Objective: We describe a double microcatheter technique for transvenous embolization (TVE) of cavernous sinus dural arterio-venous fistulas (CSdAVFs).
Method: Eleven patients with CSdAVF were treated by TVE. We tried to navigate two microcatheters through the inferior petrosal sinus to the cavernous sinus (CS) and catheterized to the veins which had shown retrograde leptomeningeal venous drainage (RLVD), and the superior ophthalmic vein (SOV). We evaluated success rate of navigation of double microcatheters to the CS, success rate of superselective catheterization to the RLVD and the SOV, and angiographical and clinical cure rates.
Result: We performed 13 sessions of TVE for 11 patients. Two microcatheters were successfully navigated to the CS in 11 of 13 sessions (85%). The microcatheters were successfully catheterized to all of the RLVD and the SOV superselectively. In one case, we were able to transfer one of the two microcatheters to the new RLVD, which appeared during embolization of pre-existing RLVD, and were able to occlude dangerous drainage immediately. Both angiographical and clinical cure rates at the initial treatment were 82%, and final angiographic and clinical cure rates were 100%.
Conclusion: A double microcatheter technique for TVE of CSdAVF is a safe and useful procedure with good angiographical and clinical outcomes.

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Objective: Transvenous embolization using coils is one of the standard treatment options for cavernous sinus dural arteriovenous fistulas (CS dAVFs). However, complete obliteration is not always obtained by transvenous coil embolization alone. We report here three patients treated by transvenous infusion of n-butyl cyanoacrylate (n-BCA), and discuss the technical aspects, safety and efficacy of this technique.
Method: Two patients presented with ocular symptoms and one with intracerebral hemorrhage. Affected CS was accessed via transfemoral-inferior petrosal sinus route in all patients. One patient was treated with transvenous n-BCA infusion alone and two patients with transvenous n-BCA infusion after coil embolization.
Result: Complete obliteration was achieved in two patients, and reduction of the shunt with obliteration of a dangerous drainage in one patient. No complications associated with the procedures were observed in any of the patients.
Conclusion: Transvenous n-BCA infusion is an effective alternative in CS dAVFs refractory to transvenous coil embolization.

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Objectives: We prospectively assessed feasibility and efficacy of carotid artery stenting (CAS) alone or without post-dilatation in patients with severe symptomatic carotid stenosis.
Methods: During a 12 month period, we treated 9 men (mean age 68.1 years) considered to be at high-risk for carotid endarterectomy with symptomatic severe carotid artery stenosis, Carotid echo demonstrated soft plaques in 6 and calcification in 2 patients. We used distal protection throughout the procedures. Of the 9 patients, pre-dilatation with low-pressure using a small sized balloon catheter was performed in 6 patients due to a small caliber of stenotic portion less than 2mm. The other 3 patients were treated by stenting alone.
Results: Preoperative mean stenosis of 83.6% decreased to 20.3% after one month, and to 11.3% after 12 months following CAS. Procedure-related hypotension with or without bradycardia was observed in 7 patients. One patient developed new ischemic neurological symptoms due to distal embolism 31 hours after the procedure.
Conclusions: Our results suggest that sufficient luminal dilatation after CAS alone or without post-dilatation can be obtained due to serial expansion of the stent during the follow-up periods. Additional studies are necessary to clarify the effect of CAS alone or without post-dilatation on reduction of periprocedural ischemic complications.

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Objective: We used transoral carotid ultrasonography (TOCU) and intravascular ultrasound (IVUS) to evaluate extracranial internal carotid artery dissection.
Case presentation: A 42-year-old woman presented with amaurosis fugax. Cerebral angiography demonstrated a stenotic lesion,4 cm in length, suggestive of dissection of the right internal carotid artery. TOCU and IVUS demonstrated an intimal flap floating in the lumen exhibiting pulsatile motion in its ulcerated portion. Self-expanding stent placement resulted in resolution of stenosis and pseudoaneurysm.
Conclusion: TOCU and IVUS are useful for stenting of internal carotid artery dissection.

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Objective: We report a case in which acute carotid stenting was performed for spontaneous dissection of the internal carotid artery (IC).
Case: A 66-year-old male developed sudden amaurosis fugax and right hemiparesis and came to us. Cerebral angiography revealed irregularities of the carotid wall, stasis of the contrast agent, and delayed cerebral blood flow from the cervical carotid bifurcation to the C5 portion of the IC. Based on these observations, IC dissection was diagnosed. After hospitalization, we initiated bed rest and medical therapy. Two days after onset, increased infarcts on MRI and a decrease of hemispheric blood flow on SPECT due to possible embolization secondary to thrombus formation were observed. We determined that active treatment was indicated and acute stenting was performed on the same day. Stenting was performed under local anesthesia and distal protection. Implementation of two Driver stents and 1 Wallstent RP improved the IC morphology and cerebral blood flow. Although sensory disturbance remained in the right lower limb, the patient was ambulatory and was discharged on Day 11.
Conclusion: Minimally invasive percutaneous carotid stenting is a useful alternative for cases presenting with spontaneous IC dissection that exhibit resistance to medical therapy.

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Objective: Dural arteriovenous fistula (dAVF) is occasionally developed concomitantly or subsequently with sinus thrombosis and stenosis, and the causal relationship between them has been discussed. We report herein a patient of dAVF complicated by severe sinus stenosis who was treated with percutaneous transluminal sinus angioplasty.
Case: A 34-year-old woman was treated for transverse sinus-sigmoid sinus (TS-SS) thrombosis and subsequent dAVF. A further dAVF occurred at the confluence associated with left TS stenosis. Intracranial venous circulation was impaired and the shunt flow drained to the deep venous systems. After percutaneous transluminal sinus angioplasty, venous flow congestion clearly decreased. Follow-up angiogram showed neither development of dAVF nor re-stenosis of the sinuses.
Conclusion: Percutaneous transluminal sinus angioplasty for sinus stenosis associated with DAVF is effective to improve venous congestion and venous hypertension.

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