Objectives: The transradial approach for diagnostic cerebral angiography is feasible, safe, and commonly used. To prevent neurological complications, unfractionated heparin (UFH) is often administered. However, the appropriate dose and administration method have not been established yet. In addition, factors that attenuate UFH efficacy during the procedure have not been examined. We determined the effect of intravenous bolus UFH administration on clot formation within arterial sheaths and the risk factors for clot formation during transradial diagnostic cerebral angiography.
Methods: We retrospectively reviewed 50 patients who underwent diagnostic transradial cerebral angiography with UFH between January 2012 and October 2013. The patients were divided into the clot and no-clot groups on the basis of clot formation in the sheath after the procedure. The patient characteristics, past medical history, reason for undertaking the procedure, dose of UFH, activated clotting time (ACT), neurological complications, and laboratory results were analyzed.
Results: Clots occurred in 60% of the patients, with no symptomatic ischemic events. About 2,000 units of UFH were intravenously administered after sheath placement. In both groups, ACT increased significantly after UFH administration, but the elevation ratio was higher in the no-clot group. White blood cell (WBC) counts and serum total protein were significantly higher in the clot group. WBC counts above the reference range increased the risk of clot detection (risk ratio, 1.77, 95% confidence interval, 1.24–2.54).
Conclusion: Elevated WBC count may predict UFH insensitivity and be a risk factor for thromboembolic complications during transradial cerebral angiography with intravenous administration of 2,000 units of UFH.

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Objective: We report a case of cavernous sinus dural arteriovenous fistula (CdAVF) successfully treated using a triple coaxial catheter system for a transfemoral superior ophthalmic vein (SOV) approach via the facial vein.
Case presentation: A 50-year-old woman presented with left chemosis and exophthalmos. Angiograms showed the left CdAVF draining into the internal jugular vein from the SOV via the facial vein. Since the cavernous sinus (CS) was inaccessible from the left occluded inferior petrosal sinus, we tried to access the CS with a SOV approach via the facial vein. The triple coaxial catheter system was used for the long and tortuous transfacial venous route. The triple coaxial catheter system consisted of a 6Fr guiding catheter, a 4Fr guiding catheter, and a microcatheter. These catheters were connected with hemostasis valves to each other. The microcatheter was successfully navigated into the CS compartment containing a fistulous point. Packing of the compartment with coils resulted in complete occlusion of the fistula.
Conclusion: The triple coaxial catheter system provides additional length and support for distal navigation of the microcatheter in CdAVF embolization via a long and tortuous transfacial venous route.

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Objective: We present a very rare case of a ruptured aneurysm at the horizontal portion (A1) of the anterior cerebral artery (ACA) arising from A1 fenestration and accessory middle cerebral artery (MCA).
Case presentation: A 43-year-old man suffered severe headache and was admitted to our hospital. CT revealed subarachnoid hemorrhage. 3D-DSA revealed a tiny aneurysm located at the A1 of the ACA arising from A1 fenestration and accessory MCA. Coil embolization of the aneurysm was performed because we thought that it was difficult to identify aneurysmal neck during clipping surgery.
Conclusion: A1 aneurysm arising from A1 fenestration and accessory MCA is very rare. Considering the location of the aneurysm and the complexity of parent arteries, coil embolization may be a better treatment choice than clipping.

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Objective: Dissection of the carotid artery can lead to pronounced stenosis, occlusion, or pseudoaneurysm formation, with subsequent formation of hemodynamic and embolic infarcts, despite anticoagulant therapy. We report a case in which coil embolization assisted with carotid artery stenting was performed for spontaneous dissection of the common carotid artery (sdCCA) with pseudoaneurysm.
Case presentation: A 68-year-old man visited our hospital complaining of neck pain. CTA revealed irregularities of the carotid wall and stenosis of the common carotid artery, whereas MRA did not demonstrate any abnormalities. Therefore we performed conservative therapy for sdCCA. However, this resulted in the formation of a pseudoaneurysm. The pseudoaneurysm enlarged gradually during the following several weeks. We determined that coil embolization assisted with carotid artery stenting was indicated for sdCCA. Coil embolization was performed under local anesthesia, which successfully reduced the pain and swelling of the neck.
Conclusion: Minimally invasive coil embolization assisted by carotid artery stenting is a useful alternative for cases presenting with sdCCA that exhibit resistance to conservative therapy.

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Objective: We report a case of a fusiform aneurysm of vertebral artery, treated by second stent placement using stent-in-stent technique on down-the-barrel view (DBV) for a stent assisted coil embolization.
Case presentation: A 60-year-old woman had a fusiform aneurysm of the right vertebral artery growing up in size during 1 year follow up. Stent-assisted coil embolization using an Enterprise stent was performed. During coil embolization with the initial Enterprise stent, coil migration to the parent artery was seen on DBV. The second Enterprise stent was deployed in a stent-in-stent manner. Following deployment of the second stent, coil migration to the parent artery disappeared with preserving the vessel lumen. Complete occlusion of the aneurysm and good patency of the parent artery were seen on 3 months’ follow up angiogram.
Conclusion: Second stent placement using stent-in-stent technique may be effective for management of coil herniation to the parent vessel during stent-assist coil embolization for fusiform vertebral artery aneurysm.

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Objective: We report three cases of meningioma complicated by increased edema or intratumoral bleeding following embolization with N-butyl cyanoacrylate (NBCA).
Case presentation: Case 1 (a 36-year-old man) presented with a parasagittal meningioma. Both Cases 2 (an 83-year-old woman) and 3 (a 63-year-old woman) presented with large convexity meningiomas. All three meningiomas were large tumors with prominent tumor staining and arteriovenous (AV) shunts. Because of the AV shunt, NBCA used for the preoperative embolization of the middle meningeal arteries flowed into the drainage vein. Patients in Cases 1 and 2 had progression of hemiparesis 2 days after embolization. Drainage vessel occlusion was presumably the cause of increased edema because Case 1 presented venous infarction on magnetic resonance imaging. The patient in Case 3 complained of headache after embolization; CT performed 1 day after embolization demonstrated intratumoral bleeding. However, CT immediately after embolization showed no clear bleeding due to the contrast and NBCA artifacts. Fortunately, an intravenous drip of steroids and osmotic diuretics prevented those symptoms from worsening. All patients underwent scheduled surgery. Although large cerebral infarctions were observed around the tumor resection sites in all cases postoperatively, the cause was not obviously venous infarction due to drainage occlusion. Patients recovered during a 3-month rehabilitation period and improved to modified Rankin Scale 1–3.
Conclusion: NBCA, a liquid embolic material, can easily infiltrate the tumor capillary bed, especially for tumors with the AV shunt. Physicians should pay close attention to injection speed and NBCA viscosity because of the risk of drainage vein occlusion.

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Objective: We report a case of acute cerebral ischemia with tandem lesion in a patient who underwent emergent carotid artery stenting (CAS) and intracranial thrombectomy.
Case presentation: A 59-year-old female suffering from aphasia and right hemiparesis was taken in ambulance, 78 minutes later from acute onset. National Institute of Health Stroke Scale was 25. Diffusion-weighted image (DWI) MRI showed acute infarction at left insula cortex, basal ganglia and frontal lobe, and MRA showed left internal carotid artery (ICA) occlusion. Clinical-DWI mismatch was admitted, we performed interventional therapy. DSA showed not only left intracranial ICA occlusion but also left cervical ICA severe stenosis. We placed carotid wallstent at cervical ICA stenosis site. After CAS, we performed thrombectomy for intracranial ICA, and gained complete recanalization. Postinterventional course was uneventful. Right hemiparesis was dramatically improved but motor aphasia was remained at discharge.
Conclusion: We reported a case of acute cerebral infarction with tandem lesion leading to improving neurological deficits by CAS and thrombectomy. Interventional therapy for tandem lesion was useful.

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