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.
Objective: In cases of cerebral arteriovenous malformation (AVM) in which perforators are involved as feeder, hemostasis is difficult during surgical removal and postoperative hemorrhage may develop. If possible, presurgical embolization should be performed. However, when the anterior choroidal artery (AChA) is the feeder, the risk of embolization is particularly high, and there are few reports describing this situation. Authors report the treatment results of five cases of AVM in which a single operator performed presurgical embolization through the AChA and describe the technique with a review of the literature.
Case Presentations: Of the five total cases (three men and two women; average age was 43.4 years [28–68 years]), one case presented with hemorrhage, two with epilepsy, the other ones with headache and trigeminal neuralgia, respectively. The lesions were located in the frontal lobe in one case and in the temporal lobe in four cases. On the Spetzler-Martin (SM) grading scale, four cases were grade III and one was grade IV. The eloquent area was involved within the nidus in four cases. Multimodal treatment was planned because all cases were high-grade AVM. Authors thought that performing presurgical embolization through the AChA would reduce the overall risk of treatment and performed the presurgical embolization. The embolization was possible in all cases, and the AVM was not angiographycally visible through the AChA in three cases. The blood flow through the AChA was reduced in two cases. All cases were awake immediately after embolization and no case had neurological symptom after embolization. CT or MRI after embolization revealed asymptomatic infarction in two cases. The AVM was removed safely without difficulty including hemostasis.
Conclusion: In this series, there were no morbidity and embolization was performed relatively safely. Embolization through the AChA was suggested to be an effective treatment, but careful consideration is required in each individual case.
Objective: To describe our 1-year experience of the practical use of a mobile communication application by our stroke team.
Methods: The mobile Join application (Allm Inc., Tokyo, Japan) was introduced into our stroke team for the purpose of immediate sharing of the patient information. We analyzed the usage situation for 1 year after the introduction of Join, particularly its efficacy in improving the door-to-puncture time (D2P) for thrombectomy cases, and reported our inter-hospital collaboration with the use of Join.
Results: The total number of events notified by Join was 337, and they included acute stroke potentially leading to reperfusion therapy in 23% (76 events), head trauma in 14%, brain hemorrhage in 12%, other infarction in 10%, subarachnoid hemorrhage in 8%, and the others in 34%. The information of the patients was shared among the team members before arrival to our hospital in 42% of acute stroke cases. Of 31 patients undergoing mechanical thrombectomy, the median interval between arrival and groin puncture for the directly transported patients with/without pre-hospital information was 77.5 min/87 min, respectively, whereas that of the patients transferred from primary hospitals with/without pre-hospital information was 19 min/71 min (p <0.0001), respectively, demonstrating the efficacy of information sharing in advance through Join in improving the timing of endovascular therapy. For inter-hospital collaboration using the telestroke system, we concluded the partnership agreement with three local primary hospitals by communication via Join at a reasonable cost.
Conclusion: Active and effective utilization of the mobile Join application for communication by our stroke team was demonstrated, and it is expected to promote inter-hospital collaboration in stroke treatment.
Objective: This study was performed to clarify the differences in blood flow strength, blood vessel diameter, and post-labeling delay (PLD) by physical experiments, and to examine whether bright vessel appearance (BVA) can be observed by arterial spin labeling (ASL).
Methods: We introduced simulated blood flow (25 cm/sec, 12.5 cm/sec) using a specially made phantom of fixed tubes in a plastic container. At each speed, we scanned at several points of PLD using ASL imaging. We measured the signal in the tube to obtain a signal intensity (SI). We revised the T1 level from the SI and obtained SIblood. We used SItissue with normal perfusion measured from obtained clinical images by ASL and compared it with SIblood.
Results: In tubes with a narrow inner diameter, the signal slightly decreased. SI also decreased under slow flow compared with fast flow. At each flow rate, SIblood significantly exceeded SItissue.
Conclusion: PLD distinguishes spin in brain tissue from 1525 msec to 2525 msec, and it can be observed. As spin signal decreases when the flow rate is slow, attention is necessary for observation. Assessment at PLD1525–2525 msec where normal perfusion was obtained suggested that BVA can be observed.
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.
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.
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: 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.
Besides cavernous sinus (CS) dural arteriovenous fistulas (AVFs), AVF may develop around the parasellar region. They can cause various symptoms, and some of them may show similar symptoms to those of CS dural AVF. Therefore, these AVFs may be misdiagnosed as CS dural AVFs. In this review, we divided parasellar AVFs into four groups based on their locations related to the CS: anterior group (orbit), anterolateral group (sphenoid wing), posteroinferior group (inferior petrosal sinus and clivus), and posterior group (superior petrosal sinus and petrosal vein). Although parasellar AVFs share common points, there are many differences between the four groups. We herein discuss commonalities and differences in parasellar AVFs based on a review of the literature and our experience.
Objective: Based on the findings of preferable outcomes from recanalization therapy in recent studies, regional partnerships for the endovascular treatment of acute ischemic stroke are being promoted. However, reports of inter-island cooperation between remote islands located far from high-volume centers on the mainland are rare.
Case Presentation: A 63-year-old man experienced an acute ischemic stroke on a small, isolated island in Okinawa, Japan. He was transferred by helicopter to the primary emergency hospital on Ishigaki Island, which was the nearest island on which he could be administered recombinant tissue plasminogen activator (rtPA). After this, he was carried again by helicopter and ambulance to the primary stroke center on Miyako Island using the drip and ship method. Mechanical thrombectomy with a stent retriever achieved recanalization of the occluded major vessels and improved the neurological disturbance. The patient became neurologically independent and could be discharged only 11 days after onset.
Conclusion: Building a local area network that includes hospitals providing mechanical thrombectomy is a meaningful approach to treating acute ischemic stroke occurring on isolated islands. It is necessary to recognize the specific restrictions imposed by helicopter transportation and to make efforts to shorten the time required for key processes to provide faster treatment.
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: Cerebral aneurysms (ANs) in the cortical segment (CS) of the distal posterior inferior cerebellar artery (PICA) with a vertebral artery (VA) of aortic origin are markedly rare. Endovascular therapy was performed to treat subarachnoid hemorrhage caused by a ruptured cerebral AN.
Case Presentation: The patient was a 68-year-old female who was transported to emergency care for headache. Detailed examination revealed an AN in the CS of the PICA with a left VA of distal aortic origin from the left subclavian artery (LT. SA). Endovascular therapy using n-butyl-2-cyanoacrylate (NBCA) was performed to treat the cerebral AN, resulting in a favorable outcome.
Conclusion: Endovascular therapy for cerebral ANs is an effective treatment method.
Objective: Stent-assisted aneurysmal embolization (SAAE) is an effective treatment for aneurysms with a low risk of recurrence. In rare cases, retreatment is necessary due to recanalization of blood flow into the aneurysm. However, only a few studies have reported on retreatment. We examined the efficacy and complications of stent-assisted aneurysm embolization for large or wide-neck aneurysms at our hospital.
Methods: Between July 2010 and June 2018, 293 patients underwent stent-assisted aneurysm embolization at our hospital. Among them, 12 (2 women, 10 men, mean age: 62 years) needed retreatment. We evaluated the initial treatment of these 12 patients, and the methods and results of their retreatment.
Results: Six of the 12 retreated patients were treated using the simple technique. It was possible to treat nine patients (75%) without placing new stents, but three needed additional stents. We were able to guide the microcatheter into the aneurysm using the trans-cell technique even with two overlapping stents. We achieved complete embolism in seven patients (58%), and remnants were observed in the neck in five (42%) patients. No complications were associated with our surgery. We were able to perform follow-up for 10 patients and there was no recurrence.
Conclusion: Embolization should be considered in recurrent cases after the initial stent-assisted coil embolization. We achieved good results and reduced the recurrence rate by selecting the appropriate treatment in each case.
The arterial anatomy of the parasellar area is complex in that it deals with extracranial–intracranial anastomosis and supply to various cranial nerves in a small area. Pathologies such as hypervascular tumors and shunts are not uncommon and require good knowledge of anatomy in planning the treatment. In this article, the basic anatomy of the arterial supply in this region is discussed, covering the origins, territories, relation to the cranial nerves, and the connections among different systems.
Objective: Surgical removal of meningiomas that have partially invaded the superior sagittal sinus (SSS) is difficult because it requires reconstruction of the SSS, which can lead to SSS occlusion and venous infarction. The present report details the case of an SSS-involved meningioma treated by stereotactic radiosurgery (SRS) and stenting.
Case Presentation: A 60-year-old woman was admitted to the hospital with blurred vision and papilledema. Lumbar puncture showed markedly increased intracranial pressure (ICP; 340 mm H2O). Gadolinium-enhanced T1-weighted imaging revealed a 1-cm meningioma located mainly in the SSS. Digital subtraction angiography revealed severe stenosis, at the posterior part of the SSS, and no collateral flow. The ICP was considered a result of the stenosis caused by the meningioma. A combined therapy comprising transarterial embolization (for tumor growth suppression), endovascular stenting of the SSS (for intracranial hypertension improvement), and SRS (for tumor control) was planned. SRS was performed first to avoid interference by the metal artifacts caused by the stent. After placement of a self-expanding stent, partial recanalization was achieved. Two months after stenting, SSS stenosis improved and MRI results showed shrinkage of the meningioma. Thirty months after the treatment, no tumor recurrence was observed.
Conclusion: The treatment strategy of SRS followed by stenting was successful for a SSS-involved meningioma. ICP and a pressure gradient between the pre- and post-stenotic segments should be considered indications for stenting.
Objective: There are many cases in which computed tomography (CT) after acute thrombectomy demonstrates high-density areas, but it may be difficult to judge whether this is hemorrhage or contrast extravasation. Dual energy CT (DECT) is an imaging method that enables discrimination of substances by acquiring X-ray image data of two different energies.
Methods: We performed DECT to distinguish hemorrhage from contrast extravasation in cases with high-density areas on CT after acute thrombectomy at our hospital, and we compared with T2*-weighted image on the following day.
Results: Six patients comprising 22 areas had high-density areas on CT after acute thrombectomy. In all, 20 of the 22 high-density areas were determined to be contrast extravasation by DECT, and no cases of subsequent symptomatic cerebral hemorrhage were observed. However, 11 areas with new microbleeds were confirmed in the 20 extravasation areas on MRI-T2* images the day after thrombectomy.
Conclusion: This examination suggested that the contrast extravasation and its concentration are involved in the presence of low-intensity areas on T2*.
Objective: Subclavian artery aneurysms are relatively rare, and have been treated by open surgery and/or endovascular treatment using a stent graft. In this article, we report a case of unruptured right subclavian artery aneurysm successfully treated using balloon-assisted coil embolization.
Case Presentation: A 77-year-old man was diagnosed with an asymptomatic unruptured right subclavian artery aneurysm of 8 mm in diameter by follow-up CTA after surgery for thoracoabdominal aortic aneurysms. He also had a history of cerebral infarction and clipping of an unruptured cerebral aneurysm. The subclavian artery aneurysm was treated by balloon-assisted coil embolization because its diameter increased to 17.6 mm in 2 years. Balloon assistance was mainly used to prevent protrusion of the framing coil into the parent artery, and satisfactory framing was achieved. Subsequently, the aneurysm was obliterated using filling and finishing coils. The postoperative course was uneventful, and the follow-up MRI at 18 months after treatment revealed no recanalization of the aneurysm.
Conclusion: Balloon-assisted coil embolization may be an effective treatment for subclavian artery aneurysms, but further long-term follow-up and case accumulation are needed.
Objective: We report a case of anterior cranial fossa dural arteriovenous fistula (dAVF) in which ocular movement was impaired after Onyx embolization from the ophthalmic artery (OphA).
Case Presentation: A 76-year-old male was admitted to our hospital for treatment of an incidentally found anterior cranial fossa dAVF. Onyx was injected from the right anterior ethmoidal artery (AEA) to close the shunt. Onyx refluxed to the third portion of the OphA to make a plug, but was unable to reach the venous side beyond the shunt; therefore, a small shunt remained. Although his visual acuity and field were normal, vertical diplopia developed after embolization and disappeared 1 month later. Diplopia worsened when the patient tilted his head to the right. Neuro-ophthalmological examination confirmed right superior oblique muscle impairment. The cause of diplopia was considered to be ischemic injury of the superior oblique muscle associated with embolization of the AEA, which provides nutrients to the superior oblique muscle and trochlear nerve.
Conclusion: Embolization from the OphA beyond the third portion may cause external ophthalmoplegia, although it may heal spontaneously.
Objective: We present a case of subarachnoid hemorrhage (SAH) due to ruptured mycotic aneurysm found in the distal superior cerebellar artery (SCA).
Case Presentation: A 64-year-old man was admitted to our hospital with sudden unconsciousness. He had a history of alcoholism but no family history of SAH. Computed tomography (CT) showed apparent SAH; however, CT angiography (CTA) showed no apparent cause of SAH except for two small aneurysms in the same branch of the left distal SCA. We suspected mycotic aneurysm and prescribed antibiotics. It was difficult to diagnose the condition as mycotic aneurysm because there were no vegetations or caries at the time of admission. Because there were two aneurysms in the same branch with partial dilatation and stenosis, we suspected dissecting aneurysm, but continued to administer antibiotics for possible mycotic aneurysm. After the first operation, we diagnosed mycotic aneurysm because a vegetation and valve degeneration was found.
Conclusion: It is difficult to distinguish mycotic aneurysms from dissecting aneurysms because of similar appearance on imaging, especially if no vegetation is found. Nevertheless, it is important to start treatment for mycotic aneurysm. If there is the possibility of mycotic aneurysm, appropriate antibiotics should be administered, and endovascular treatment could be considered for patients with deteriorating conditions.
Objective: Graft stent for carotid cavernous fistula (CCF) is known to be a useful treatment. Here, we report our experiences of treatment with graft stents for CCFs.
Case Presentations: From 2015 through 2018, six patients underwent graft stent placement for CCF occlusion. Clinical and angiographic data were retrospectively reviewed. Access and deployment of a graft stent was successful in all patients and complete occlusion immediately after the procedure or 3-month follow-up angiography.
Conclusion: Graft stents should be considered as an alternative option of treating CCFs and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.
Objective: Iatrogenic artery dissection during reperfusion therapy is one of the complications causing a poor prognosis. We report two cases of emergent stent placement for iatrogenic cervical carotid artery dissection during reperfusion therapy for acute ischemic stroke.
Case Presentation: Two patients, a 77-year-old woman and a 77-year-old man, were diagnosed with acute major cerebral artery occlusion, and underwent reperfusion therapy. The iatrogenic internal carotid artery dissection was caused by derivation of a 6-Fr catheter and 0.014-inch wire in the tortuous cervical internal carotid artery, and emergent stent placement was performed. Recanalization was confirmed and no deterioration caused by the iatrogenic dissection was found.
Conclusion: In patients in whom cerebral infarction is localized on MRI, additional stent placement may be effective for preventing adverse events caused by iatrogenic cervical internal carotid artery dissection during reperfusion therapy for intracranial cerebral artery occlusion related to atherosclerotic change.
Objective: We report a patient with basilar artery embolism caused by vertebral artery stenosis who was successfully treated using simultaneous percutaneous transluminal angioplasty (PTA) and mechanical thrombectomy.
Case Presentation: A 64-year-old male, who had undergone medical treatment for cerebellum infarction at another hospital, was referred to our hospital due to disturbance of consciousness. Angiography revealed acute occlusion of the first part of the right vertebral artery and an embolism of the top of basilar artery. After performing PTA to create an approach route for the embolism, we collected it using a clot recovering device. The postoperative course was good, and the patient was discharged with mild ataxia and dysarthria.
Conclusion: We report the successful treatment of progressive cerebral infarction of the posterior circulation with revascularization 30 hours after symptom onset. Unlike the anterior circulation, the posterior circulation consists of smaller arteries and fewer collateral arteries, making it vulnerable to ischemic attack. Therefore, shortening the time until treatment may improve the outcome.
Acute ischemic stroke (AIS) is a severely disabling disease. Endovascular therapy is a powerful and highly effective treatment option for these patients and has recently become standard of care. The benefits of endovascular treatment (EVT) are tremendous both from a patient and from an economic perspective, since it dramatically improves individual patient outcomes while reducing long-term healthcare costs at the same time. The effect of EVT is highly time-dependent. Thus, the overarching goal in AIS is to quickly transport and diagnose the patient to minimize treatment delays. In this review, we provide an overview about the current state of stroke care, propose a fast and simplified imaging protocol and management approach for AIS patients. We also highlight the challenges we are currently facing in endovascular stroke treatment and suggest possible solutions to overcome these.