Objective: This study was conducted to clarify the characteristics of preprocedural vascular images in patients with acute embolic occlusion of the carotid artery in whom the internal carotid artery (ICA) could be recanalized by manual suction with syringe via the balloon guiding catheter (SS-BGC) alone.

Methods: The subjects were 64 consecutive patients who underwent SS-BGC for carotid artery embolic occlusion at our institution between May 2006 and September 2017. The subjects were classified into those who with recanalization (R-SS-BGC group) and no recanalization (N-SS-BGC) of ICA by SS-BGC alone, and the background factors including findings of preprocedural vascular imaging and outcomes were compared between the two groups.

Results: The R-SS-BGC and N-SS-BGC groups consisted of 16 and 48 patients, respectively. In the R-SS-BGC/N-SS-BGC groups, the horizontal segment of the ipsilateral anterior cerebral artery (A1) was patent in 15/24 (94/50%) and the horizontal segment of the ipsilateral middle cerebral artery (M1) was patent in 6/16 (38/34%) on preprocedural MRA. The ipsilateral posterior communicating artery (PcomA) was patent in 3/14 (19/29%) and the ipsilateral ophthalmic artery (OphA) was patent in 1/14 (6/29%) on preprocedural angiography. The median duration of operation was 39/86.5 minutes, and complete recanalization could be achieved in 15/34 (94/71%). The outcome was favorable in 10/11 (63/23%).

Conclusion: In the R-SS-BGC group, the percentages of patients with patent ipsilateral A1 and M1 were high, and the percentages of those with patent ipsilateral PcomA and OphA were low.

Objective: While the effectiveness of thrombectomy for anterior circulation proximal intracranial arterial occlusions has been established, there is no solid evidence concerning its therapeutic effect on acute ischemic stroke due to middle cerebral artery M2 occlusion. In this study, we evaluated the efficacy and safety of a direct aspiration first pass technique (ADAPT) using the Penumbra 4MAX aspiration catheters (4MAX; Medico’s Hirata Inc., Osaka, Japan) for M2 occlusion.

Methods: Of the 17 patients with acute ischemic stroke who underwent thrombectomy for M2 occlusion between January 2016 and December 2017 at our institution, 12 patients in whom ADAPT using the 4MAX was performed as the first-line procedure were evaluated. The stent retriever (SR) was used concomitantly in patients in whom recanalization could not be achieved by ADAPT using the 4MAX only. The retrospective evaluation was performed according to effective recanalization (thrombolysis in cerebral infarction [TICI] scale 2b-3) and independence in daily activities (modified Rankin Scale [mRS] score 0-2 after 3 months) as the efficacy endpoints and symptomatic intracranial hemorrhage as a safety endpoint.

Results: The median age of the 12 subjects was 77 (interquartile range [IQR] 69–80) years, 9 (75.0%) were males, and the median preprocedural National Institutes of Health Stroke Scale (NIHSS) score was 19.5 (IQR: 16–24.5). The 4MAX reached the clot in 11 (91.7%), and effective recanalization was obtained by ADAPT alone in 8 (66.7%). Effective recanalization was achieved in 11 (91.7%) at the end of all procedures, the outcome was favorable in 8 (66.7%), and no symptomatic intracranial hemorrhage was observed.

Conclusion: In M2 occluded region, a high recanalization rate could be achieved by ADAPT using the 4MAX without causing symptomatic intracranial hemorrhage, and the results suggested high efficacy and safety of the technique.

Objective: We report a patient in whom thrombectomy for occlusion of the middle cerebral artery was performed, and a pial arteriovenous fistula (AVF) developed in the relevant vascular area.

Case Presentation: The patient was a 72-year-old male. In 2011, thrombectomy with a Penumbra system for right M1 occlusion causing right cerebral infarction was performed. Recanalization was achieved (modified thrombolysis in cerebral infarction [TICI] 2b) although occlusion of the M2 anterior trunk remained. After 1 week, MRA confirmed complete recanalization. The course was favorable, and he was discharged. After 5 years, convulsion occurred, and he was brought to our hospital by ambulance. MRI showed subcortical hemorrhage of the right precentral gyrus. DSA confirmed an arteriovenous (AV) shunt between the right central artery and vein of Trolard, which had not been present. There was no nidus, leading to a diagnosis of a pial AVF. Under craniotomy, the shunt point was disconnected.

Conclusion: Intraoperative findings suggested the involvement of cortical vein thrombosis after thrombectomy in the etiology.

Objective: Pseudoaneurysms of the internal carotid artery (ICA) and sphenopalatine artery (SPA) are recognized as sources of arterial epistaxis following head and face trauma. However, epistaxis involving pseudoaneurysm of the anterior ethmoidal artery (AEA) is extremely rare.

Case Presentation: A 25-year-old man experienced massive epistaxis due to a ruptured traumatic pseudoaneurysm of the AEA. The patient had suffered head and face trauma in a car accident. CT showed fractures of the frontal, ethmoidal, and maxillary bones, and he was managed conservatively. Nine days after the injury, he had sudden, massive epistaxis. Angiography showed a right AEA aneurysm, which was treated successfully with transarterial embolization using n-butyl-2-cyanoacrylate (NBCA).

Conclusion: Although pseudoaneurysm of the AEA is a rare cause of epistaxis, it is important to consider this diagnosis, in addition to pseudoaneurysm of the SPA and ICA, when a patient has massive arterial epistaxis following a traumatic skull base fracture, especially if the fracture is adjacent to the ethmoid sinus. Transarterial embolization using glue is a feasible therapeutic option for this condition.

Objective: In patients with infectious endocarditis requiring cardiac surgery, the presence of unruptured infectious intracranial aneurysms is an important issue. We report a patient in whom endovascular treatment for an unruptured infectious intracranial aneurysm was performed prior to cardiac surgery.

Case Presentation: A 20-year-old woman was admitted with infectious endocarditis. During the assessment, a cerebellar abscess was noted and drainage was conducted. An infectious intracranial aneurysm was observed in the posterior cerebral artery and treatment with an antimicrobial drug was continued. Due to severe heart failure, cardiac surgery was required, but there was a slight increase in the aneurysmal size. Intra-aneurysmal embolization was performed while preserving the parent artery. Subsequently, valve plasty was conducted. The patient was discharged.

Conclusion: If cardiac surgery is necessary, the treatment of infectious intracranial aneurysms should be performed in advance. If the heart failure is severe, endovascular treatment, which does not influence hemodynamics, may be useful.

Objective: We report a patient with hyperperfusion-related cerebral hemorrhage after neuroendovascular treatment for symptomatic vertebral artery stenosis.

Case Presentation: The patient was a 75-year-old male, who presented with repeated attacks of vertigo. He was diagnosed with vertebral-basilar insufficiency. Subsequently, medical treatment involving the administration of an antiplatelet drug was performed, but brainstem infarction developed. Cerebral angiography showed occlusion of the left vertebral artery and stenosis at the origin and intracranial area of the right vertebral artery. Cerebral blood flow scintigraphy revealed a reduction in cerebellar blood flow as well as the site of infarction. The patient was considered to be resistant to medical treatment, and angioplasty was performed at two stenotic sites of the left vertebral artery. Despite strict blood pressure control, brainstem hemorrhage occurred 4 hours after surgery. The postoperative cerebral blood flow scintigraphy findings suggested hyperperfusion-related hemorrhage.

Conclusion: For endovascular treatment of vertebral artery stenosis with cerebral blood flow failure, postoperative hyperperfusion-related cerebral hemorrhage may not be prevented by blood pressure control alone. Therapeutic strategies, such as a staged angioplasty, should be established based on cerebral blood flow examination findings.

Objective: We here report the methods for and efficacy of C-arm cone-beam CT (CBCT) with diluted contrast medium during the recanalization therapy in acute ischemic stroke patients with middle cerebral artery occlusion.

Case Presentation: The subjects were 30 patients who underwent recanalization therapy for acute ischemic stroke with occlusion of the middle cerebral artery at our hospital between January 2015 and December 2016. Utilizing leptomeningeal anastomosis (LMA), 20-second CBCT with fourfold diluted contrast medium was performed, and 3D image processing was subsequently conducted. In 25 (83.3%) of the 30 patients, a blood vessel distal to the site of occlusion and the extent of thrombus were favorably visualized.

Conclusion: This procedure may be useful as an auxiliary examination that provides more detailed information to safely perform recanalization therapy for acute occlusion of the middle cerebral artery through the visualization of a blood vessel distal to the site of the occlusion.