Objective: We examined the current status of ruptured cerebral aneurysm treatment and results of coil embolization in a district.

Methods: We conducted a prospective, multicenter, cooperative observational study involving 169 patients with ruptured cerebral aneurysms who were treated in the acute phase between September 2013 and March 2016. Predictive factors for poor outcome (90-day modified Rankin Scale 3–6) were investigated, and the results were compared between craniotomy and coil embolization.

Results: Coil embolization was performed for 39 patients (23.1%). In all, 63 (37.3%) patients had poor outcome. Univariate analysis showed that predictive factors for poor outcome included an advanced age, pre-onset disability, history of cerebral infarction, poor grade on admission, modified Fisher grade 4, acute hydrocephalus, cerebrospinal fluid drainage, craniotomy, craniotomy-related complications, the absence of fasudil hydrochloride administration, delayed cerebral ischemia, delayed cerebral infarction, shunting, pneumonia, and heart failure. On multivariate analysis, predictive factors for poor outcome included pre-onset disability, poor grade on admission, modified Fisher grade 4, delayed cerebral infarction, and heart failure, whereas the prophylactic administration of intravenous fasudil hydrochloride and coil embolization were independent factors associated with good outcome. In patients who underwent craniotomy, the incidences of cerebral vasospasm and cerebral infarction were significantly higher than in those who underwent coil embolization.

Conclusion: This was an observational study, and the indication of treatment or strategies differed among institutions, which was a limitation. However, coil embolization was an independent factor associated with good outcome.

Objective: We examined whether the introduction of tailored carotid artery stenting (CAS) was effective for the prevention of periprocedural ischemic complications.

Methods: In patients who underwent CAS, we compared the incidence of new ischemic lesions on postprocedural diffusion weighted image (DWI) and periprocedural ischemic stroke between three periods: the early period when primarily distal balloon protection was used, the intermediate period when primarily distal filter protection was used, and the late period after the introduction of tailored CAS.

Results: CAS was performed in 16 lesions in the early period, 30 lesions in the intermediate period, and 69 lesions in the late period. New ischemic lesions on postprocedural DWI were detected in 1 (6.3%), 6 (20.0%), and 12 (17.4%), respectively. Periprocedural ischemic stroke occurred in three lesions (10%) during the intermediate period, but did not occurred during the early and late periods.

Conclusion: The incidence of new ischemic lesion on DWI did not change even after the introduction of tailored CAS, but no periprocedural ischemic stroke occurred, suggesting that tailored CAS is effective for its prevention.

Objective: While intracranial mechanical thrombectomy has been established as a treatment, atherothrombotic brain infarction due to stenosis of major cerebral arteries is occasionally difficult to treat as severe stenosis persists after recanalization, eventually requiring percutaneous transluminal angioplasty (PTA) or stent placement. The contents and results of mechanical thrombectomy for atherothrombotic brain infarction that we have encountered are presented.

Methods: The subjects were 17 patients diagnosed with atherothrombotic brain infarction among the 99 patients with cerebral infarction accompanied by major intracranial artery occlusion treated at our hospital during the 30 months from January 2014 and June 2016. Recanalization graded as Thrombolysis in Cerebral Infarction (TICI) 2b or higher was regarded as effective, and the outcome was evaluated using the modified Rankin Scale (mRS).

Results: The responsible lesion was located at the origin of the internal carotid artery (ICA) in three patients, in the ICA siphon in four patients, middle cerebral artery (MCA) in five patients, vertebral artery (VA) in two patients, and basilar artery (BA) in three patients. Effective recanalization was achieved in 82.4%, the mRS score was 0-2 in 52.9%, and the postoperative mRS score was the same as before treatment in 11.8%.

Conclusion: The outcome of intracranial mechanical thrombectomy for atherothrombotic brain infarction accompanied by major intracranial artery stenosis was favorable in many patients, and aggressive treatment is considered recommendable. In addition, safe and appropriate execution of additional treatments for residual stenotic lesions leads to favorable outcomes.

Objective: A case of folding deformation of a PROTÉGÉ RX (PROTÉGÉ; eV3 Covidien, Irvine, CA, USA) stent during carotid artery stenting (CAS) with distal filter protection is reported. Folding deformation complicated retrieval of the filter device.

Case Presentation: A 67-year-old man was diagnosed with left asymptomatic cervical internal carotid artery stenosis, which gradually progressed despite medical treatment. The stenosis was long and eccentric, comprising soft plaque with partial calcification. CAS was performed under distal filter protection using a right brachial artery approach. After pre-dilation, a PROTÉGÉ 10-mm × 60-mm stent was placed from the internal carotid to common carotid artery. Since the stent was not sufficiently dilated even after postdilation, additional balloon angioplasty was attempted. However, the balloon was trapped by the stent strut and could not cross the lesion. Cone-beam CT showed stent folding deformation extending from the internal carotid to common carotid artery. The deformed part of the stent was dilated with stepwise balloon angioplasty from proximal to distal, and the filter device was eventually retrieved. The patient showed no new neurologic symptoms after the procedure and no infarction was noted on postprocedural MRI.

Conclusion: In performing CAS using PROTÉGÉ for long, eccentric stenosis with calcification, the risk of stent folding deformation should be carefully considered.

Objective: We report a case of severe stenosis at the origin of the persistent primitive proatlantal artery (PPPA) for which a favorable outcome was obtained through stent placement.

Case Presentation: A 75-year-old man was admitted to our hospital primarily complaining of sudden onset numbness of the left side of the body. MRA showed infarction on the dorsal side of the right pons. Cerebral angiography revealed a PPPA that arose from the right carotid artery, with marked stenosis at its origin. With balloon protection of the internal carotid artery and PPPA, a stent was placed in the stenosed area. Adequate dilatation was achieved and no new neurologic deficits were noted after treatment.

Conclusion: Stenting could be performed safely with the concomitant use of appropriate protection for stenosis of the origin of the PPPA.

Objective: We report a case wherein coil embolization with an intention to preserve the hemispheric branches was performed to treat a ruptured saccular aneurysm in the distal posterior inferior cerebellar artery (PICA) during the acute period. The considerations that led to the selection of the endovascular treatment are discussed.

Case Presentation: The patient was an 87-year-old woman who presented with subarachnoid hemorrhage. After considering the patient’s age and the severity of her condition, intra-aneurysmal coil embolization was performed to treat a saccular aneurysm in the left telovelotonsillar segment. The parent artery was preserved, and no postoperative complications were noted.

Conclusion: Either parent artery embolization or intra-aneurysmal embolization should be selected as the endoscopic treatment methodology for de novo saccular aneurysms located in the PICA, except for those in the vertebral artery bifurcation area. The treatment selection should be based on careful evaluation of the aneurysm size, parent artery diameter, and aneurysm site.

Objective: Pipeline Embolization Device (PED; Medtronic, Minneapolis, NM, USA) is the first and currently only flow diversion device approved by the Ministry of Health, Labour and Welfare in Japan. The PED is able to embolize the unruptured intracranial aneurysm (UIA) due to the disruption of blood flow into the aneurysm sac while preserving the normal blood flow of parent and surrounding branch vessels. One of the drawbacks of PED embolization is to require the coil embolization when the aneurysms are deemed to be high-risk delayed aneurysm rupture.

Case Presentations: We report two cases suffered from delayed hydrocephalus after combined treatment with PED and platinum coil for large UIAs. Both patients had an improvement of symptoms related to delayed hydrocephalus after lumboperitoneal shunts (LPS). Gadolinium (Gd)-diethylenetriamine penta-acetic acid (DTPA)-enhanced magnetic resonance (MR) images before the LPS showed the aneurysm wall enhancement, suggesting the inflammation of aneurysm wall. The examinations of cerebral spinal fluid (CSF) sampled during the LPS procedures showed the high protein level without elevated cells/decreased glucose, suggesting aseptic meningitis. The aneurysm wall inflammation and aseptic meningitis were thought be main causes of the delayed hydrocephalus.

Conclusion: In this case report, we warn that combined treatment with PED and platinum coil has the risk of delayed hydrocephalus.

Objective: We examined the usefulness of Doppler ultrasonography for the diagnosis of severe stenosis of the proximal vertebral artery (VA).

Case Presentations: We performed Doppler ultrasonography of the VA in patients diagnosed with cerebral ischemia of the posterior circulation. Incorporating the diagnostic criteria for severe stenosis at the origin of the internal carotid artery (maximum peak systolic flow velocity: ≥200 cm/sec, or acceleration time: ≥110 msec), patients were screened for proximal VA stenosis and cerebral angiography was conducted if they fulfilled the above criteria. In all six patients in whom proximal VA stenosis was suspected on ultrasonography, angiography confirmed severe stenosis, and endovascular treatment was performed. In five patients who underwent postoperative ultrasonography, an improvement of the stenosis was confirmed.

Conclusion: Doppler ultrasonography is useful for the screening and postoperative assessment of proximal VA stenosis.