Objective: We retrospectively compared the results of treatment between patients aged ≥85 years and those aged <85 years among those who underwent thrombectomy for acute cerebral infarction in our hospital.

Methods: Of patients with acute cerebral infarction who underwent thrombectomy in our hospital between October 2014 and September 2017, the subjects were those with an interval of ≤8 hours from onset until arrival, a diffusion-weighted imaging-alberta stroke program early CT score (DWI-ASPECTS) of ≥6, and occlusion of the internal carotid (IC) artery, middle cerebral artery M1/M2, basilar artery (BA), or posterior cerebral artery P1.

Results: The subjects consisted of 12 patients aged ≥85 years and 27 aged <85 years, with mean ages of 88.5 and 72.3 years, respectively. The rate of patients who had taken antithrombotic drugs before onset was significantly higher in the latter. There were no significant differences in the diagnosis, risk factors, modified Rankin Scale (mRS) score before onset, National Institute of Health Stroke Scale (NIHSS) score on arrival, DWI-ASPECTS, or site of occlusion. Concerning treatment results, the mRS score on discharge was significantly higher in those aged ≥85 years, but there were no significant differences in the recanalization rate or incidence of hemorrhagic complications between the two groups.

Conclusion: In those aged ≥85 years, the mRS score on discharge was significantly higher. However, the recanalization rate was relatively high, and an improvement in the NIHSS score was achieved. Although the indication of thrombectomy should not be restricted based on the age alone, acute cerebral infarction patients aged ≥85 years must be accumulated to evaluate whether the procedure should be indicated.

Objective: This study was carried out to evaluate the clinical characteristics of patients with embolic stroke of undetermined source (ESUS) treated by endovascular reperfusion therapy for emergent large vessel occlusion (ELVO).

Subjects and Methods: Of 87 consecutive acute ischemic stroke patients with ELVO treated by endovascular reperfusion therapy, clinical characteristics, treatments, and outcomes were compared in 14 patients diagnosed with ESUS at discharge and 42 patients with cardioembolic stroke (CES).

Results: In the ESUS group, the patients were younger (63.9 vs. 76.4 years, P <0.05), and the percentage of males was lower (21.4% vs. 64.3%, P <0.05), than in the CES group. Most patients in both groups received mechanical thrombectomy, and there was no significant difference in the National Institutes of Health Stroke Scale (NIHSS) score on admission (median: 17 vs. 18), diffusion weighted image-Alberta Stroke Program Early CT score (DWI-ASPECTS) (median: 8 vs. 7), or successful reperfusion (thrombolysis in cerebral infarction [TICI] grade 2b or 3) rate (78.6% vs. 61.9%). Favorable outcome (modified Rankin Scale [mRS] score of 0-2 at discharge) tended to be more frequent in the ESUS group (71.4% vs. 42.9%, P = 0.06).

Conclusion: The relatively younger age of the ESUS group compared with the CES group is considered to have contributed to the more favorable outcome.

Objective: A rare case of large dissecting aneurysm of the internal carotid artery caused by elongated styloid process is reported.

Case Presentation: A 45-year-old woman, who had noted an uncomfortable feeling of the pharynx from 2 years before, developed swelling of the left neck, pharyngalgia, and dysphagia 3 months before. Cervical CTA revealed an aneurysm 27 mm in diameter in the left extracranial internal carotid artery. The styloid process was elongated and displaced the aneurysm, and dissecting aneurysm due to compression was suspected. A covered stent was placed to induce thrombosation in the aneurysm, resulting in alleviation of symptoms, and imaging examinations confirmed thrombosation and regression of the aneurysm.

Conclusion: Reports of treatment for elongated styloid process complicated by large aneurysm are very rare. A covered stent is a possible therapeutic option if direct surgery is difficult.

Objective: We report a patient in whom coil embolization of a dural arteriovenous fistula with a shunting point at the venous lacuna of the superior sagittal sinus led to radical cure.

Case Presentation: The patient was a 45-year-old female. She had a 4-month history of pulsatile tinnitus. For the purpose of treatment, she was referred to our hospital. Angiography showed blood flow from the bilateral middle meningeal arteries to the superior sagittal sinus (SSS) through the venous lacuna. The tip of a 4 Fr intermediate support catheter was inserted into the venous lacuna, and a microcatheter was retrogradely inserted into the right middle meningeal artery. Coil embolization involving the venous lacuna was performed. The disappearance of a shunt was confirmed.

Conclusion: In a patient with a shunting point at the venous lacuna of the SSS, the insertion of an intermediate support catheter with an S-shaped tip into a venous lacuna facilitated embolization.

Objective: We report a patient with severe cerebral sinus thrombosis (CST) in whom mechanical thrombolysis with a balloon and thrombectomy with a stent retriever were effective.

Case Presentation: The patient was a 32-year-old male. Headache occurred, and magnetic resonance venography (MRV) showed occlusion of the superior sagittal sinus. Transvenous anticoagulant therapy was performed, but consciousness disorder and paralysis progressed in a few days. Head CT revealed marked edema of the bilateral frontal lobes and cerebral hemorrhage. Cerebral angiography showed occlusion of the superior sagittal sinus, and endovascular treatment with a balloon and stent retriever was performed, leading to recanalization. Finally, the course was favorable.

Conclusion: Endovascular treatment with a stent retriever may be safe and effective for severe CST.

Objective: For thrombectomy, it is sometimes difficult to advance a guiding catheter using the transfemoral artery approach. In this study, we report five patients in whom intraoperative switching to the transbrachial artery approach led to successful results.

Case Presentations: This procedure was performed for five patients in whom it was difficult to guide a catheter using the transfemoral artery approach. A 6-Fr sheath-introducer was newly inserted into the brachial artery, and an aspiration catheter was directly inserted into the sheath’s insertion opening using an attached inserter and advanced to reach a target vessel. Subsequently, thrombectomy with the aspiration method or a stent retriever was conducted, and Thrombolysis in cerebral infarction (TICI) 2b or higher recanalization was achieved in four patients in a relatively short time.

Conclusion: The direct aspiration catheter insertion technique using the transbrachial approach may be useful as an alternative method for patients in whom transfemoral approach is difficult.

Objective: A method to deal with situations in which the protective sleeves of the Pipeline Flex embolization device (Medtronic, Minneapolis, MN, USA) cannot be released in its placement due to strong resistance to the delivery wire is presented.

Case Presentation: The patient was a 60-year-old woman with symptomatic aneurysm in the cavernous portion of the left internal carotid artery. We attempted to navigate the Pipeline Flex to, and place it in, the target vessel, but the resistance to the delivery wire in the microcatheter was so strong that it was totally impossible to expose the Pipeline Flex from the catheter tip. Therefore, we expanded the tip of the Pipeline Flex ex vivo, resheathed it after releasing the protective sleeves, and attempted to place the device again with success.

Conclusion: While this method cannot be recommended, it may be effective if there is strong resistance in releasing the protective sleeves.

Purpose: We evaluated the efficacy of 3D time-of-flight MRA (3D-TOF MRA) using parameters optimized to reduce metal artifacts in follow-up imaging of cerebral aneurysm treatment by stent-assisted coiling (SAC).

Methods: The radiological data from seven patients (eight aneurysms) who underwent SAC for unruptured cerebral aneurysms were retrospectively analyzed. Standard MRA (normal TOF: N-TOF) and stent-mode TOF (S-TOF) imaging using various parameters, such as the flip angle, were performed to compare the signal intensity of the parent blood vessel and the stent lumen.

Results: Stent lumen vascular signal intensity for S-TOF was significantly higher than N-TOF in patients with stent alone (P = 0.012, <0.05). The mean signal reduction rate for LVIS Jr. (Terumo Corporation, Tokyo, Japan) was 39.0% ± 9.6%. For similar size stents signal reduction ranged from 26.1% to 48.9%. The signal reduction rate for double LVIS coiling was 73.2%. Although the size of the neck remnant was overestimated in some patients, it was possible to detect a slow flow volume at the aneurysm neck in all patients.

Conclusion: 3D-TOF MRA for blood flow assessment facilitated the visual recognition of the stent lumen after SAC. Confirmations of aneurysmal neck remnants were also possible. However, the results suggest that differences in the mesh intervals for similar sized braided stents influenced the signal intensity, leading to overestimation of residual aneurysm. This should be further investigated in future studies.