Objective: For perioperative management after carotid artery stenting (CAS), it is important to predict hyperperfusion syndrome (HPS). In this study, we qualitatively evaluated cerebral blood flow during the perioperative period following CAS using the pulsed arterial spin labeling (ASL) method, and examined the usefulness of this method. Furthermore, we devised the labeling position so that there was no influence of stenting, reducing errors before and after CAS.

Methods: Of patients with carotid artery stenosis who underwent CAS in our hospital between June 2015 and December 2016, the subjects were 13 in whom ASL could be performed before and after CAS. ASL was performed within 1 week before CAS, as well as 1 and 7 days after CAS. For blood flow assessment, differences in the cerebral cortex at the basal ganglia level between the left and right and between the preoperative and postoperative states after CAS were qualitatively compared.

Results: After CAS, favorable dilation at the lesion site was achieved in all patients. Before CAS, ASL on the affected side showed a reduction in blood flow in nine patients although qualitative assessment was conducted. The day after procedure, findings presage of HP were obtained on ASL in four patients. Of these, HP syndrome-related internal capsule hemorrhage was noted in one case. ASL 7 days after CAS facilitated the assessment of an improvement in cerebral blood flow in comparison with the preoperative state in nine patients.

Conclusion: In perioperative management following CAS, ASL is a rapid, noninvasive procedure, facilitating repeated imaging in a short period. This procedure was useful for evaluating cerebral blood flow.

Objective: We report two patients for whom balloons for carotid artery stenting (CAS) were mis-selected, and review balloon selection for CAS and the purpose of predilatation.

Case Presentations: Case 1: A 73-year-old man developed amaurosis fugax on his right eye. An unstable, plaque-abundant stenotic lesion of the right internal carotid artery with calcification was detected. Under flow reversal, a Carotid WALLSTENT 8 mm × 29 mm was inserted, and postdilatation was performed using a Jackal 4.5 mm × 30 mm until a nominal pressure was achieved. In-stent plaque protrusion was noted. A Carotid WALLSTENT 8 mm × 21 mm was overlapped, and the procedure was completed. Subacute thrombosis (SAT) with North American Symptomatic Carotid Endarterectomy Trial (NASCET) 40% restenosis was observed 5 days after CAS. Anticoagulant therapy gradually reduced SAT.

Case 2: An 83-year-old woman presented an asymptomatic acute phase ischemic lesion in left cerebral hemisphere by scheduled MRI as a follow-up study of medical checkup. An irregular, plaque-abundant, markedly stenotic lesion of the left internal carotid artery with calcification was detected. Under flow reversal, predilatation was performed using a Sterling 3 mm × 40 mm (Boston Scientific, Marlborough, MA, USA) until a nominal pressure was achieved, and a PRECISE 9 mm × 40 mm (Cardinal Health, Inc., Dublin, OH, USA) was inserted. It was impossible to pass an Aviator 4 mm x 30 mm (Cardinal Health, Inc.) for postdilatation through the site of stenosis, and a Gateway 2.5 mm × 12 mm (Stryker, Kalamazoo, MI, USA) and Jackal 4.5 mm × 30 mm (Kaneka Medix Corp., Osaka, Japan) were used. Dilatation was achieved.

Conclusion: To improve the results of CAS, it is important to establish the purpose of balloon dilatation and select a balloon in accordance with its purpose, as indicated for the selection of embolic protection devices (EPDs) and stents.

Objective: We encountered a rare case of steal phenomenon via the vertebral artery due to occlusion of the brachiocephalic artery that developed dissecting aneurysm in the right vertebral artery and suffered subarachnoid hemorrhage.

Case Presentation: A 68-year-old woman was transported due to headache and disturbance of consciousness. Close examinations disclosed subarachnoid hemorrhage, dissecting aneurysm of the right vertebral artery, occlusion at the origin of the brachiocephalic artery, and consequent steal phenomenon. After a stent was placed retrogradely from the right posterior inferior cerebellar artery to the union of the two vertebral arteries via the left vertebral artery, coil embolization was performed.

Conclusion: For ruptured vertebral artery dissecting aneurysm ipsilateral to occlusion of the brachiocephalic artery, coil embolization was performed after retrograde stenting. This procedure is considered to have been useful as a radical endovascular treatment to preserve the parent artery and prevent re-rupture of the aneurysm.

Objective: One case of venous anomaly arising from the cranium in which intraoperative hemorrhage could be effectively controlled by direct puncture sclerotherapy using N-butyl-2-cyanoacrylate (NBCA) is reported.

Case Presentation: A 76-year-old male noted gradually progressing right exophthalmos and swelling of the right temporal region and was found by imaging studies to have a space-occupying lesion extending inside and outside the cranium and in the orbit. On diagnostic biopsy of the extracranial part under local anesthesia, massive and spouting venous hemorrhage was observed. From intraoperative and pathological findings, a diagnosis of venous anomaly was made, and sclerotherapy was performed using NBCA under direct percutaneous puncture. After 4 days, the lesion could be resected totally with only slight bleeding.

Conclusion: Sclerotherapy using NBCA by direct puncture is considered useful as a preoperative treatment for venous anomalies.

Objective: We report a case of ruptured anterior communicating artery aneurysm in which residual aneurysm after coil embolization could be completely occluded by LVIS Jr. stent placement.

Case Presentation: A 73-year-old woman underwent coil embolization in the acute phase of ruptured anterior communicating artery aneurysm. Since the parent artery was narrow with a diameter of 1 mm, and since the bifurcation angle of the A1 segment was sharp, manipulation of the microcatheter was difficult, and the treatment was terminated after partial embolization. After 40 days, retreatment was performed by LVIS Jr. stent placement. No intra- or postprocedural complication was observed, and complete occlusion of the aneurysm was confirmed by angiography after 3 months.

Conclusion: Complete occlusion of the residual aneurysm could be achieved due to the flow diversion effect of LVIS Jr. stent. This procedure can be an option in retreatment.

Objective: We report two patients with cerebral infarction who underwent endovascular treatment for internal carotid artery dissection related to an elongated styloid process.

Case Presentations: Case 1: A 48-year-old male. Paralysis of the left upper/lower limbs occurred. On arrival, the National Institute of Health Stroke Scale (NIHSS) score was 14. MRI revealed acute-stage infarction, narrowing of the high-level internal carotid artery adjacent to the right styloid process, and occlusion of the right middle cerebral artery (MCA). After internal carotid artery stenting (CAS), mechanical thrombectomy for distal embolism was performed, leading to recanalization. Case 2: A 45-year-old male. Aphasia and paralysis of the right upper/lower limbs occurred. On arrival, the NIHSS score was 8. MRI showed acute-stage infarction and narrowing of the high-level internal carotid artery adjacent to the left styloid process. Conservative treatment was administered. As there was a dissecting aneurysmal change at the stenotic site, carotid-stent-assisted coil embolization was performed. In the two patients, endovascular treatment led to a favorable prognosis.

Conclusion: For the treatment of arteriogenic cerebral infarction related to atypical stenosis of the high-level cervical internal carotid artery, it is important to review therapeutic strategies, considering the possibility of an elongated styloid process.

Objective: A case of basilar bifurcation aneurysm associated with unilateral moyamoya disease (MMD) treated by stent-assisted coiling (SAC) following bypass surgery is reported.

Case Presentation: The patient was a 41-year-old man with a basilar bifurcation aneurysm associated with left unilateral MMD. Treatment was indicated because the aneurysm showed a gradual increase in size. The left middle cerebral artery (MCA) territory was revealed to have reduced cerebrovascular reactivity although the area was supplied through collateral channels from the left posterior cerebral artery (PCA). A left superficial temporal artery (STA)-MCA anastomosis was performed first, and SAC was performed after 3 month interval. DSA performed 1 year after the endovascular procedure showed progressive occlusion of the aneurysm although the immediate angiographic result was dome filling.

Conclusion: An aneurysm associated with MMD located in a major vessels may be treated effectively with a combination of bypass surgery and SAC.

This study describes hyperintensity of dural venous sinuses due to jugular venous reflux (JVR) and their respiration- and position-induced changes, and discusses the significance of this phenomenon in endovascular treatment.