Vascular malformations of the brain and its coverings encompass several different vascular pathologies of the brain and its coverings, which substantially differ in morphology, clinical presentation, and prognosis, reaching from incidental, asymptomatic vascular abnormalities to life-threatening diseases with high risks of morbidity, most frequently caused by intracranial hemorrhage. In this article, the most common vascular malformations of the brain with and without arteriovenous shunting of blood (e.g., arteriovenous malformations [AVMs], dural arteriovenous fistulas [DAVFs], and cavernous malformations) are explained with a focus on definition, diagnosis, classification, and management.

Objective: Multiple randomized trials have demonstrated the efficacy of mechanical thrombectomy (MT), but very elderly patients aged ≥90 years were excluded. It remains uncertain whether endovascular therapy is effective for nonagenarians. The objective of this study was to investigate the effectiveness and safety of MT in nonagenarians.

Methods: Between January 2016 and March 2019, acute ischemic stroke patients aged ≥80 years who underwent MT at our hospital were retrospectively reviewed. Patients with a baseline pre-stroke modified Rankin Scale (mRS) score ≥3 were excluded from the analysis. They were divided into octogenarians (80–89 years old) and nonagenarians (90–99 years old).

Results: Forty-five patients met the inclusion criteria, including 34 octogenarians and 11 nonagenarians. Nonagenarians were more likely to be female (47.0% vs 90.9%; p <0.05). There was a significantly lower rate of a pre-stroke mRS score of 0–1 among the nonagenarians (91.1% vs 63.6%; p <0.05). Revascularization was successful in 71.0% and 81.8% (p = 0.46) of octogenarians and nonagenarians, respectively. Functional independence (mRS ≤2) at discharge was observed in 26.4% vs 27.2% (p = 0.95) of octogenarians and nonagenarians, respectively.

Conclusion: MT in nonagenarians can be considered safe without increasing hemorrhagic complications in comparison with that in octogenarians. One in four patients may have a good outcome and obtain effects equivalent to those in octogenarians if they have a good pre-stroke functional status.

Objective: There are few papers regarding repeat mechanical thrombectomy or thrombectomy for Trousseau’s related stroke. We present a unique case of repeat thrombectomy due to Trousseau’s syndrome affecting the same vessel in a patient with metastatic cancer.

Case Presentation: A 47-year-old male presented with a full left middle cerebral artery syndrome and a National Institute of Health Stroke Scale of 17, despite regular apixaban use. He underwent mechanical thrombectomy successfully but developed recurrent symptoms on postoperative day (POD) 6 while on warfarin. He underwent two additional thrombectomies, the final one requiring glycoprotein IIa/IIIb inhibitor for emergent implantation of intracranial stent. Successful recanalization (thrombolysis in cerebral infarction 2b) was achieved, and the patient was discharged home on dual antiplatelet therapy and enoxaparin on POD 10 after last thrombectomy, ambulatory and independent in his activities of daily living. The patient expired as a result of his metastatic disease 109 days after the third procedure and was ambulatory for 91 of those days.

Conclusion: This case illustrates the palliative aspects of mechanical thrombectomy and the complexities of anticoagulation management in patients with the metastatic disease Trousseau’s syndrome.

Objective: We report a case of acute occlusion of the vertebral artery and radial artery. We performed mechanical thrombectomy for the radial artery following mechanical thrombectomy for the vertebral artery.

Case Presentation: A 73-year-old woman developed sudden-onset dizziness and dysesthesia of the left finger, and was taken to our hospital. Atrial fibrillation was observed. Image inspection revealed acute cerebral infarction of the left lateral medulla and left cerebellar hemisphere, and occlusion of the vertebral and radial arteries. Mechanical thrombectomy for the left vertebral artery occlusion was performed after intravenous recombinant tissue plasminogen activator (rt-PA), and then mechanical thrombectomy was performed for the left radial artery occlusion.

Conclusion: This case suggests that it is possible to guide the system to the radial artery and to perform thrombectomy using existing intracranial endovascular treatment devices.

Objective: We report a case of acute cerebral infarction that may have been associated with high-energy trauma due to onset while driving.

Case Presentation: A 67-year-old man had a traffic accident. His neurological symptoms were left hemiplegia and contrast CT revealed right middle cerebral artery occlusion. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and intravascular treatment were performed. Right carotid artery angiography demonstrated internal carotid artery stenosis. Middle cerebral artery (MCA) revascularization was performed only by percutaneous transluminal angioplasty (PTA) of the internal carotid artery. Thoracic hemorrhage was observed a few hours after surgery, and hemostasis was performed by thoracotomy. Carotid artery stenting (CAS) was performed 8 days after onset. The patient was transferred to a convalescent rehabilitation hospital.

Conclusion: Rt-PA and acute CAS were not recommended for cerebral infarction due to traffic accident.

Objective: We report a case of intracerebral hemorrhage following emergency transvenous embolization for an acute symptomatic non-hemorrhagic dural arteriovenous fistula (dAVF).

Case Presentation: An 83-year-old woman demonstrated gait disorder and disturbance of consciousness. A transverse-sigmoid dAVF with retrograde deep venous drainage was detected on DSA. The left sigmoid sinus-jugular vein and the sinus confluence were occluded and the dAVF drains via the straight sinus (SS), medial superior cerebral veins and deep veins to the superior sagittal sinus (SSS). The dAVF was emergently treated by sinus packing of the transverse-sigmoid sinus with coils with contralateral approach via the occluded sinus confluence. Although the dAVF was markedly regressed, massive cerebral hemorrhage developed in the left parietal lobe immediately after embolization.

Conclusion: Although early treatment is required for dAVFs with aggressive symptoms, precious evaluation of their hemodynamics, particularly for drainage pattern, is mandatory to avoid a serious complication.

Background: During carotid artery stenting (CAS), retrieval of the distal umbrella portion of the anti-embolic device (AED) could be difficult. Herein, we report a case of left CAS managed with balloon angioplasty and stent placement with successful retrieval of the umbrella portion of the AED using the balloon bridge technique after failure of retrieval with the standard technique.

Case Presentation: After successful revascularization of the asymptomatic severe carotid bulb stenosis in a 62-year-old woman, we could not pass the re-sheathing catheter over the deployed stent because of the ledge effect between the guidewire of the AED and the stent mesh. However, using the balloon bridge technique, which helped minimize the ledge effect, we could advance the guiding catheter beyond the stented segment over the partially inflated balloon. The umbrella portion of the AED could be easily retrieved through the guiding catheter without complications.

Conclusion: During CAS, the balloon bridge technique could be used to retrieve the AED after failure of retrieval with the standard techniques.

Objective: Carotid artery stenting (CAS) and carotid endarterectomy are relatively difficult for proximal common carotid artery (CCA) stenosis because of the difficulty in anatomical approach. We treated proximal CCA stenosis by retrograde stenting using a 9Fr Optimo for peripheral intervention with a sheathless method.

Case Presentation: A 60-year-old woman was scheduled for total arch replacement (TAR) for an aortic arch aneurysm. Preoperative cervical MRI incidentally revealed tandem stenosis in the left CCA. We intended to treat CCA stenosis prior to aortic arch replacement. Under general anesthesia, distal left CCA was exposed. A 9Fr Optimo was introduced into CCA by retrograde with a sheathless method. The retrograde CAS was performed under distal balloon protection. Her postoperative course was uneventful.

Conclusion: Retrograde stenting using a 9Fr Optimo for peripheral intervention with a sheathless method was safe and useful for proximal CCA stenosis.