Purpose: The usefulness of stent-assisted coiling (SAC) of ruptured cerebral aneurysms has been reported, but a consensus has not been reached. We review the merits and limitations of this procedure based on our series.

Subjects and Methods: Out of 96 ruptured cerebral aneurysms treated by endovascular treatment between July 2010 and July 2016, five (5%) had SAC. We investigated this group’s clinical characteristics, postoperative complications, and modified Rankin Scale (mRS) score after 6 months.

Results: In all five patients, it was possible to insert a stent without difficulties, and there were no procedure-related complications. Diffusion-weighted brain MR images showed high-signal-intensity “spot-like” areas in all patients, remaining as asymptomatic cerebral infarctions and all stents remained completely patent. A hemorrhagic complication was observed in one patient who underwent later ventricle drainage. The mRS scores after 6 months were 0 in one patient, 1 in one patient, 3 in one patient, 4 in one patient, and 6 in one patient.

Conclusion: SAC of ruptured cerebral aneurysms could be considered a useful treatment option although indicated for a limited number of patients with adequate use of antiplatelet treatment and cerebral spinal fluid (CSF) drainage for the subarachnoid hemorrhage (SAH).

Objective: To explain the results of endovascular treatment for unruptured cerebral aneurysms in elderly patients, we divided patients with unruptured cerebral aneurysms who underwent endovascular treatment in our hospital into three groups: elderly (75 years and older), pre-elderly (65–74 years), and young (65 years and younger) groups, and compared the treatment results.

Subjects and Methods: In our hospital, 646 patients (elderly: 53, pre-elderly: 242, young: 351) with unruptured cerebral aneurysms underwent initial endovascular treatment between April 2007 and December 2015. We retrospectively compared aneurysmal factors, treatment methods, and treatment results (complications, results of embolization immediately after surgery, and results of follow-up imaging).

Results: The mean ages of the subjects in the aforementioned groups were 77.8 ± 2.45 (75–84 years), 69.2 ± 2.93 (65–74 years), and 53.3 ± 8.64 (26–64 years) years. Mean volume embolization ratios (VERs) of the elderly and pre-elderly groups were significantly lower when compared with that of the young group. Complete occlusion (Raymond Scale [RS] 1) was found in 48 (94.1%), 210 (87.5%), and 316 (91.6%) patients in the elderly, pre-elderly, and young groups, respectively, using digital subtraction angiography. Complications were noted in 8 (15.4%), 23 (9.5%), and 27 (7.7%) patients in the elderly, non-elderly, and young groups, respectively. In the elderly group, the incidence of embolic complications was slightly, although not remarkably, higher. On the final follow-up imaging, RS 1 was achieved in 40 (80.0%), 196 (83.1%), and 295 (86.5%) patients in the elderly, pre-elderly, and young groups, respectively; these differences did not rise to the level of statistical significance. Recanalization was achieved in 9 (18.0%), 31 (13.1%), and 39 (11.4%) patients in the elderly, pre-elderly, and young groups, respectively. Additional treatment was required for 1 (2.0%), 5 (2.1%), and 4 (1.2%) patients, in the elderly, pre-elderly, and young groups, respectively, showing no significant between-group differences.

Conclusion: The results of endovascular treatment for unruptured cerebral aneurysms in both the elderly and pre-elderly groups were similar to those in the young group. After due consideration of all known indications and treatment methods, endovascular treatment should be considered a feasible management for elderly patients.

Objective: We report a patient in whom overlapping stent placement with coil embolization was useful for treating a ruptured basilar artery (BA) dissecting aneurysm with rapid enlargement.

Case Presentation: A 50-year-old female presented with subarachnoid hemorrhage (SAH). On evaluation, a fusiform dilatation of the BA was noted, suggesting a dissecting aneurysm. Rapid enlargement of the aneurysmal dilatation was observed between days 9 and 16. On day 18, overlapping stent placement was performed in the dilated BA, and the aneurysmal dilatation was roughly embolized using coils. No neurologic deficit was observed in the postoperatively, and the patient was discharged with modified Rankin Scale (mRS) 0. Follow-up DSA at 8 months after the procedure showed the complete obliteration of the aneurysm with the remodeling of the BA. During the 29-month follow-up, there has been no recurrence.

Conclusion: Overlapping stent placement for a dissecting BA aneurysm was effective treatment leading to favorable vascular remodeling.

Objective: We report the case of a patient who presented with a subarachnoid hemorrhage as an initial symptom and who underwent parent artery occlusion of the internal carotid artery while maintaining the anterior circulation through the posterior circulation using a stent to treat an anterior-wall aneurysm of the internal carotid artery.

Case Presentation: The patient was a 54-year-old female who was brought to our hospital by ambulance with symptoms of headache and vomiting. A cephalic CT scan revealed a subarachnoid hemorrhage. DSA led to a diagnosis of a right internal carotid artery dissection. A balloon occlusion test (BOT) was conducted 2 days after admission, and endovascular treatment was performed 3 days after admission. An Enterprise vascular reconstruction device (VRD) was inserted into the right middle cerebral artery via the posterior communicating artery through the posterior cerebral artery, and a parent artery occlusion, which incorporated the rupture site, was performed proximal to the stent.

Conclusion: The number of patients for whom this procedure is indicated is limited, but it may facilitate safe treatment at the distal end of a parent artery occlusion while maintaining the anterior circulation.

Objective: A condition that presents with recurrent embolism due to “hidden bow hunter’s syndrome,” a subtype of bow hunter’s syndrome with a different pathogenic mechanism, is reported.

Case Presentation: The patient was a 78-year-old male who exhibited recurrent embolic stroke of the posterior circulation territory resistant to medical treatment. DSA showed occlusion of the right vertebral artery (VA), but dynamic left vertebral arteriography (VAG) presented no change in blood flow. Since indirect signs of occlusion and recanalization of the right VA were retrospectively obtained, dynamic right VAG was performed again on another day, which revealed that the occluded right VA in the neutral neck position recanalized when the neck was rotated to the left. Suspecting that thrombi formed during occlusion scattered with recanalization, we performed embolization of the parent artery in the distal right VA for the prevention of recurrence.

Conclusion: This pathological condition should be considered as a differential diagnosis if unexplained ischemia of the posterior circulation is accompanied by unilateral VA occlusion.

Objective: For transvenous embolization (TVE) of dural arteriovenous fistulae (dAVF) in the anterior condylar confluence (ACC), stable placement of a guiding catheter is important to approach the ACC from the jugular bulb (JB) with a microcatheter. We document our method and present a review of the literature.

Case Presentations: We used a 5-Fr internal mammary artery (IMA) catheter to guide the microcatheter into the ACC for coil embolization. In one patient, we placed the steeply angled tip of a 5-Fr IMA catheter into the entrance of the ACC from the JB, guided the microcatheter into the ACC, and performed coil embolization. In another patient, we created a coaxial setup by inserting a 5-Fr IMA catheter into a 6-Fr guiding catheter and advanced the tip of the IMA catheter from the JB into the ACC entrance in accordance with the angulation of the ACC entrance.

Conclusion: It is useful to select an IMA catheter based on anatomical structure when a direct approach from the JB to the ACC is required. Ours is the first report of an approach for TVE from the involved side using a guiding catheter adapted to the anatomical structure. We recommend the use of an IMA catheter adapted to the anatomical structures when a direct approach from the JB to the ACC is needed for TVE of dAVF in the ACC.

Objective: A major risk associated with carotid artery stenting (CAS) is embolic event caused by disturbance of plaque in the aortic arch. To avoid it, we developed a novel and simple technique of transbrachial carotid angioplasty and stenting for right carotid stenosis patients without crossing the aortic arch.

Case Presentations: The patient with complex aortic plaque (CAP) was selected. A 6F guiding sheath was inserted via the right brachial artery. A steam-shaped 6F JB2 diagnostic catheter with an acute “J”-shaped distal tip was used as the inner catheter. The JB2 catheter was advanced into the innominate artery. Under roadmap guidance, JB2 was pulled and cannulated in a common carotid artery (CCA), and a 0.035-inch guide wire was advanced to the distal CCA without insertion into the external carotid artery. JB2 and guiding sheath were advanced to the distal CCA. After JB2 removal, the usual carotid intervention was performed. We applied this method to six patients. For all patients, technical success was achieved. No patient experienced a symptomatic stroke or cholesterol embolism after the procedure.

Conclusion: Our novel and simple technique was safe and successful. This technique might prevent embolic stroke and dislodgement of cholesterol from atherosclerotic aortic arch plaques during neurointervention.

Objective: We report the mechanical thrombectomy (MT) of posterior circulation large vessel occlusion (pc-LVO) in which the transradial approach (TRA) was selected as an initial approach route to reduce the duration of treatment.

Case Presentation: We performed MT using the TRA for four patients with pc-LVO between November 2015 and March 2017. The TRA was used as an initial approach route in patients in whom preoperative MRI showed that the right vertebral artery (VA) was predominant. In all patients, the procedure could be accomplished without changing the approach route. Thrombolysis in Cerebral Infarction (TICI) 2b or better recanalization was achieved in all patients (100%), and TICI 3 recanalization in three patients (75%). Mean time from radial artery puncture to initial intracranial angiography and to the effective recanalization was 7.3 ± 1.5 and 28.8 ± 6.2 minutes, respectively. There was no complication at the site of puncture.

Conclusion: Recanalization was promptly and effectively achieved by the MT of pc-LVO using the TRA. The results suggest that TRA can be utilized as an initial access route in patients in whom an approach to the right VA is possible.