White matter lesion (WML) is an advancing disease, and originated from chronic hypoperfusion and by the destruction of blood-brain barrier due to angiopathy, including hypertensive microangiopathy and amyloid angiopathy. WML was investigated for related diseases and risk factors. WMLs originated from multiple factors. Recently, some genetic origins of WML were also identified. MRIs frequently demonstrate spotty WMLs in elderly people suggesting that it may be a finding of aging, but not abnormal. However, advanced WML is associated with many diseases and needed to be followed carefully, and the control of risk factors. In people with severe WML, the incidence or recurrent rates of strokes, in particular intracerebral hemorrhages or lacunar infarctions, are higher than those without WML. Severe WML might be a surrogate marker for stroke occurrences. However, there was no guideline for anti-platelet drug use or anti-coagulant drug use for people with severe WML. Further studies are needed to investigate antithrombotic drug uses in patients with severe WML. WMLs are reported to be associated with Alzheimer’s disease, vascular dementia, depression, and general malaise.

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Cryptogenic ischemic stroke, stroke with no clear definable cause even after extensive workup, does not have fixed diagnostic criteria. Proportion of this type of stroke among overall ischemic stroke varies much, ranging from 16% to 39%. Majority of cryptogenic ischemic stroke is considered as embolism, and the concept of embolic stroke of undetermined source has been recently proposed. In particular, covert atrial fibrillation is drawing attention, and it was identified in 30% of patients in long-term observation using an insertable cardiac monitor. A next-generation insertable cardiac monitor is small and has the capability of remote monitoring. Thus, it has been in clinical use to detect atrial fibrillation in patients with cryptogenic ischemic stroke in the United States, Europe, and Australia. If atrial fibrillation would be identified, anticoagulants can be legally used for prevention of stroke recurrence, and could reduce its recurrence in patients with cryptogenic ischemic stroke. A request has been submitted by the Japan Stroke Society to the Ministry of Health, Labor and Welfare, Japan, indicating the high medical needs of the next-generation insertable cardiac monitor to detect covert atrial fibrillation after cryptogenic ischemic stroke. If the use of the device is approved, patients appropriate for the use should be selected based on detailed examination including head MRI in accordance with the current situation of medical practice in Japan.

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We report a case in which stepwise revascularization was performed for highly calcified and hemodynamically compromised internal carotid artery (ICA) stenosis with contralateral ICA occlusion to prevent intraoperative ischemic stroke and postoperative hyperperfusion. A 74-year-old man having vertigo was initially diagnosed with asymptomatic lacunar infarction of the left thalamus. Additional examinations revealed severe stenosis of the right ICA with occlusion of the left ICA, aplasia of the right posterior communicating artery, and anastomosis of each branch from the right vertebral and occipital arteries. Single photon emission computed tomography (SPECT) showed bilateral hemispheric hypoperfusion, which suggested the risks of intraoperative ischemic stroke during ICA cross clamping for carotid endarterectomy (CEA) and postoperative hyperperfusion syndrome. To prevent these risks, we performed right superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis prior to CEA. Vertebral angiograms obtained after anastomosis indicated blood flow in the MCA territory via the occipital artery and STA, and SPECT confirmed improvement in cerebral hemodynamics. One month later, right CEA using a shunt was successfully performed without any intraoperative ischemic event. The patient experienced no symptom of ischemic stroke or hyperperfusion syndrome. Stepwise revascularization may prevent postoperative hyperperfusion in patients with severe hemodynamic compromise. In addition, increasing the cerebral blood flow by STA-MCA anastomosis would prevent ischemic events during CEA. However, the indications should be strictly limited to the angioarchitecture of anastomosis between the vertebral and occipital arteries, as in this case.

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Acute aortic dissection complicated by stroke is not uncommon, but may be difficult to evaluate. Case 1: An 82-year-old man was transferred to our hospital due to transient left hemiparesis. On admission, neurological signs and symptoms gradually improved. Laboratory data showed that D-dimer was 3.5 μg/ml. MR-DWI showed an ischemia lesion in the right corona radiate. Source image of aortic arch and neck MRA showed an aortic dissection. The ascending aorta was replaced 1 day after admission, and the postoperative course was uneventful. Case 2: A 64-year-old man was transferred to our hospital due to the dissection of bilateral internal carotid artery. Two months ago, he suffered from back pain. Source image of aortic arch and neck MRA showed a sub-acute aortic dissection extending from the ascending to the descending aorta. Therefore, he was directed to the cardiovascular surgeon for immediate consultation. We suggest that source image of aortic arch and neck MRA is a useful tool in the diagnosis of aortic dissection complicated by transient ischemia attack.

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A 45-year-old male presented with left hemiparesis. Magnetic resonance imaging (MRI) showed the stenosis of right middle cerebral artery. Although the medication was started, hemiparesis recurred frequently. Percutaneous angioplasty was performed. Thereafter the symptom disappeared. The blood test result on admission came out after the surgery the high value of homocysteine. We performed angioplasty on the middle cerebral artery stenosis with hyperhomocysteinemia.

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Many articles report that the incidents of in-stent restenosis after carotid artery stenting (CAS) were higher in radiation-induced carotid stenosis. We report a case of repeated plaque protrusion after CAS for radiation-induced carotid stenosis, in a patient who received surgical treatment and adjuvant radiotherapy for neck cancer 11 years previously. The patient was a 71-year-old man who received treatment for diabetes mellitus, hypertension, and hyperlipidemia. He was diagnosed with cerebral infarction that caused right hemiplegia. Diffusion-weighted magnetic resonance imaging (MRI) revealed infarction at the frontal operculum, and cerebral angiography revealed bilateral internal carotid artery stenosis; the left side, symptomatic, showed 50% stenosis with soft plaque seen on MRI plaque imaging and the right side, asymptomatic, showed 80% stenosis with hard plaque. We chose carotid stenting instead of carotid endarterectomy for both carotid arteries because of the risks of surgery and radiation therapy. However, repeated carotid stenting and angioplasty were needed on both sides due to repeated in-stent restenosis. The incidence of ischemic stroke is significantly increased in patients receiving radiotherapy to the neck, especially in patients with risks of atherosclerotic disease. In such cases, strict observation and early intervention are thought to be important before accumulation of soft plaque due to atherosclerotic change, which may result in difficulty of treatment for carotid stenosis.

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Coil embolization for basilar tip aneurysms (BTAs) requires a special endovascular technique, as BTA represents the terminal location, exhibits commonly as a wide-neck morphology, and has a potentially high recurrence rate after coiling. Y-configured stent-assisted coil embolization has been reported to decrease the recurrence rate of BTA. However, the efficacy and safety of this technique are unclear. Herein, we report five cases of aneurysm embolization using the Y-configured stent-assisted technique. Complete obliteration without any ischemic and hemorrhagic complications was achieved in all cases. Mean imaging follow-up was 12.2 months and there were no retreatment cases during this period. These data suggest that Y-configured stent-assisted coil embolization is a safe and an effective technique for the treatment of BTA.

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We report a rare case of transient acute hydrocephalus due to intraventricular hemorrhage. A 76-year-old man, who had undergone warfarin treatment for atrial fibrillation, developed right thalamic hemorrhage with ventricular perforation and was admitted to the hospital for an emergency. We selected a conservative treatment and the followup CT scan showed rapid wash-out of the intraventricular hematoma however, the patient suddenly deteriorated his consciousness 2 days after the onset. The emergent CT scan revealed an acute hydrocephalus due to the clot plaque at the aqueduct. An emergent external ventricular drainage was performed; however, his consciousness improved during the operation. The postoperative CT demonstrated the improvement of hydrocephalus and the disappearance of the clot plaque. The fragile clot due to warfarinization might play a critical role in the transient plaque formation at aqueduct, causing acute hydrocephalus.

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Coil embolization is one of the established cerebral aneurysm treatments. Several perioperative complications such as the cerebral infarction and hemorrhage are known. We experienced the case of a symptomatic perianeurysmal edema after coil embolization. An 86-year-old woman had an aneurysm growing slowly on her vertebral artery. The coil embolization was performed usually with bare platinum coil as usual, and she discharged after 72 hours from the coil embolization. After 3 days from the date of discharge, double vision, dizziness, and dysarthria were presented. Magnetic resonance image (MRI) showed the presence of perianeurysmal edema. The recurrence of the aneurysm was not revealed. After the medication including the steroids was started, the symptom was recovered within a week. Thereafter the perianeurysmal edema on the MRIs was disappeared gradually. Perianeurysmal edema after coil embolization is one of the considerable complications.

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A 68-year-old man presented with blurred vision after a pass of Japanese fencing at his right neck. Though he had no symptoms, 3DCTA revealed right carotid occlusion. He was treated with antiplatelet. Thirty-six hours after the injury, carotid artery was recanalized and resulted in brain infarction. Despite we started a continuous infusion of heparin, infarction became progressively worse and he suffered from permanent right hemiplegia. Dissecting flap and pocket in right carotid artery remained for 3 months and caused asymptomatic ischemia that was treated by endarterectomy. It is essential to know that blunt carotid arterial injuries especially in occlusions carry high stroke risk. Early aggressive treatment, antithrombotic therapy, surgery, and endovascular management may be effective to prevent them from stroke.

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