Background: Early recognition of stroke symptoms, pre-notification to the hospital, and rapid transport of the patients has been associated with faster intervention and better outcomes. We studied the impact of continuous monthly educational intervention to the emergency medical services (EMS) members on the therapeutic time till mechanical thrombectomy in acute ischemic stroke.

Methods: Our hospital manages Doctor Heli (DH) and Doctor Car (DC). Since April 2017, continuous monthly educational sessions on stroke care have been conducted involving the EMS doctors and paramedics, using the modalities like lectures and focus group discussions. We evaluated the change in performance time indicators prior to and after the initiation of this educational intervention.

Results: In all, 10 patients underwent mechanical thrombectomy for acute ischemic stroke before and 36 patients underwent the procedure after the initiation of educational intervention program. The number of EMS-transported patients (by DH and DC) out of the total patients who underwent mechanical thrombectomy increased from 20% to 42% after the initiation of the educational intervention. The median time interval of onset to door (O2D) decreased from 109.5 to 71 minutes and that of door to recanalization (D2R) decreased from 164 to 88 minutes following the educational intervention. Other performance time indicators were also notably reduced. This improvement of time indicators was observed gradually and annually.

Conclusion: This study showed that the continuous monthly education on stroke care to EMS members notably increased the number of EMS-transported patients as well as improved the performance time indicators till treatment in acute ischemic stroke.

Objective: The purpose of this study was to investigate the current status of treatment for intracranial artery stenosis (ICAS) in Japan.

Methods: A questionnaire was administered to a member of the Japanese Society for Neuroendovascular Therapy (JSNET), and data regarding the number of treatments for ICAS and the treatment strategies employed were collected via e-mail.

Results: Responses were received from 261 hospitals (25.8%) with JSNET members. From January 1 to December 31, 2017, the number of endovascular treatments for ICAS was 783. Among them, symptomatic lesions were seen in 89.8% of the cases, and 30.3% of ICAS cases were diagnosed after the reperfusion of an acute occlusion. Among the treatment strategies for ICAS detected after the reperfusion of an acute large-vessel occlusion (ALVO), antiplatelet therapy was utilized in 23.8% of cases and endovascular therapy was utilized in 70.4% of cases, in addition to antiplatelet therapy.

In cases involving symptomatic severe ICAS resistant to medical treatment with cerebral blood flow (CBF) impairment, 97.8% of physicians suggested intervention. However, in cases without CBF impairment, the percentage of physicians who suggested intervention decreased to 53.1%. In contrast, for asymptomatic ICAS without CBF impairment, more than 95% of physicians selected medical treatment.

Conclusion: In cases involving symptomatic ICAS resistant to medical treatment with CBF impairment, the rate of physicians who suggested intervention was quite high in Japan. Thirty percent of ICAS cases were diagnosed after the reperfusion of an ALVO.

Objective: We report a case of ruptured brain stem arteriovenous malformation that was successfully treated by transvenous embolization in addition to transarterial embolization using Onyx.

Case Presentation: A 61-year-old woman was admitted because of consciousness disorder following sudden-onset headache. CT revealed brain stem hemorrhage and MRI revealed abnormal vessels around the brainstem. Cerebral arteriovenous malformation on the right side of the pons was identified from an angiography. Her consciousness gradually improved from conservative treatment. Thereafter, endovascular treatment was performed. First, transarterial embolization with Onyx was performed to reduce the nidus as much as possible. Then, transvenous embolization for the remaining nidus was performed to completely embolize the cerebral arteriovenous malformation. No new neurological deficits were observed after treatment and no recurrence was noted on follow-up angiography 1 month after treatment.

Conclusion: We treated the brainstem arteriovenous malformation using a combination of transvenous and transarterial embolizations. In suitable cases, transvenous embolization can be an alternative treatment for deep-seated cerebral arteriovenous malformations that are difficult to treat by transarterial embolization or direct surgery.

Objective: We herein describe a rare case of intraventricular hemorrhage (IVH) due to a distal anterior choroidal artery (AChA) aneurysm associated with an arteriovenous malformation (AVM) in the trigone of the lateral ventricle during early pregnancy.

Case Presentation: At 8 weeks of pregnancy, a 36-year-old woman developed sensory aphasia and mild right hemiparesis due to a left lateral IVH. Digital subtraction angiography showed a peripherally located aneurysm branching from the medial perforating branch (MPB) of the plexal segment in the AChA associated with a micro-AVM in the trigone of the left lateral ventricle. Endovascular embolization was performed. A microcatheter was guided to a feeder branching out from the MPB. The aneurysm and the nidus, including the feeder, were occluded by 20% n-butyl-2cyanoacrylate (NBCA). However, right homonymous hemianopsia was apparent postoperatively, although the blood flow of the cisternal segment was preserved. Head MRI showed an acute infarction in the perfusion area of the AChA, including the internal capsule and optic radiation.

Conclusion: We performed endovascular embolization to temporarily treat both the aneurysm and the nidus because the source of bleeding was unclear considering the hematoma position and angiographic features. Ischemic complications of the embolization for the aneurysm and the nidus with the preservation of the cisternal segment of the AChA are unusual.

Objective: Sinus thrombosis often deteriorates despite anticoagulation therapy. Early endovascular therapy may lead to a better outcome in such cases. We report a case of sinus thrombosis treated by mechanical thrombectomy as an initial treatment.

Case Presentation: A 45-year-old female presented with headache and tonic seizure affecting the right arm. Computed tomography revealed subcortical hemorrhage at the right superior frontal gyrus. Occlusion of the superior sagittal sinus (SSS) was found on CTA and we diagnosed sinus thrombosis. Digital subtraction angiography demonstrated complete occlusion of the SSS and venous congestion at the middle third of the SSS. Immediately after diagnosis, we performed mechanical thrombectomy as an initial treatment. Partial recanalization was achieved after mechanical thrombectomy. Postoperative anticoagulation therapy was continued, and her symptom was improved.

Conclusion: Mechanical thrombectomy as an initial treatment for sinus thrombosis may be a useful treatment option when aggravation of the symptoms is predicted.