Objective: To examine the involvement of segmental arterial mediolysis (SAM) in intracranial artery dissection.

Methods: In four autopsy cases of subarachnoid hemorrhage related to the rupture of the intracranial vertebral artery (IVA) with intraperitoneal hemorrhage, we calculated the extent of arterial dissection using elastica van Gieson staining from the tissue sections of the left/right IVAs and intraperitoneal arteries (IPAs), and examined the properties of the vascular smooth muscle and responses of mesenchymal cells using immunostaining with anti-α smooth muscle antibody (SMA) and anti-S100A4 antibodies.

Results: The length of the adventitia at the site of IVA rupture was ≤2.4 mm, and that of disruptions of the internal elastic lamina was 5.4–11 mm. The IVA/IPA rupture sites showed acute arterial dissection. In the blood vessels at the sites of dissection, defect/necrosis of the vascular smooth muscle, which are characteristic of SAM, were noted. In three cases, the topical infiltration of mesenchymal cells was observed in the adventitia at the dissected site of the ruptured IVA. In all cases, dissection of unruptured intracranial or -peritoneal arteries was also present. Its pathological properties vary from acute to old dissection.

Conclusion: Autopsy revealed SAM-related systemic multiple arterial dissection in all cases, suggesting the involvement of SAM in the development of intracranial artery dissection.

Purpose: We examined the outcome of coil embolization for symptomatic unruptured cerebral aneurysms, and investigated factors contributing to symptom relief after surgery.

Methods: We retrospectively reviewed 19 patients who underwent coil embolization between January 2008 and April 2016.

Results: After surgery, symptoms reduced in 13 patients (68%), but not in 6 (32%). In the improved group, the mean duration of disease was significantly shorter than in the unimproved group (1.3 vs. 16.2 months, respectively, p <0.05). There was a significant reduction in the aneurysmal size in the former (mean rate of reduction: 3.51 mm), whereas there was an increase in the latter (mean increase: 1.63 mm) (p <0.05).

Conclusion: Early therapeutic intervention and a postoperative reduction in the aneurysmal size may be important to achieve the relief of symptoms of symptomatic unruptured cerebral aneurysms after surgery.

Purpose: We report a patient who underwent stenting for dissection related to internal-shunt insertion during carotid endarterectomy (CEA).

Case Presentation: A 77-year-old female with a history of stenosis of the left carotid artery. During admission due to infectious enteritis, right hemiplegia occurred, and arteriogenic embolism was observed. After an improvement in the general condition was achieved, CEA was performed. Intimal thickening involving the periphery to the most stenotic site was noted. When inserting a shunt into the internal carotid artery, there was a resistance, and there was no blood flow regurgitation, suggesting iatrogenic dissection. After plaque removal and vascular suture, the patient was transferred to the angiography room while maintaining general anesthesia, and a stent was inserted to the site of dissection. Anterograde blood flow was achieved, and the postoperative course was favorable.

Conclusion: Stenting for carotid artery dissection related to shunt insertion during CEA may be effective.

Purpose: In spinal dural arteriovenous fistulae (SDAVF), the most common clinical symptoms are gradually progressive gait disturbance, sensory disturbance, or sphincter dysfunction which are caused by venous congestion. We report a patient of SDAVF with acute exacerbation leading to complete paraplegia in 2 days.

Case Presentation: The patient was a 65-year-old female. Complete paraplegia occurred in 2 days. MRI showed the rapid progression of spinal edema. Spinal angiography conducted 3 days after onset confirmed the diagnosis of a SDAVF at the right L1 level, endovascular treatment was performed at the same session. The shunt completely disappeared, and voluntary knee flexion of both sides was possible at 3 hours after treatment. The next day, she was able to raise her legs. After 3 months, the patient could walk without any assistance.

Conclusion: We encountered a case of SDAVF with rapid progression of symptoms. Early recognition of the symptoms and prompt treatment are necessary in this rare clinical setting of SDAVF.

Objective: Coil migration is a complication related to endovascular coil embolization. In this study, we report a patient in whom an intraoperatively migrated coil was successfully retrieved using a stent retriever.

Case Presentation: A 57-year-old male. To treat an unruptured aneurysm of the right internal carotid artery, endovascular coil embolization was performed. During embolization, one end of a framing coil migrated into the parent artery, and it was retrieved using a microsnare. However, this resulted in the extra-aneurysmal deviation of a filling coil. We tried to retrieve it using a microsnare, but the formation of a coil mass made retrieval difficult. Eventually, retrieval with a stent retriever was successful. After operation, mild subarachnoid hemorrhage and slight muscle weakness of the left upper/lower limbs were observed, but recovery was achieved during the course, and the patient was discharged.

Conclusion: To our knowledge, no study has reported retrieval with a stent retriever for the management of coil migration in Japan. However, this method was considered to be effective. We report this patient, and review the literature.

Objective: A case of cerebral embolism due to left atrial myxoma successfully treated using a direct aspiration first pass technique (ADAPT) is reported with a review of the literature.

Case Presentation: The patient was a 31-year-old male who developed left hemiparesis and dysarthria and was transported to our hospital. Based on MRI and MRA findings, a diagnosis of acute cerebral infarction due to occlusion of the distal part of M1 of the right middle cerebral artery, and transthoracic echocardiography suggested left atrial myxoma. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy were carried out, and complete recanalization could be achieved 196 minutes after the onset. The symptoms were resolved, and the embolus was pathologically confirmed to be left atrial myxoma.

Conclusion: ADAPT using Penumbra was suggested to be useful for the treatment of cardiogenic cerebral embolism due to left atrial myxoma.

Objective: We report a case of a spinal dural arteriovenous fistula (s-dAVF) involving feeders from multiple intervertebral levels. Transarterial glue embolization was performed with controlling the blood flow from a feeder other than the one through which n-butyl-2-cyanoacrylate (NBCA) was injected using a balloon placed at a different level of a segmental artery. With this technique, complete occlusion was achieved with satisfactory penetration of NBCA.

Case Presentation: A 57-year-old male presented with progressive gait disturbance and bladder bowel dysfunction. DSA revealed an s-dAVF fed by the right 6th, 7th, and 8th intercostal arteries (ICAs). During injection of NBCA from the radicular artery of the 6th ICA, the blood flow was controlled by occluding the feeder from the right 7th ICA with NBCA and a balloon placed at the orifice of the feeder from the right 8th ICA. Complete occlusion of the fistula was achieved by the balloon-assisted injection of NBCA.

Conclusion: NBCA injection with flow control using a balloon placed in a feeder from a different segmental artery was useful for the treatment of an s-dAVF fed by multiple segmental arteries.

Objective: Catheter operations in the aortic arch with atheromatous ulcers, aortic aneurysms, or artificial blood vessels increase the risk of complications, such as cholesterin embolism. We report two cases in which a guiding sheath was directly guided into the right carotid artery through the radial artery using a 5 Fr 110-cm pigtail catheter as an inner catheter to avoid the above complications.

Case Presentations: Case 1: A 51-year-old female with an anterior communicating artery aneurysm. Balloon-assisted embolization of the aneurysm was performed using this method as she had undergone aortic arch replacement.

Case 2: A 74-year-old male with stenosis of the right internal carotid artery. Carotid artery stenting (CAS) was conducted using this method due to shaggy aorta.

Conclusion: This method may be simple and useful for avoiding the complexity of catheter exchange and risk of intra-aortic-arch manipulation.