Objective: The purpose of this study was to investigate the characteristics, time-line, and treatment results of in-hospital acute ischemic stroke due to large vessel occlusion (LVO) treated by mechanical thrombectomy.

Methods: The authors investigated 10 patients (six males and four females; mean age 78.6 years, range 65–92) with in-hospital LVO treated by thrombectomy between January 2016 and July 2018 in our institute. Patient characteristics, procedural results, clinical outcome, and time-line data of thrombectomy (last well known [LWK]/onset, recognition, arterial puncture, and recanalization) were retrospectively evaluated. Results obtained from in-hospital LVO were compared with those from 13 patients with community-onset LVO (eight males and five females; mean age 78.3 years, range 45–87).

Results: The initial admitting departments of in-hospital LVO were cardiology in six (60%) and hematology, otolaryngology, urology, and gastroenterology in one each (10%). The etiologies of ischemic stroke were cardioembolism in eight (80%), thrombosis in one (10%), and iatrogenic consequence in one (10%). The comorbid disease of in-hospital LVO included cardiac disease in eight (80%) and malignant tumor in four (40%) with overlapping. The factor contributing to in-hospital LVO was invasive procedure with withdrawal of antithrombotic agents in three (30%). The interval between LWK and recognition was a median of 60 minutes in in-hospital LVO, which was shorter than LWK-to-arrival time in community-onset LVO (medial 225 minutes). The interval between recognition and consultation to the neuroendovascular team was a median of 50 minutes. The recognition-to-puncture time was compared with arrival-to-puncture time in community-onset LVO. That presented no difference between them (median 130 vs 150 minutes). The LWK-to-recanalization time in in-hospital LVO was shorter than that in community-onset LVO (median 240 vs 495 minutes). The procedural results of thrombectomy demonstrated no differences between them. The rate of thrombolysis in cerebral infarction (TICI) 2b-3 was 70% in in-hospital vs 85% in community-onset LVO. The rate of favorable outcome (modified Rankin Scale [mRS] 0-2) at discharge was not different (30% vs 23%); however, higher rates of mortality and severe disability (mRS 5-6) were observed in patients with in-hospital LVO compared to those with community-onset LVO (40% vs 15%).

Conclusion: In this series, the procedural results of thrombectomy were not different between in-hospital and community-onset LVO. The recognition-to-puncture time in in-hospital LVO was similar to the arrival-to-puncture time in community-onset LVO, although the LWK-to-recognition/recanalization time in in-hospital LVO was shorter compared with the LWK-to-arrival/recanalization-time in community-onset LVO. The rate of clinical favorable outcome was similar, although a higher rate of poor outcome was observed in in-hospital LVO. Comorbid diseases may be associated with poor outcome in in-hospital ischemic stroke due to LVO.

Objective: The authors report a rare case of symptomatic unruptured fusiform vertebral artery (VA) aneurysm causing hemifacial spasm, which was successfully treated by endovascular parent artery occlusion (PAO).

Case Presentation: A 56-year-old man presented with left hemifacial spasm, and the symptom progressed rapidly over 3–4 weeks including difficulty of eye opening. Brain MRI showed a left fusiform VA aneurysm with a maximum diameter of approximately 10 mm, which compressed the root exit zone (REZ) of the left facial nerve. Endovascular PAO of the left VA was performed with coils. The hemifacial spasm disappeared immediately after PAO. The size of the aneurysm was markedly reduced on MRI on the next day. No recurrence of the hemifacial spasm and aneurysm was observed after half a year after PAO.

Conclusion: This rare case suggested that endovascular PAO may be an effective treatment for hemifacial spasm caused by a relatively large aneurysm.

Objective: We encountered the case of re-occlusion occurred within a short time after thrombectomy to the patient with acute cerebral embolism complicated by protein C deficiency. We have reported this case as its clinical presentation is rare and important for considering a treatment strategy for young adult-onset cerebral embolism in the future.

Case Presentation: A 34-year-old male developed dysarthria, aphasia, and right hemiparesis and was diagnosed with cerebral infarction caused by left M1 occlusion. Mechanical thrombectomy was performed and achieved recanalization, but the same region was re-occluded after 7 hours and thrombectomy was repeated. The patient was diagnosed with protein C deficiency based on the blood test findings. Re-occlusion was considered due to epithelial damage by a stent retriever and a hypercoagulable state induced by protein C deficiency.

Conclusion: Since young adult-onset cerebral embolism may be complicated by underlying disease, such as coagulopathy like this patient, the possibility of re-obstruction induced by epithelial damage should be considered.

Objective: We report a 73-year-old male in whom a traumatic pseudoaneurysm of the middle meningeal artery (PMMA) increased during conservative treatment for traumatic subarachnoid hemorrhage, an acute subdural hematoma, and brain contusion, leading to intracerebral hemorrhage related to its rupture.

Case Presentation: During decommissioning operations, he fell down from the bed of a truck, and was brought to our hospital by ambulance. Head CT revealed traumatic subarachnoid hemorrhage, left acute subdural hematoma, and brain contusion. Conservative treatment was performed. Left temporal lobe hemorrhage related to the rupture of a traumatic pseudoaneurysm of the left middle meningeal artery (MMA) was observed 20 days after onset. Emergency endovascular treatment and hematoma removal under craniotomy were conducted.

Conclusion: In cases of subarachnoid hemorrhage after head trauma, serial changes should be assessed using CTA and DSA, considering the possibility of a traumatic PMMA.

Objective: The clinical course of extracranial internal carotid artery dissection (eICAD) treated with medical therapy alone is usually benign, but late embolism may cause intracranial large artery occlusion (iLAO). We report a new procedure to treat iLAO caused by eICAD.

Case Presentation: A 47-year-old man patient presented with two episodes of transient right hemiparesis and mild neck pain. An emergent MRI detected a left internal carotid artery (ICA) occlusion but no new infarction. Because it was strongly suspected that eICAD was the cause, medical therapy was started, and the patient’s neurological condition was frequently checked to ensure prompt response if a late embolism developed. One day after onset, a follow-up MRI revealed recanalization of the ICA occlusion and eICAD without a new infarction. Unfortunately, a late embolism of the left middle cerebral artery occurred 2 days after onset. We started intravenous tissue plasminogen activator administration immediately after a CT scan. We performed a mechanical thrombectomy (MT), resulting in thrombolysis in cerebral infarction (TICI) score of 3. Subsequently, we performed carotid artery stenting (CAS) for eICAD. Ten days after the stroke, the patient’s National Institutes of Health Stroke Scale (NIHSS) score was 2.

Conclusion: When treating iLAO due to eICAD by MT and CAS, further vascular injury and intracranial embolism must be prevented. We used proximal and distal protection in combination, employing an aspiration catheter to withdraw the stent retriever and deliver a distal embolic protection device before CAS. As a result, the patient’s condition improved.

Objective: Transarterial embolization (TAE) for dural arteriovenous fistula (dAVF) is sometimes risky because of dangerous anastomosis. We successfully treated orbital apex dAVF by blocking back-flow to the internal carotid artery and ophthalmic artery with coil and balloon.

Case Presentation: A 51-year-old man had red right eye and exophthalmos, and was diagnosed with right orbital apex dAVF. TAE using n-butyl-2-cyanoacrylate (NBCA)/lipiodol mixture via the artery of the superior orbital fissure was performed under flow control of the internal carotid artery and ophthalmic artery with balloon microcatheter and temporary placing of detachable coil. After the treatment, the shunt disappeared and the symptoms were improved.

Conclusion: A proper understanding of dangerous anastomosis is important for safe and effective use of TAE for dAVF.