Objective: In cases of stent-assisted coil (SAC) embolization, visualization of stents with cone-beam CT is interfered significantly by the coil mass with streak artifacts. Metal artifact reduction (MAR), which is the algorithm for contrast-enhanced cone-beam CT, improves visualization of stents. We analyzed our cases of SAC embolization and report efficacy of MAR.

Materials and Methods: We reviewed 37 images of cone-beam CT of 37 aneurysms treated with SAC embolization between 2011 and 2013 in our institution. The 80 kV high-resolution XperCT was performed, and stent images were reconstructed with and without MAR. Neuroradiologists evaluated the following findings using a 3-point scale: stent apposition, stent lumen, and stent strut and anatomy of surrounding small vessels.

Results: By applying MAR, scores of findings listed above were improved at least by 1 point in 83.8%, 86.5%, 89.2%, and 29.7% of the cases, respectively, and overall visibility was improved in all of the cases. Improvement of the total score with MAR did not significantly correlate with aneurysm size (r = -0.079).

Conclusion: It was significantly valuable to apply MAR for the images after the SAC embolization treatment to observe stent apposition, stent lumen, and stent strut and surrounding vessels. This technique will also provide valuable information for cases of re-treatment or risk analysis for ischemic complications.

Objective: The treatment for traumatic carotid cavernous fistula (TCCF) that occurred after head trauma is evaluated based on our experience.

Methods: The clinical characteristics, treatments, and outcomes were retrospectively evaluated in six patients with TCCF that we treated between April 2012 and July 2015.

Results: The mean age of the patients, consisting of five males and one female, was 45.5 ± 16.8 years. The head trauma was acute subdural hematoma (ASDH) in one patient, acute epidural hematoma (AEDH) in one, brain contusion in two patients, and skull fracture in three patients. The patients exhibited bulbar conjunctival congestion, exophthalmos, and disturbance of ocular movement mean of 2.2 ± 1.8 months (2 days and 5 months) after injury, and the one patient who suffered rupture of pseudoaneurysm showed arterial nasal bleeding. The presence of fistula in the cavernous portion of the internal carotid artery was confirmed by cerebral angiography, and the mean maximum diameter of the fistula, measured by 3D DSA, was 9.6 ± 3.2 mm (2.4–19.9 mm). Endovascular procedures were completed in all patients, but among those with a large fistula, parent artery occlusion (PAO) was selected for three patients with ischemic tolerance, and transvenous embolization (TVE) of the cavernous sinus was selected for two patients with no tolerance. In a patient with a small and simple fistula, percutaneous transluminal angioplasty (PTA) was performed with covered stent placement. The shunt disappeared, and neurological symptoms were resolved within 1 month, in all patients. The postoperative course during a mean follow-up period of 21.0 ± 13.5 months was uneventful without recurrence.

Conclusion: Satisfactory outcomes could be achieved by endovascular treatment for TCCF by selecting an appropriate method for each patient.

Objective: We examined the long-term incidence of in-stent restenosis (ISR) on angiographic follow-up and ipsilateral ischemic events after Wingspan stenting for intracranial arterial stenosis.

Methods: Between July 2014 and September 2015, patients who underwent Wingspan treatment at our institution and have been followed for more than 1 year were retrospectively analyzed.

Results: In all, 13 lesions of 12 patients (average age, 67.1 years; 9 men) were enrolled. Target lesions involved nine internal carotid, three middle cerebral, and one vertebral artery. Wingspan was successfully placed in all 13 lesions. Pretreatment stenosis was 79.7 ± 9.3% (mean ± SD), which improved to 20.8 ± 9.6% after stent placement (p <0.001). There was one temporary periprocedural neurological complication and no ischemic stroke in follow-up (mean follow-up: 20.4 months). At 3–6 months, aggravation of the stenosis occurred in seven patients; however, all lesions improved 1 year later. As a result, ISR was demonstrated in one patient (8.3%).

Conclusion: One-year clinical and angiographic outcomes of Wingspan stenting were promising for intracranial atherosclerotic diseases.

Objective: We evaluated the outcomes of endovascular therapy for ruptured vertebral artery dissecting aneurysm (VADA), focusing on its location relating to the posterior inferior cerebellar artery (PICA) origin.

Materials and Methods: Patients with ruptured VADA, treated in our hospital from January 2007 to July 2015, were divided into four groups with respect to the location of the PICA origin. In seven patients, the dissecting segment involved the origin of the PICA (PICA origin type). In all, 10 patients had dissection distal to the origin of the PICA (PICA distal type). In the remaining two patients, there was no definite PICA (non-PICA type). There were no patients with dissection proximal to the origin of the PICA (PICA proximal type). The postoperative course was retrospectively compared between the groups.

Results: Endovascular parent artery occlusion just proximal to the PICA origin was performed in the PICA origin group, whereas parent artery occlusion involving the whole dissected segment was performed for the other groups. In the PICA origin group, although re-bleeding had occurred in one patient, the modified Rankin scale score 3 months after the surgery, was less than 3 in all patients. Cerebral infarctions occurred in six patients in the PICA distal group and two patients in the non-PICA group. All two patients in the non-PICA group experienced medullary infarction, which occurred in only one patient in the PICA distal group.

Conclusion: Parent artery occlusion just proximal to the PICA in the PICA origin group is effective, but frequent follow-up is necessary to evaluate increase in the blood flow to the residual dissection due to newly developed collaterals. Embolization in the short segment is advised in the PICA distal group to minimize the risk of cerebral infarction due to occlusion of the perforating arteries. Avoiding medullary infarction in treating the non-PICA group remains a challenge.

Objective: A case of symptomatic cervical carotid artery stenosis with persistent primitive hypoglossal artery (PPHA) treated by carotid artery stenting (CAS) with appropriate embolic protection is reported.

Case Presentation: The patient was a 65-year-old male presenting with left hemiplegia. MRI revealed infarction in the right cerebral hemisphere, and cerebral angiography demonstrated stenosis affecting the proximal segment of the internal carotid artery (ICA), proximal to the origin of the PPHA. Since blood flow was observed from the PPHA to the ICA during simultaneous obstruction of the common and external carotid arteries, a filter protection device was placed in the ICA along with proximal protection, and CAS could be performed without complications.

Conclusion: In performing CAS for symptomatic stenosis of the cervical carotid artery with PPHA, it is considered important to select appropriate embolic protection based on the evaluation of the direction of the blood flow of the ICA and PPHA under balloon occlusion conditions.

Objective: A case of metastatic bone tumor difficult to approach via the transfemoral route in which preoperative tumor embolization through a small cervical incision was effective is presented.

Case Presentation: The patient was a 73-year-old male being treated for liver cancer. A mass 60 mm in maximum diameter that rapidly grew inside and outside the cranium was noted in the parietal region. Since the lesion was difficult to approach transfemorally because of the history of Stanford type A aortic dissection, a sheath was inserted into the common carotid artery through a small incision in the neck, and tumor embolization was performed by settings similar to the transfemoral approach. No procedural complication was observed, and the control of hemorrhage during tumor resection was adequate.

Conclusion: Tumor embolization by direct carotid artery puncture through a small cervical incision was a safe and effective approach.

Objective and Case Presentation: The patient was an 86-year-old woman with histories of surgery for stomach, colon, and pancreatic cancers. In addition to left hemiparesis as a sequela of two past episodes of cerebral infarction, she newly developed right hemiplegia and acute cerebral infarction due to left middle cerebral artery (MCA) occlusion. Since the condition was not an indication for intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA), mechanical thrombectomy was immediately performed, and almost complete recanalization could be achieved about 5 hours after the onset. The retrieved thrombus was a white and elastic hard fibrin thrombus that contained no blood cells. Although temporary symptomatic relief was obtained, bilateral MCA occlusion occurred in succession, and the patient died on the 35th day of illness.

Conclusion: Accumulation of cases and pathological evaluation of retrieved thrombi are necessary for the elucidation of the optimal mechanical thrombectomy or antithrombotic therapy for acute cerebral infarction due to Trousseau syndrome.

Objective: Flat detector CT perfusion (FD-CTP) imaging is a new modality that permits rapid assessment of the state of perfusion in the angiography suite. We present a case in which FD-CTP was useful for the determination of the therapeutic strategy for embolism that occurred during angiography.

Case Presentation: Cerebral angiography performed before surgery for brain tumor suggested left posterior cerebral artery occlusion. Since the judgment of whether it was chronic occlusion or embolism that occurred during the examination was difficult, FD-CTP was performed. As hypoperfused area was observed in the left occipital lobe without previously known infarction, the lesion was judged not to be chronic occlusion but to possibly cause cerebral infarction without treatment. We immediately performed thrombectomy and prevented its development into cerebral infarction.

Conclusion: FD-CTP was useful for the diagnosis and determination of the therapeutic strategy for intracranial vascular occlusion as a complication of cerebral angiography because it can be promptly performed in the angiography suite.