Background and Purpose: Internal carotid artery dissection (ICAD) is relatively rare in Japan. We investigated the characteristics of ICAD patients after non-hemorrhagic onset in our department. Methods: We reviewed and analyzed the clinical records of 16 patients (18 lesions) treated between January 2011 and December 2017. We analyzed the background and treatment methods, complications, clinical course and outcome of 16 patients. Results: Patient age was ranged from 20 to 72 years (average, 48.5 years). Fifteen patients were male (93.8%). Fifteen lesions located on the extracranial and 3 lesions located on the intracranial. Nine lesions were cerebral infarction onset and 7 lesions were headache and neck pain onset, 2 lesions were incidental. Nine lesions were performed only medical treatment and 9 lesions underwent endovascular treatment. Medical treatment was blood pressure management and antithrombotic therapy, and in all cases of endovascular treatment, the stent placement was made in the dissection part. In the course after treatment, good outcome [modified Rankin Scale (mRS): 0–2] were 13 patients and poor outcome [mRS: 3–6] were 3 patients. Conclusion: Depending on the case, 9 patients who underwent intravascular treatment for cases of acute occlusion and symptoms worsening obtained relatively good outcome.

A 41-year-old man with ulcerative colitis and antiphospholipid antibody syndrome as the underlying disease was taken the direct oral anticoagulant for a history of repetitive deep venous thrombosis, which was temporarily stopped because of the recent bloody stool. As the pulmonary embolism was occurred immediately after the discontinuation of the anticoagulant, the patient was hospitalized and the intravenous heparin administration was started. Headache and the left hemiparesis were suddenly appeared on the day six of the hospitalization. Magnetic resonance images revealed a cerebral infarction on the right parietal lobe and the thrombus in the sagittal sinus and the transverse sinus. The patient was diagnosed with cerebral venous sinus thrombosis. On the following day, decompressive craniectomy was performed for acute brain swelling from the expanded bilateral cerebral hemorrhagic infarction. Unfortunately, the patient was died on the day nine of the hospitalization. Eventhough either ulcerative colitis or antiphospholipid antibody syndrome can be a risk of thrombosis, report of thrombosis concurrent with the two diseases is extremely rare and only four cases have been reported in the literature. We reported another rare case with literature review.

Here, we describe a case of carotid artery stenting (CAS) for common carotid artery mobile plaque associated with ipsilateral retinal artery occlusion. The plaque recurred as a mobile protrusion after the first CAS. Deployment of the second overlapping stent was not able to cover the entire plaque either, but the plaque was immobilized. The plaque disappeared in 3 months under conservative therapy. Although the mechanisms of the mobile plaque regression after CAS remains to be elucidated, the unique clinical course of the present case may suggest healing process of the mobile plaque other than compression and coverage by the stent.

We report a case of symptomatic intracerebral hemorrhage (ICH) after thrombolysis with recombinant tissue plasminogen activator (rt-PA) in a patient treated with edoxaban. An 82-year-old man consulted our hospital due to sudden onset of dysarthria and right hemiparesis. Physical examination was done in the National Institutes of Health Stroke and found the scale score of 5. His past history included atrial fibrillation, chronic kidney disease, and sick sinus syndrome. He was taking edoxaban 15 mg every morning, less than the usual dosage of 30 mg/day, to reduce the risk of hemorrhagic complication. Laboratory data on admission were unremarkable, except for elevated serum creatinine level. Head computed tomography (CT) revealed no abnormalities. Administration of rt-PA was performed at 3 h 20 min after onset and 7 h after the last intake of edoxaban. Immediately after completion of rt-PA administration, the patient became drowsy and right hemiplegia worsened. Emergent brain CT showed left putaminal hemorrhage. The ICH had enlarged by the next day, so the patient was transferred to a rehabilitation hospital with a modified Rankin scale score of 4. The retrospective review of T₂^*-weighted magnetic resonance imaging and magnetic resonance angiography obtained at 9 months before the stroke discovered a faint hypointense lesion in the left putamen and chronic occlusion of the left middle cerebral artery. Risk factors of ICH after thrombolysis with rt-PA are unclear in patients receiving direct oral anticoagulant. In this case, advanced age, chronic kidney disease, very recent intake of direct oral anticoagulant, and the old asymptomatic small hemorrhagic lesion may have promoted the occurrence of ICH.

We report a case of symptomatic chronic total occlusion of the common carotid artery after bilateral fronto-temporal craniotomies treated by carotid artery stenting (CAS). In June 2016, a 61-year-old man developed a subarachnoid hemorrhage. Neck clipping was performed on the ruptured cerebral aneurysm in the right internal carotid artery. In September 2016, neck clipping was performed on the unruptured cerebral aneurysm in the left internal carotid artery. In June 2017, the same person complained of dysarthria and left hemiplegia. Magnetic resonance imaging (MRI) showed a cerebral infarction in the corona radiata on the right side and cervical magnetic resonance angiography (MRA) showed an occlusion spanning from the right common carotid artery to the internal carotid artery. Medical therapy was performed; however, transient ischemic attack (TIA) occurred repeatedly, so the patient was transferred to our hospital, where percutaneous CAS for the chronic total occlusion (CTO) spanning from the right common carotid artery to the internal carotid artery was performed. No abnormal neurological findings were exacerbated postoperatively, and the repeated TIA also disappeared. At this time, the patient was transferred to the initial hospital (mRS 1). There is no established treatment for CTO spanning from the common carotid artery to the internal carotid artery. As in this case, the patient may be resistant to medical treatment, but the extracranial-intracranial bypass is difficult to perform, CAS is considered to be a feasible treatment for CTO.

We report a rare case of a 68-year-old man who presented with delayed cerebral vasospasm following intracerebral hemorrhage with ventricular rupture. His initial computed tomography (CT) revealed a hemorrhage in the left basal ganglia and a hematoma throughout all ventricles without evident subarachnoid hemorrhage. CT angiography on the same day did not show any cerebral vasospasm. Follow-up CT on the next day demonstrated diffuse subarachnoid clots in the sulci of the brain and the wash-out of intraventricular hemorrhage. He suffered disturbance of consciousness and left hemiparesis on 12 days after the hemorrhage. Magnetic resonance imaging revealed cortical infarction in right parietal lobe and angiography revealed severe narrowing of the bilateral anterior, middle, and posterior cerebral arteries. His level of consciousness and hemiparesis improved 3 weeks after the neurological deterioration. Magnetic resonance angiography on 3 weeks after the neurological deterioration demonstrated improvement of the severe vasospasm of the cerebral arteries. We should consider the risk of delayed cerebral vasospasm after intracerebral hemorrhage with ventricular rupture, even if there is no subarachnoid clot on initial CT scan.

We report a rare case of brain stem infarction caused by an intracranial thrombosed aneurysm in Kimura’s disease (KD) treated with long-term steroid therapy. A 58-year-old man was admitted to our hospital with dysarthria. Magnetic resonance imaging and magnetic resonance angiography revealed brain stem infarction and a thrombosed fusiform aneurysm from the basilar artery to the left vertebral artery. Digital subtraction angiography revealed another fusiform aneurysm in the extracranial portion of the right vertebral artery. Abdominal computed tomography angiography revealed a thrombosed aneurysm of the right common iliac artery. KD is an immune-mediated chronic inflammatory disease of unknown etiology and its treatment is unclear. Several reports have described arterial diseases associated with KD, and this report suggests that KD with long-term steroid therapy can potentially cause complications, such as thromboembolism and vasculitis.

A 68-year-old woman experienced episodes of repeated photic attacks of variable color lights and of color perception error for a part of the objects in her left visual field. The visual symptoms represented a simple unformed visual hallucination. MRI study showed a small infarction of right lateral geniculate body. The Goldmann perimetry showed asymptomatically incongruent small scotomas in her left visual field. The lateral geniculate body constitutes cell layers with color-sensitivity, and integrates visual information from both the eyes through ipsilateral uncrossed and contralateral crossed retinal fibers. Its partial dysfunction may be the underlying mechanism.