovascular coil embolization from the orifice of the pTPA was performed.Conclusion: Aneurysms of the pTPA are rare. Hemodynamic stress due to the left PCA (P1 segment) occlusion might be a cause of this aneurysm. Endovascular treatment is a good option if catheterization is possible.

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Objective: A case of a carotid-cavernous fistula (CCF) that was close to the superior ophthalmic vein (SOV) that occurred during endovascular catheter navigation and was treated by transarterial coil embolization is reported.Case Presentations: An arteriovenous fistula and eye swelling occurred during percutaneous transluminal angioplasty (PTA) balloon catheter navigation. Suspecting and searching for a carotid-cavernous fistula, the microcatheter passed from the internal carotid artery (ICA) to the SOV. The fistula was considered to have occurred in the cavernous sinus close to the SOV. The fistula was closed by coil embolization from another microcatheter.Conclusion: It is important to be aware that a CCF may occur at the anterior genu of a cavernous ICA during catheter navigation. In the case of a fistula caused by a guidewire/microcatheter, transarterial coil embolization is possible and may be tried first.

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We recently developed an improvement on our original Masamune balloon microcatheter, the “Super-Masamune,” which the balloon is more compliant and has a double lumen. It easily herniates into a free space and improves neck protection. Because of the double lumen, it can be used for both neck plasty and for coil insertion. In case 1, a ruptured aneurysm was located in the distal portion of the right posterior cerebral artery. A collateral vessel was derived from the aneurysmal dome. We inserted the Super-Masamune into the aneurysm and performed coil embolization with collateral protection. Case 2 was a basilar tip aneurysm with a very wide neck. We first navigated the Super-Masamune into the aneurysmal dome, and then deployed Enterprise from the right posterior cerebral artery to the basilar artery. Then, coils were inserted from the Super-Masamune to inflate the balloon. Super-Masamune thus enables intraaneurysmal neck plasty with a single microcatheter.

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Objectives: We report our experience with a patient undergoing horizontal stent-assisted coil embolization for an aneurysm of the basilar tip, in which favorable coil embolization was achieved through innovative approaches that enhanced our intraoperative working views.Case Presentation: A 50-year-old woman was referred to our institution for further evaluation and treatment of an unruptured basilar tip aneurysm which had been diagnosed by magnetic resonance angiography (MRA). A cerebral angiogram showed a wide-necked saccular aneurysm (7.2-mm diameter/6.8-mm neck length), and bilateral posterior cerebral arteries (PCAs) arising directly from the aneurysmal neck. A right internal carotid artery (ICA) angiograms revealed a relatively developed right posterior communicating artery (PcomA) (1.1-mm diameter), and there was neither severe vascular bending nor tortuosity in the areas encompassing the right PcomA and the left P1 and P2 of PCA. We performed horizontal stent-assisted coil embolization via the right PcomA, because horizontal stent-assisted coil embolization was possible to perform anatomically and was considered safer and simpler than other adjunctive techniques. Simultaneous internal carotid-vertebral angiograms allowed stent delivery systems to be navigated from the right ICA to the left PCA via the right PcomA using fewer steps.Conclusions: If the anatomy would be favorable, horizontal stent-assisted coil embolization could be considered as an alternative method, in the case of other adjunctive techniques being difficult to perform for a wide-necked basilar tip aneurysm. Innovative approaches designed to enhance an appropriate intraoperative working view would facilitate performing horizontal stent-assisted coil embolization.

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