Objective: It is important to guarantee intra-aneurysmal stability of microcatheters during coil embolization. We developed a simple and reproducible microcatheter shaping method for medially-directed paraclinoid internal carotid artery aneurysms.

Methods: An injection needle cap was used to make a smooth curve on the mandrel, which was first wound around the back end of the cap to create a primary curve. Next, a secondary curve was created using near the tip of the cap. Thus, a two-dimensional (2D), pigtail-shaped mandrel with a two-stage curve was created. The pigtail-shaped mandrel was inserted from the tip of a straight microcatheter and heat-shaped using a heat gun. Lastly, a microcatheter having a curve whose tip was approximately 6 mm longer than that of the preshaped J was created. We evaluated the ease of navigating the microcatheter into the aneurysm and its stability during coil embolization.

Results: In all, 34 consecutive medially-directed paraclinoid internal carotid artery aneurysms were treated using the shaped catheters. It took 50–300 seconds (intermediate value: 90 seconds) from inserting the microcatheter with a microguide wire to navigate and place it into an aneurysm. There were no cases that required reshaping of the microcatheters during navigation into the aneurysm. There were no cases that resulted in kickback of the microcatheters from the aneurysm during coil placement, and microcatheter stability was good until the end of the procedure. In all, 12 cases required the balloon-assisted technique and three cases required stent-assisted coiling. The angiographic outcomes immediately after embolization were as follows: 25 cases (73.5%) with complete occlusion; 3 cases (8.8%) with dome filling; and 6 cases (17.6%) with a neck remnant. There were no perioperative complications.

Conclusion: The shaping method with a pigtail-shaped mandrel using an injection needle cap is simple and reproducible, and is useful for medially-directed paraclinoid internal carotid artery aneurysms.

Objective: We retrospectively analyzed the current status of treatment for anterior circulation large vessel occlusion (LVO) in island areas with a high population aging rate.

Methods: We investigated 62 consecutive patients with ischemic stroke due to acute anterior circulation LVO between October 1, 2017 and June 30, 2019.

Results: In all, 26 (41.1%) patients underwent endovascular treatment (EVT). The successful recanalization rate of EVT was 88.5% (23/26). There was a significant difference in the age (median, 75.5 years vs. 81 years, respectively, P = 0.0411) and the rate of intravenous tissue plasminogen activator (tPA) therapy (53.5% vs. 11.1%, respectively, P <0.001) between the EVT group and the non-EVT group. Patients in the EVT group achieved a favorable outcome more frequently than those in the non-EVT group (50% vs. 11.1%, respectively, P = 0.0012). In the analysis based on the place of onset among the three cities comprising Awaji Island and the four groups with in-hospital onset, there was no significant difference in the rate of EVT, and the outcome of the in-hospital onset group was poor. Among the EVT group, there was a significant difference in the pre-treatment National Institutes of Health Stroke Scale score (median, 15 vs. 19, respectively, P = 0.0237) and time from onset to recanalization (O2R; median, 240 min vs. 323 min, respectively, P = 0.0128) between the favorable outcome group and the unfavorable outcome group.

Conclusion: Even in an island area, it is possible to complete the treatment of ischemic stroke due to LVO within the regional medical area.

Objective: We investigated in-hospital stroke (IHS) treated by mechanical thrombectomy in comparison with out-of-hospital stroke (OHS) to clarify the points of concern in IHS at our institution.

Methods: Between September 2015 and June 2018, 19 patients with IHS who underwent mechanical thrombectomy (IHS group) were enrolled, and compared with 154 patients with OHS (OHS group) regarding patient characteristics, technical results, and outcome. In this study, we set the detection time in the IHS group as patient arrival time, termed “Door” in the OHS group.

Results: Cardiology and gastroenterology were the two main admitting departments, including four (21%) patients of IHS group. In all, 15 (79%) patients had atrial fibrillation; however, less than one-third of them was taking anticoagulant drugs at onset. There were only two cases of direct consultation to the stroke specialists, although IHS onset was mainly recognized by nurses. The median age in the IHS group was 81 (interquartile range (IQR), 76–86.5) versus 80 in the OHS group (IQR, 73–85; p = 0.43), and the median initial National Institutes of Health Stroke Scale score was 21 (IQR, 16–23) versus 21 (IQR, 14–26; p = 0.92), respectively. Sex, Alberta Stroke Program Early CT Score, etiology, and occlusion site did not differ between groups. The rate of use of intravenous tissue plasminogen activator (IV-tPA) was 26% in the IHS group versus 49% in the OHS group (p = 0.065). The median time of detection to imaging, detection to needle for IV-tPA, and detection to puncture were 32, 69, and 87 minutes, respectively, in the IHS group, being significantly longer than those in the OHS group (11, 30, and 50 minutes; p <0.01, p <0.01, and p <0.01, respectively). The median time of puncture to reperfusion was 39 minutes, being significantly shorter than that in the OHS group (82 minutes; p <0.01). Successful reperfusion defined as thrombolysis in cerebral infarction (TICI) 2b-3 was obtained in 94.7% of the IHS group versus 83.1% of the OHS group (p = 0.19). A favorable outcome (modified Rankin Scale score 0–2) at 90 days was achieved by 36.8% (IHS) versus 35.1% (OHS) of patients (p = 0.88). The rate of symptomatic procedural complications was 0% (IHS) versus 7.1% (OHS; p = 0.23). The rate of death at 90 days was 15.8% (IHS) versus 12.3% (OHS; p = 0.67).

Conclusion: The times of detection to imaging and of detection to puncture in the IHS group were longer than those in the OHS group; however, patients in the IHS group had shorter reperfusion. The outcome of the IHS group did not differ from that of OHS group. Our study suggests that the time course of treatment should be improved and rapid stroke pathways involved in consultation with the stroke specialists for IHS should be organized.

Objective: We report two cases of acute proximal anterior circulation occlusion after pulmonary lobectomy.

Case Presentation: Case 1 was a 64-year-old male who presented with occlusion of the right middle cerebral artery (MCA) one day after left lower lobectomy. Case 2 was a 68-year-old male who presented with occlusion of the right internal carotid artery (ICA). In both cases, mechanical thrombectomy was performed for complete recanalization and symptoms were improved.

Conclusion: Prompt mechanical thrombectomy in the acute phase after pulmonary lobectomy improved the prognosis of patients with acute proximal anterior circulation occlusion. It is important to share information about ischemic complications with medical staff engaged in thoracic surgery.

Objective: We report a rare case of symptomatic vertebral and posterior inferior cerebellar arteries (VA-PICA) aneurysm-caused ipsilateral hemifacial spasm (HFS) for which coil embolization of the aneurysm with the assistance of abnormal muscle response (AMR) monitoring was effective.

Case Presentation: A 62-year-old woman presented with left HFS. Magnetic resonance imaging showed a saccular aneurysm of the left VA-PICA which compressed the seventh cranial nerve at its root exit zone (REZ). Stent-assisted coil embolization resulted in intraoperative disappearance of AMR in the intraoperative electrophysiological study and HFS was relieved temporally. One month after endovascular surgery, HFS slightly occurred again with the re-appearance of the AMR, although there was no recurrence of aneurysm. Thereafter, the frequency of her HFS markedly decreased to once per several days 1 year after the coiling.

Conclusion: Although complete disappearance of symptoms was not obtained, it was suggested that coil embolization is one of the therapeutic options for HFS which is caused by aneurysmal compression of REZ and intraoperative AMR is useful for identification of responsible lesions and determination of therapeutic effects.

Objective: The objective of this study was to evaluate the reproducibility of three-dimensional (3D) images of the aortic arch reconstructed using a novel image processing algorithm for non-enhanced computed tomography (CT) images of the cervicothorax and abdomen obtained before emergency endovascular surgery.

Case Presentations: In all, 46 patients who underwent acute mechanical thrombectomy between January and December 2018 were examined. The anatomical variations of the aortic arch were reproduced in all cases; however, the reproduction of the carotid arteries was difficult.

Conclusion: Our novel 3D analysis system enables obtaining information on the aortic arch easily from plain CT data that may be useful in acute endovascular treatment.