Objective: To establish a strategy for addressing recanalization of intracranial aneurysms previously embolized with Guglielmi detachable coils (GDC), efficacy and safety of additional treatments was evaluated.
Methods: A total of 168 patients with acute ruptured intracranial aneurysms were subjected to GDC embolization. Follow-up angiograms were obtained 6 months, and 1 and 2 years post-embolization. Patients with major recanalization that had not disappeared at 1 year after the first embolization underwent retreatment.
Results: Of the 168 patients, 18 (10.7%) underwent additional treatment, with 14 receiving a second coil embolization and 2 undergoing a total of 3 or more additional embolization procedures. One patient died after the 4th coil embolization. Both of the other 2 patients undergoing 3 or more embolization procedures required surgery, with it very difficult to achieve complete occlusion of the residual neck in one of them.
Conclusions: Additional treatment of previously coil-embolized aneurysms is safe. The strategy of retreating patients with angiographically confirmed major recanalization at 1-year follow-up is appropriate.

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Background: There are few reports specifically evaluating endovascular surgery (endosaccular coil embolization) for acutely ruptured anterior communicating artery (ACoA) aneurysms. The objectives of this study were to evaluate the feasibility, safety, and efficacy of endovascular surgery in this setting.
Methods: Incidents of endovascular surgery for acutely ruptured ACoA aneurysms were retrospectively reviewed from medical records to evaluate technical results, clinical outcomes and angiographic images. The clinical outcomes were recorded at discharge or transfer to other hospitals according to the Glasgow Outcome Scale. Immediate and follow-up angiographic results were categorized as complete occlusion (CO), residual neck (RN) or residual flow (RF). Failure of coil placement within the aneurysm after placing the guiding catheter was defined as attempted embolization. Angiographic changes during the follow-up period were categorized as: unchanged, minor recurrence, major recurrence, and progressive thrombosis.
Results: Between August 2002 and June 2007, 82 patients with ruptured ACoA aneurysms were treated by endovascular surgery within 72 hours of the primary rupture. There were 49 females (59.8%) and mean age was 59.1 ± 12.3 years. The clinical outcomes of 77 endovascularly treated patients were good recovery and moderate disability in 68 (88.3%), severe disability/persistent vegetative state or dead in 9 (11.7%). Immediate angiographic outcomes demonstrated CO in 61 (74.4%), NR in 6 (7.3%) and RF in 10 (12.2%) patients. Attempted embolization occurred in 5 aneurysms (6.1%). Follow-up angiography (>3 months) was available for 56 patients and found to be unchanged in 32 (57.1%), minor recurrence in 14 (25%), major recurrence in 7 (12.5%), and progressive thrombosis in 3 (5.4%). Five aneurysms required 6 sessions of additional coil embolization due to a major recurrence. No patient that completed coil placement rebled from the treated aneurysm during the clinical follow-up period (mean, 16.8 mo). There were three procedural-related complications, all of which were intraoprative aneurysm ruptures (4.4%). One of them resulted in mortality, and the remaining 2 patients were asymptomatic.
Conclusion: Endovascular surgery for acutely ruptured ACoA aneurysms can be performed with excellent clinical results and promises a decreasing risk of future aneurysmal bleeding. We believe that this modality can become a primary alternative to surgical clipping.

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Objectives: To identify preoperative risk factors for development of postoperative cerebral hyperperfusion syndrome (CHS).
Methods: 103 consecutive patients that underwent a revascularization procedure (CAS, n=52; CEA, n=51) from January 1998 to October 2006 in our department were analyzed.
Results: The incidence of CHS was 6.8%. On multivariate analysis, Type III cerebral blood flow (CBF) in the middle cerebral artery (MCA) territory and crescendo transient ischemic attacks/ fluctuating minor stroke (cTIAs/ fMS) were significant risk factors for postoperative CHS. The incidence of CHS was 0% in cases with no risk factors (Grade 0), 15% in cases with one risk factor (Grade I), and 80% in cases with two risk factors (Grade II); with a statistically significant difference in incidence of CHS between grades.
Conclusion: These findings suggest that type III CBF in the MCA territory and cTIAs /fMS are risk factors for postoperative CHS. The incidence of CHS increases according to the number of risk factors.

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Objective: Initial clinical experience with mechanical disruption of clots is reported using a specially modified microguidewire to treat acute ischemic stroke. This strategy was adopted to increase the recanalization rate without increasing risk of intracerebral hemorrhage.
Methods: The coil spring of the wire tip was manually uncoiled for indentation and manipulated to grind the clots in the occluded artery.
Results: Immediate and complete recanalization was achieved in all 5 patients with acute thromboembolic occlusion of the M2 or more peripheral segment of the middle cerebral artery. No vessel injury or intracranial hemorrhage was observed. All patients recovered to a modified Rankin scale score of 0 or 1.
Conclusion: Mechanical clot disruption for acute M2 or more distal occlusion using the specially modified microguidewire is a potentially useful treatment with a high rate of vessel recanalization and clinical improvement. This strategy may reduce the risk of hemorrhagic complication observed with thrombolytic therapy. Further examination and device refinement are encouraged.

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Purpose: We report a case of cavernous dural arteriovenous fistulas (dAVFs) completely occluded by transarterial embolization with n-butyl cyanoacrylate (NBCA) as the embolic agent and using balloon assisted technique.
Case: A 37-year-old woman presented with right conjunctival injection, proptosis and diplopia. She was initially treated with right carotid compression without improvement of symptoms. Two weeks prior to admission to our institution, she experienced acute worsening of the symptoms. Her right intraocular pressure was 31mmHg on admission. MRI showed right cavernous dAVFs. Angiographic study showed dAVFs to the right anterior inferior cavernous sinus supplied by the branches of the right internal and external carotid arteries. Endovascular treatment was performed by a bi-femoral approach. A microballoon catheter was placed in the right internal carotid artery across the cavernous segment. A microcatheter was wedged into the carotid branch of the ascending pharyngeal artery. Under balloon inflation to close the origin of the C4 feeder to the fistulas, 0.7cc of 25% NBCA mixed with ethiodol was injected from the wedged microcatheter, resulting in complete occlusion of the fistulas. The patient showed immediate improvement of the symptoms and her right intraocular pressure was normal one week after treatment.
Conclusion: Trans-arterial embolization may be the best treatment option for selected cases of cavernous dAVFs. Balloon protection of the internal carotid artery may be necessary for aggressive trans-arterial embolization to prevent NBCA migration into the cerebral circulation through the anastomosis between the external and internal carotid arteries.

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Objective: Oculocardiac reflex sometimes occurs as a result of pressure on the eye or traction of the intraorbital surrounding structures during ophthalmic surgery. This can result in bradycardic arrhythmia and cardiac arrest. A case of oculocardiac reflex due to catheterization for an anterior cranial fossa dural arteriovenous fistula (DAVF) is reported.
Case Report: A 45-year-old man was incidentally diagnosed with an anterior cranial fossa DAVF by magnetic resonance angiogram. Bilateral carotid angiograms revealed the DAVF was supplied by bilateral anterior ethmoidal arteries. An attempt was made at transarterial embolization using a liquid embolic material. The DAVF was mainly supplied by the left anterior ethmoidal artery, however tortuosity of its arterial origin prevented catheterization with a microcatheter. Therefore catheterization was attempted using the right ophthalmic artery. The microcatheter was advanced to an area more distal in the third segment of the right ophthalmic artery to avoid ophthalmic complications. When the microcatheter had been advanced as distally as possible to be close to the shunt point of the DAVF, the patient's pulse rate gradually decreased and temporary cardiac arrest occurred just after the patient complained of eye pain. Immediately after pulling back the microcatheter, the pulse rate began to gradually increase for about 20 seconds. Ultimately, the attempt at transarterial obliteration of the fistula was abandoned.
Conclusion: To our knowledge, this is the first report describing a patient that developed an oculocardiac reflex as a result of catheterization of the distal ophthalmic artery. Operators attempting catheterization into the distal ophthalmic artery need to be familiar with this phenomenon.

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Objective: There is an ongoing debate as to the proper management of a ruptured vertebral artery dissecting aneurysm (VADA) involving the origin of the posterior inferior cerebellar artery (PICA). This article describes a case of ruptured VADA successfully treated in the acute stage with endovascular intervention.
Clinical Presentation: A 50-year-old male presented with subarachnoid hemorrhage and was admitted to our institution. Preoperative right vertebral angiogram showed a VADA in which the PICA arose from the wall of the aneurysm and a sufficient interval between the rupture point and the origin of PICA. The aneurysm was treated on the day of rupture while preserving the origin of PICA with limited internal trapping of the vertebral artery at the rupture point and entry into the pseudolumen (partial trapping). Postoperative MR angiography demonstrated rapid shrinkage and almost complete disappearance of the residual aneurysm within 2 months while maintaining the patency of PICA. The patient recovered completely without any episodes of recurrent hemorrhage.
Conclusion: Partial trapping preserving the origin of PICA offers potential as a treatment for this complex lesion in a select group of patients.

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Purpose: Internal carotid artery (ICA) pseudo-aneurysm is a rare complication after trans-sphenoidal surgery (TSS) for pituitary adenoma. A patient with ICA pseudo-aneurysm treated by endosaccular coil embolization assisted by stenting is reported.
Case presentation: A 68-year-old man presented with pituitary adenoma and bilateral hemianopsia. Cerebral angiograms showed a broad neck aneurysm arising from the C4 portion of the right ICA. The diagnosis was a post-traumatic pseudo-aneurysm that developed 12 years after TSS. It was treated via the endovascular approach, using a stent to preserve the ICA flow and coil embolization. Post-embolization angiograms showed complete occlusion of the aneurysm and preservation of the parent artery.
Conclusion: Endosaccular coil embolization assisted by stenting was found to be a suitable alternative treatment for traumatic pseudo-aneurysm.

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Objective and importance: Spinal arteriovenous metameric syndrome (SAMS) is a complex of vascular malformations involving the skin, paraspinal soft tissue, spine, and spinal cord in the same metamere. Treatment of this condition is often difficult due to the extent of the lesion. We report a case of successful palliative management of SAMS presenting predominantly with radiculopathy.
Clinical presentation: A 19-year-old male patient presented with weakness and hypesthesia of the right upper extremity, plus spasticity of the right lower extremity. Workup imaging studies indicated C2 to C5 spinal cord arteriovenous malformation (AVM) and paraspinal arteriovenous fistula (AVF) with destruction of C2 and C3 vertebrae.
Intervention: Due to the extensive nature of the AVF/AVM, the goal of treatment was to neurologically stabilize the patient using endovascular embolization. After the first embolization with N-butyl cyanoacrylate, the patient made immediate neurological recovery to normal. Recurrence of the same symptoms 4 months after the first embolization prompted an additional 3 procedures over the next 3 months. The patient remained neurologically normal after the second procedure. Follow-up CT at 27 months after the initial procedure demonstrated osseous formation of the vertebral body at the embolized level, as well as progressive destruction at the untreated level. Therefore, the patient underwent another embolization with Onyx and is currently undergoing close follow-up.
Conclusion: Although cure of SAMS is difficult, improvement of neurological symptoms can be achieved with targeted endovascular embolization. Ossification and possible prevention of destruction of vertebral bodies can be realized by embolizing intraosseous lesions. Close follow-up is necessary to detect neurological and radiographical progression of the condition.

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Purpose: Development of a novel interventional approach for treatment of a fusiform brachiocephalic artery aneurysm in a patient for whom direct surgery could not be performed due to a systemic complication.
Methods: As the distal side of the aneurysm involved both the common carotid and subclavian arteries, a combination of parallel stenting and coil embolization was used to avoid disturbing the blood flow in each artery.
Result: Successful endovascular obliteration of the aneurysm was achieved with preservation of the common carotid and subclavian arteries without any ischemic complications.
Conclusion: To our knowledge, this is the first report describing combined use of coil embolization and parallel stenting for treatment of a fusiform brachiocephalic artery aneurysm. This therapeutic approach is an excellent alternative that should be considered as a treatment option for this type of aneurysm.

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Objective: A rare case of cerebral infarction associated with a mobile plaque in a patient with essential thrombocythemia is reported.
Case: A 49-year-old male presented with right hemiparesis and acalculia. He was diagnosed as having essential thrombocythemia by hematological examination. Diffusion-weighted MRI demonstrated acute cerebral infarction in the border zones between territories of the anterior and middle cerebral arteries, plus the middle and posterior cerebral arteries. Carotid ultrasonography performed on the 4th day of hospitalization showed a mobile plaque in the left common carotid artery. The mechanism of cerebral infarction was diagnosed as artery to artery embolism from the mobile carotid plaque, with essential thrombocythemia.
Results: Treatment included antiplatelet and anticoagulant drugs, as well as hydroxyurea. The plaque was no longer present after treatment, with no recurrence of embolic events.
Conclusion: To our knowledge, this is the first report of cerebral infarction due to a mobile carotid plaque in a patient with essential thrombocythemia.

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