Objective: We investigated the efficacy and safety of the calcium alginate hemostasis-pad Tricell^TM (Alliance Medical Group, Tokyo) for puncture site hemostasis after neuroendovascular surgery.
Materials and Methods: Puncture site hemostasis using the Tricell^TM was examined in 12 patients undergoing neuroendovascular surgery between March 2011 and July 2011 in our institute. We evaluated the relationship of hemostasis time to introducer sheath size, use of antiplatelet agents and anticoagulants, and activated clotting time (ACT) just before removal of the introducer sheath.
Results: Hemostasis was achieved at the puncture site, which was the femoral artery, in all patients (4 women and 8 men; average age 68.8 years [range, 63 to 83]). As to introducer sheath size, 9Fr, 8Fr, 7Fr, 6Fr, and 5Fr sheaths were used in 3, 1, 4, 3, and 1 cases, respectively. There were 7, 2, 2, and 1 cases, respectively, of cerebral aneurysm, internal carotid artery stenosis, acute cerebral infarction, and brain tumor. Time to hemostasis was approximately 5-12 minutes, maximum 43 minutes. Two, two, and one patients required 3, 2, and 1 types of antiplatelet agents and anticoagulants, respectively, before neuroendovascular surgery. One patient required intravenous tPA and 6 patients required neither antiplatelet agents nor anticoagulants. The ACT just before introducer sheath removal was 107-286 seconds. Puncture site hemostasis was achieved within 10 minutes, when the introducer sheath size was 8Fr or smaller, no more than 2 antiplatelet agents or anticoagulants were taken preoperatively, and ACT just before introducer sheath removal was less than 250 seconds. No painful hematomas were observed.
Conclusion: Puncture site hemostasis using a calcium alginate containing hemostasis-pad after neuroendovascular surgery is effective and safe.

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Objective: The advantages of neuroendovascular treatment (NET) include low invasiveness and the ability to be performed under local anesthesia. However, the psychological burden of surgery might be increased because patients remain conscious during the operation. A multi-media digital versatile disc (DVD) showing the neuroendovascular course was created to reduce the anxiety of patients scheduled to undergo NET under local anesthesia by giving them information about the procedual process. The purpose of this study was to examine the usefulness of this DVD and to discuss the kind of information that patients desired.
Methods: A questionnaire survey on perioperative anxiety was conducted in 30 patients who underwent NET under local anesthesia, including 20 patients who watched the DVD and 10 who did not. A different questionnaire was used to survey the 10 patients who did not watch the DVD.
Results: Of the patients who watched the DVD, all had better understanding of NET and approximately 70% had less anxiety. The information acquired from the DVD was helpful in reducing patient anxiety. Most commonly, patients wanted information about the atmosphere of the angiography room and issues related to pain or discomfort, such as information about local anesthesia, hemostasis at the puncture site, and intraoperative bed rest.
Conclusions: The DVD was useful in reducing the anxiety of patients scheduled to undergo NET under local anesthesia. The patients desired information regarding the angiography room and invasive procedures.

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Objective: Intracranial internal carotid artery (IICA) dissection manifesting as an ischemic stroke is a rare phenomenon, for which the optimal treatment has not yet been established. We report 3 cases, each treated successfully with stent placement.
Methods: The data of 3 consecutive patients with IICA dissection treated with stent placement were retrospectively reviewed.
Results: The indications for stent placement were impending extensive infarct (n = 2) and recurrent ischemic attack during antithrombotic treatment (n = 1). All dissections were treated with balloon-expandable coronary stents. In all 3 cases, dissection-related vessel abnormalities were resolved after stent placement. No recurrent strokes were observed during the follow-up period (mean, 38.7 months). All cases had excellent or good clinical outcomes at the end of the follow-up. Follow-up angiography showed healing of dissection segments in all patients, without any restenoses. Case 1 was a 28-year-old male patient who presented with progressive hemiparesis on the left side after a sudden headache. A magnetic resonance imaging (MRI) diffusion-weighted image (DWI) showed infarcts in the territory of the right ICA; angiography showed high-grade stenosis and a double lumen in the right supraclinoid ICA. A balloon-expandable coronary stent was placed 4 hours after the onset of symptoms; the stenosis was completely resolved after stenting. Follow-up angiography performed 48 months later showed complete healing of the dissection. The patient had persistent but mild left arm monoparesis. Case 2 was a 29-year-old female patient who presented with hemiparesis on the left side after a seizure. MRI-DWI showed infarcts in the right basal ganglia. Angiography showed a 'pearl and string' sign in the right supraclinoid ICA. Anticoagulant therapy was initiated, and her symptoms resolved. The hemiparesis on the left side recurred; however, 4 days after the initial onset, her DWI revealed a new infarct. Stent placement was performed. Angiography obtained 44 months later showed complete healing of the dissection. The patient's residual symptoms at the conclusion of follow-up were limited to mild monoparesis of the left arm. Case 3 was a 17-year-old male patient who presented with severe right hemiplegia and total aphasia after a sudden headache. MRI revealed a diffusion-perfusion mismatch in the territory of the left ICA, and angiography showed high-grade long segment stenosis in the left supraclinoid ICA. Stent placement was performed 10.5 hours after the onset of symptoms and a complete resolution of the stenosis was achieved. Follow-up angiography obtained 24 months later showed complete healing of the dissection, with residual numbness of the right forearm, the only symptom.
Conclusion: Our case series indicates that stent placement may be an effective treatment for intracranial ICA dissection presenting with ischemic stroke.

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Objective: Intracranial meningioma surgery in the elderly sometimes causes neurological complications that significantly degrade quality of life. We report a case of intracranial meningioma that was effectively and safely treated by endovascular embolization using liquid materials without subsequent surgical removal.
Case presentation: Our case of intracranial meningioma was in an 86-year-old woman treated by endovascular embolization using ethanol and n-butyl cyanoacrylate. Six days after embolization, preoperative neurological deficits were improved, no cognitive deterioration was detected, and tumor shrinkage was evident on brain magnetic resonance imaging. Tumor size remains unchanged two years after embolization.
Conclusion: Endovascular embolization using liquid materials may be safe for symptomatic meningioma in elderly patients to prevent various complications associated with surgical removal.

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Objective: Symptomatic in-stent thrombosis with or without plaque protrusion is a relatively rare but devastating complication of carotid artery stenting (CAS).
Case presentation: A 72-year-old man presented with repeated transient ischemic attacks (TIAs). Digital subtraction angiography (DSA) showed severe stenosis in the left internal carotid artery at its origin. Cervical MRI revealed carotid soft plaque. Balloon-protected CAS was planned. A self-expandable open-cell-type stent (PRECISE^TM) was successfully placed with a good angiographic result. However, he suffered a recurrent TIA several hours after the CAS procedure. Enhanced computed tomography (CT) scan revealed a contrast defect in the stent suggesting acute thrombus formation. Despite medical treatment including systemic heparinization and triple anti-platelet therapy, a follow-up ultra-sound examination showed enlargement of the thrombus in the stent. His neurological condition deteriorated and we decided to perform another stenting procedure. DSA demonstrated a significant contrast defect in the stent. A self-expandable closed-cell-type stent (Wallstent RP^TM) was successfully deployed on the inside of a PRECISE^TM stent under distal balloon protection. A satisfactory angiographic result was achieved. After the second procedure, he showed good recovery from the neurological symptoms and no more TIAs.
Conclusion: This case demonstrated the usefulness of the stent-in-stent technique for medically refractory in-stent thrombosis with or without plaque protrusion. A closed-cell-type stent would be theoretically more effective in this situation.

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Objective: We report a case of traumatic carotid-cavernous fistula treated with a combination of endovascular therapy and direct surgery.
Case presentation: A 24-year-old man presented with blurred vision and diplopia 6 years after a traffic accident. Cerebral angiography revealed a right carotid cavernous fistula with dilated cavernous sinus. After initial transarterial embolization of the cavernous sinus and internal carotid artery, a residual shunt was detected at the distal end of the coil mass. To reduce hemodynamic stress in the sacrificed internal carotid artery, we performed extracranial-intracranial high-flow bypass using a radial artery graft, and direct trapping of the internal carotid artery between the cervical bifurcation and the immediately proximal portion of the ophthalmic artery. However, a residual shunt from the distal end of the clip remained. Coil embolization of the fistula via radial artery graft occluded the residual shunt completely.
Conclusion: Endovascular treatment via radial artery graft is a safe and valuable alternative when the primary access route is eliminated.

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Objective: We present a case of dural arteriovenous fistulas (DAVFs) near the anterior condylar confluence (ACC) manifesting as pulsatile tinnitus, treated with transvenous coil embolization through an anastomosis between the left internal jugular vein and the vertebral venous plexus.
Case presentation: A 59-year-old male presented with pulsatile tinnitus. Cerebral angiography revealed left DAVFs near the ACC, fed by the left occipital artery, ascending pharyngeal artery, and meningeal branches of the vertebral artery, and drained by the lateral (LCV) and posterior condylar veins (PCV) into the suboccipital cavernous sinus (SCS), vertebral artery venous plexus, and the deep cervical vein. An anastomosis between the left internal jugular vein and the vertebral venous plexus was also revealed at the second cervical level. Embolization was performed with coils inserted from the anastomosis through the SCS into the LCV and PCV. The DAVFs disappeared immediately after treatment and the pulsatile tinnitus also disappeared a few days later.
Conclusion: The anastomosis between the internal jugular vein and the vertebral venous plexus could provide an alternative route for embolization of dural arteriovenous fistulas near the anterior condylar confluence.

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Objective: We report two cases of atherosclerotic vertebral and subclavian stenosis presenting with subclavian steal syndrome.
Case presentation: Two patients, who had symptoms of upper extremity weakness and vertebrobasilar insufficiency, underwent stent replacement for obstructive lesions of the subclavian and vertebral arteries. Stents were successfully placed in both, resulting in resolution of symptoms.
Conclusion: Surgical revascularization techniques, bypass graft and endarterectomy, have been the mainstay treatment for vertebral and subclavian stenosis, but the morbidity rate associated with surgical treatment was relatively high. Recently, the endovascular treatment has been widely used for stenotic lesions and associated with a high rate of technical success. In two cases, we used new stents that did not require a system for remounting. These new devices solve the problem of balloon injury during catheter insertion, passage through the stenotic lesion, and stent placement except at the site of the target lesion. Endovascular treatment for obstructive lesions of the subclavian and vertebral arteries is considered to be a feasible and safe treatment and may be effective for stroke prevention.

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Objective: A transfemoral approach is usually used for carotid artery stenting (CAS), but postoperative recovery is painful. A transbrachial approach may result in puncture site complications, pain in the forearm, or sensory loss, and can also result in median nerve palsy due to subcutaneous bleeding. To reduce the postoperative burden on the patient and mitigate the potential for complications, transradial CAS (TR-CAS) was performed at our institution, as reported here.
Methods: TR-CAS was performed on 20 lesions in 19 patients (4 female, 15 male; mean age, 69.9 years [range 59-83]; 14 symptomatic lesions, 6 asymptomatic lesions) from August 2010 to December 2011. The right carotid artery was stented in 17 patients and the left was stented in 3.
Results: Stents were placed in all patients. Cerebellar infarction was noted in 1 patient and subcutaneous bleeding in the forearm was noted in another. No puncture site problems were noted. Caution was required since protracted radial artery puncture could lead to vasospasms, the guidewire could be misdirected into small branches, and patients could have anatomical variations such as absence of the ulnar artery or the presence of an ulnar loop.
Conclusion: TR-CAS is not a difficult procedure for an interventional neuroradiologist and is less invasive for the patient.

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Objective: We present the "lash method" for reinsertion of a dislodged microcatheter into an insufficiently embolized cerebral aneurysm.
Case presentation: A 71-year-old male presented with a subarachnoid hemorrhage from a ruptured anterior communicating aneurysm. Until complete occlusion was achieved, the microcatheter slipped out of the aneurysm. Keeping the tip of the microcatheter nearby the neck of the aneurysm and pulling the micro-guidewire back, the microcatheter was advanced and adequately repositioned. The aneurysm was completely occluded.
Conclusion: This method of microcatheter reinsertion into an incompletely embolized cerebral aneurysm can be considered, especially when the coils are unevenly distributed.

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