Objective: It is still controversial whether coiling or clipping has a lower incidence of cerebral vasospasm following an aneurysmal subarachnoid hemorrhage (SAH). In this study, we compared angiographic vasospasm (AV), symptomatic vasospasm (SV), and the outcome of both procedures for ruptured cerebral aneurysms.

Methods: From 2007 to 2018, 127 patients were coiled and 127 were clipped for ruptured cerebral aneurysms. We retrospectively reviewed AV, SV, and the outcome of both procedures.

Results: The incidence of AV was 32 (25%) patients for coiling and 59 (46%) patients for clipping. SV occurred in eight (6%) patients for coiling and 19 (15%) patients for clipping, and was significantly less in the coiling group. A favorable outcome (modified Rankin scale [mRS] 0-2 on discharge) was in 71 (56%) patients for coiling and 77 (61%) patients for clipping, and there was no significant difference between the two groups.

Conclusion: The incidence of SV was significantly less in the coiling group for ruptured cerebral aneurysms. Even if SV occurred following aneurysmal SAH, early therapeutic intervention may prevent deterioration of the outcome.

Objective: Insertable cardiac monitoring (ICM) systems are useful for diagnosing paroxysmal atrial fibrillation (PAF) in cryptogenic stroke (CS). We assessed the initial treatment outcome using insertable cardiac monitors in CS treated by endovascular reperfusion therapy.

Methods: Of 102 consecutive acute ischemic stroke patients with large vessel occlusion (LVO) treated by endovascular therapy, we included 10 with CS who underwent insertable cardiac monitor placement between December 2016 and June 2018 at our hospital. Atrial fibrillation (AF) was determined by performing screening tests such as 12-lead electrocardiography (ECG), Holter ECG, and continued electrocardiographic monitoring for 3 days. Transesophageal echocardiogram (TEE) was essential to diagnose CS. We analyzed the parameters of AF and the time at which AF was first detected within 1 year.

Results: There were eight (80%) male patients, and the median age was 68 (interquartile range [IQR]: 59–76) years. The parameters of AF were not outliers. The detection rate of AF at 12 months was 60%. The median time from onset of stroke to device insertion was 17 (range: 10–22) days, and the median time from device insertion to detection of the first AF episode was 52 (range: 12–344) days.

Conclusion: The detection rate of AF in acute ischemic stroke patients with LVO treated by endovascular therapy was higher than that in previous reports.

Objective: We report a case of stent fracture caused by an elongated styloid process, a form of Eagle syndrome.

Case Presentation: A 58-year-old man presented with sudden right hemisensation disturbance and aphasia. MRI revealed multiple acute cerebral infarction in the left parietal and insula cortex. MRA revealed a left-sided internal carotid artery (ICA) occlusion distal to the carotid bifurcation. Digital subtraction angiography (DSA) revealed a left-sided ICA dissection distal to the carotid bifurcation. We performed acute revascularization with aspiration of the thrombus and stenting to treat the carotid dissection. Recanalization with thrombolysis in cerebral infarction (TICI) grade III was achieved. We performed DSA 3 months after an operation, it showed stent fracture and aneurysmal formation in the stent fractured department. From CT findings, the carotid artery dissection and stent fracture appeared to be triggered by the elongated styloid process. We performed stent-assisted coil embolization. After conducting percutaneous transluminal angioplasty (PTA) at high pressure after coil embolization, the elongated styloid process was fractured, and accepted a shift to the outside of the stent contact department. The patient was discharged without medical problems, and no recurrence was observed for 2 months after the surgery.

Conclusion: We experienced a rare case of ICA dissection and carotid stent fracture from Eagle syndrome. Eagle syndrome is an important disease to consider in the differential diagnosis of extracranial carotid artery dissection.

Objective: Spontaneous vertebral arteriovenous fistula (VAVF) is a rare vascular disorder. Herein, we report a case of high-flow VAVF with ipsilateral persistent primitive trigeminal artery (PPTA) treated by trans-arterial target embolization (TE) using balloon remodeling technique (BRT).

Case Presentation: A 58-year-old woman with a medical history of non-tuberculous mycobacterial lung disease had complained of right-sided pulsatile tinnitus for 3 years; however, there were no symptoms due to brain or spinal cord dysfunction. DSA revealed high-flow VAVF in the right V3 segment at the C2 vertebral body level and ipsilateral PPTA. The multi-planar reconstruction (MPR) images of cone-beam CT (CB-CT) obtained from 3D rotational angiography (3D-RA) in the arterial phase were useful to evaluate the morphology of VAVF. The fistula was single and positioned in the V3 segment at the C2 vertebral body level. The venous side of the fistula had expanded into a spheroid-like shape. A planned trans-arterial TE was performed 39 months after diagnosis due to recurring lung hemorrhage. Using BRT, TE was successful by packing back from the spheroid-like space with coils. The spheroid-like space was located slightly caudal to the fistula, and occlusion balloon inflated just distal to the fistula was helpful to navigate the microcatheter. After 12 months, DSA showed no recurrence of VAVF.

Conclusion: The MPR images of CB-CT obtained from 3D-RA were useful for evaluation of the morphological structure of VAVF. The BRT was useful for successful TE.

Objective: We report two cases of folding deformation of open-cell stents that occurred during carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis.

Case Presentations: Case 1: A 64-year-old man was diagnosed with asymptomatic right ICA severe stenosis. The stenosis was eccentric, comprising soft plaque with calcification. CAS was performed by standard procedure under protection with MOMA (Medtronic, Minneapolis, MN, USA) and GuardWire (Medtronic). We attempted post-dilation two times because PRECISE (Cordis, Miami, FL, USA) stent did not sufficiently dilate. Cone-beam CT showed a folding deformation of the stent. Case 2: A 60-year-old man was diagnosed with asymptomatic left carotid artery severe stenosis 5 years after radiation therapy for esophageal carcinoma. The stenosis was long, comprising soft plaque without calcification. CAS was performed under protection with MOMA and GuardWire. A PROTÉGÉ (Covidien, Irvine, CA, USA) stent was placed in the etiologic portion. After post-dilation, intravascular ultrasound (IVUS) examination showed suspected in-stent plaque protrusion, but cone-beam CT revealed a folding deformation of the PROTÉGÉ. We did not try any additional treatment. Both patients had no ischemic complications after the procedure and no infarction was detected on MRI.

Conclusion: We reported two cases of folding deformation with PRECISE or PROTÉGÉ. In addition to careful attention to not using an oversized stent, it is important to select a protection device and a balloon as a device to avoid deformation. It is difficult to predict or repair stent deformity. Continuation of antiplatelet therapy and long-term follow-up are required.

Objective:We report the first case of a vertebral artery (VA) dissecting aneurysm involving the posterior inferior cerebellar artery (PICA) treated by placing a stent on the PICA from the contralateral VA and parent artery occlusion in the acute hemorrhagic phase.

Case Presentation: The patient was a 47-year-old man with World Federation of Neurosurgical Societies (WFNS) grade 3 subarachnoid hemorrhage (SAH) and a VA dissecting aneurysm involving the origin of the PICA. We approached from the contralateral VA, and placed a stent from the PICA to VA to preserve the PICA, and parent artery occlusion of the VA was performed. As of 6 months postoperatively, no rebleeding or recurrence of aneurysm has been observed.

Conclusion: Although the use of stents in the acute phase is difficult, they can fully preserve the PICA and parent artery occlusion, and may be an effective treatment method to prevent rebleeding and chronic phase recurrence.