Objective: This study evaluated the efficacy of middle meningeal artery (MMA) embolization for organized chronic subdural hematoma (OCSDH).

Methods: Between 2013 and 2017 at our institution, 11 consecutive patients with 14 OCSDH lesions required MMA embolization, accounting for 4.5% of the 314 patients treated for chronic subdural hematoma (CSDH) in this period. Initially, all lesions underwent burr-hole surgery (BHS) under local anesthesia. At the regrowth, BHS was first performed under local anesthesia. OCSDH was diagnosed based on second-operative findings and postoperative CT or magnetic resonance imaging of the brain, and MMA embolization was performed for OCSDH. We investigated the efficacy of MMA embolization in reducing the hematoma and preventing regrowth of OCSDH.

Results: In the second surgery, 12 lesions underwent BHS. Additionally, two lesions were treated with small craniotomy after BHS under local anesthesia. In all lesions, MMA embolization was performed within 3 weeks after the second surgery. In all, 12 lesions improved on brain CT within 2–4 weeks. Two lesions underwent craniotomy and membranectomy under general anesthesia, 2 and 10 days after MMA embolization. In one case, the BHS and small craniotomy were insufficient to reduce the mass effect. In the other case, infectious CSDH was diagnosed at craniotomy.

Conclusions: MMA embolization may be effective additional modality for OCSDH after BHS.

Objective: Distal anterior cerebral artery (DACA) aneurysms are rare, accounting for 1–9% of all intracranial aneurysms. These aneurysms, however, are challenging to treat using surgical clipping and endovascular coiling. Nevertheless, according to recent reports, advances in endovascular therapy devices and technologies have produced better results. We therefore aimed to assess the current status of endovascular treatment of DACA aneurysms.

Methods: Between 2004 and 2017, we treated 47 consecutive patients with 49 DACA aneurysms using endovascular coiling at Juntendo University Hospital and entered them into a database. In this retrospective study, we reviewed the patients’ clinical presentation, radiographic findings, endovascular management, and outcomes. The results were then compared with those in the previous literature for DACA aneurysms that were treated by surgical clipping.

Results: Among the 49 aneurysms, 15 (30.6%) presented with subarachnoid hemorrhage (SAH). Nine cases were lost to follow-up. Among the 15 aneurysms with SAH, 13 became Hunt and Hess grades I–III and 2 were grade IV. Intracerebral or intraventricular hematoma occurred in five patients with ruptured aneurysms. The mean aneurysm dome measured 4.6 mm (range 1.8–10.5 mm), and the mean aneurysm neck was 2.5 mm (range 0.7–5.6 mm). Altogether, 22 of the 49 aneurysms (44.9%) arose from the origin of the callosomarginal artery. After the initial procedure, complete occlusion (CO) and residual neck (RN) were achieved in 63.3% of the cases. Periprocedural complications were minimal, including one intraoperative rupture and two cases in which thromboembolization was happened, although one case of hemorrhage was asymptomatic. There was one death, and five aneurysms required reoperation.

Conclusion: Endovascular coiling to treat DACA aneurysms is useful and can replace surgical clipping. However, the coil’s recanalization rate was higher with the endovascular coil treatment than with surgical clipping, and long-term follow-up is often necessary.

Objective: Dural arteriovenous fistula (DAVF) is classified as sinus type if it occurs in a venous sinus and as non-sinus type if it directly flows into a cortical vein. The latter is considered to have a high risk of hemorrhage because blood flow directly returns to the cerebral vein.

Case Presentation: A 63-year-old man presenting with right hemiparesis and dysarthria was diagnosed with DAVF. We diagnosed transient ischemic attack (TIA) due to left internal carotid artery stenosis or cortical reflux of the DAVF. Treatment of DAVF was undertaken first, followed by carotid artery stenting (CAS) of the internal carotid artery stenosis.

Conclusion: Transarterial embolization (TAE) can be used for the treatment of DAVF located on the wall of the superior sagittal sinus (SSS). Further studies with greater accumulation of case are required.

Objective: We report a case of cerebral infarction with mechanical reperfusion therapy for tumor embolism caused by lung cancer.

Case Presentation: The patient was a 72-year-old man. We performed emergency mechanical thrombectomy alone for acute left internal cerebral artery (ICA) occlusion and achieved complete reperfusion at the fifth pass with Trevo 4 × 20 mm. Pathologically, the embolus was diagnosed as squamous cell carcinoma. In chest contrast CT, lung cancer invaded the left atrium and pulmonary vein, diagnosed as tumor embolism by this invading tumor.

Conclusion: We experienced a very rare case of tumor embolism caused by lung cancer. Although it was difficult to re-canalize, the strut structure of Trevo and push and fluff technique may have been effective against the hard embolus.

Objective: There are few reports of fungal aneurysms developing in the basilar artery where endovascular therapy has been provided. Cerebral infarction was observed before the occurrence of the aneurysm. The aneurysm ruptured repeatedly during treatment. Since the clinical course was complicated, it is reviewed in the literature.

Case Presentation: A 71-year-old female patient receiving chemotherapy was admitted with a chief complaint of fever. On the day of hospitalization, right-sided paralysis appeared. MRI confirmed a pontine infarction. A sudden decrease in the consciousness level was observed on the 7th day of hospitalization. Head CT showed subarachnoid hemorrhage. The formation of a basilar artery aneurysm was confirmed on 3D-CTA. We suspected an infectious aneurysm and treated using coil embolization. This aneurysm ruptured repeatedly during treatment. The patient died on the 28th day of hospitalization. From the cerebrospinal fluid examination and autopsy results, subarachnoid hemorrhage due to ruptured infectious aneurysm caused by Aspergillus was diagnosed.

Conclusion: An endosaccular embolization of an Aspergillus aneurysm caused repeated intraoperative rupture and the prognosis was poor.

Objective: Acute large vessel occlusion is treated with endovascular thrombectomy. We encountered a patient in whom the internal carotid artery (ICA) was injured by direct aspiration through a balloon guide catheter (BGC).

Case Presentation: The patient was an 82-year-old woman being treated with oral warfarin for atrial fibrillation. Endovascular thrombectomy was performed for right ICA occlusion presented with left hemiplegia when direct aspiration was applied through BGC which placed into the right ICA, extravasation was noted on imaging immediately after its application. Hemostasis was acquired by coil embolization, but extensive subarachnoid hemorrhage was noted on postoperative CT and the patient died after 3 days.

Conclusion: The direct aspiration technique through BGC should be carefully performed because it may have a risk of vascular injury.