Although transfemoral approach is common for thrombectomy, it is time-consuming in some patients such as bovine type aortic arch, type 3 aorta, and extreme arterial tortuosity. The patient is a 90-year-old female presented with right paralysis and aphasia, NIHSS16. Cerebral CT/CTA showed a cerebral infarction due to a left middle cerebral artery occlusion. CTA of aortic arch showed a chronic aortic dissection, bovine type aortic arch, and type 3 aorta. Mechanical thrombectomy was performed via the right transbrachial approach with TICI 2b recanalization. Transbrachial approach can be an effective choice for the difficult approach of mechanical thrombectomy. Preoperative evaluation of the aortic arch is effective for selecting the appropriate approach route.

A 91-year-old woman was admitted to our hospital due to the right conjugate deviation, left conjugate gaze palsy, left central facial palsy and right hemiparesis. MRI of the brain revealed an infarction located in the left paramedian lower pontine tegmentum and upper medulla. Her conjugate deviation and conjugate gaze palsy were caused by the damage of paramedian pontine reticular formation and/or abducens nucleus at the lower pontine tegmentum. Although her conjugate deviation and conjugate gaze palsy were consistent with Foville syndrome, her facial palsy was not peripheral but the central and the infarction did not involve the corticospinal tract at lower pontine on MRI. In this case, we considered that her contralateral hemiparesis and ipsilateral central facial palsy were caused by the lesion of the corticospinal tract and the aberrant fibers of the facial corticopontine tract (ex. the aberrant pyramidal tract in the medial leminiscus) at upper medulla.

The case was a 57-year-old male. The patient visited our department with the main complaint of pain in the left side of the neck, fever and facial edema. Disturbance of consciousness, neck stiffness, left hemiparesis and ataxia of the left arm were observed. An examination of the cerebrospinal fluid revealed findings suggestive of bacterial meningitis and a brain MRI showed left cerebellar infarction as well as occlusion from the left transverse sinus to the left internal jugular vein. A chest CT showed multiple septic emboli in both lungs. Staphylococcus capitis subsp. ureolyticus was detected from a blood culture and Lemierre’s syndrome was diagnosed. Antibiotic drug treatment was given with ceftriaxone, vancomycin, and meropenem and the signs of infection eased. Lemierre’s syndrome is a rarely occurring disease, but it has a variety of symptoms and delayed diagnosis that can be fatal. Cerebral infarction can also occur as seen in this case, thus and the possibility of Lemierre’s syndrome must be considered when patients present with cerebral infarction and signs of infection.

We report a case of gestational hypertension complicated by hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome in a 33-year-old primigravida the day after she underwent an emergency cesarean section at a different medical facility. Two days after the cesarean section, she was referred to our hospital after developing acute subdural hematoma and intracerebral hemorrhage. We performed an emergency evacuation of the acute subdural hematoma followed by decompressive craniotomy. However, intracranial pressure remained extremely high after surgery, and was treated with barbiturate therapy. With these treatments, her general condition and neurological symptoms gradually recovered. We performed cranioplasty, and she is now undergoing rehabilitation with the goal of ADL independence.

A 35-year-old male presented with sudden onset tetraplegia and consciousness disturbance. He had past history of congenital myopathy with a modified Rankin Scale (mRS) score of 3 points and a National Institutes of Health Stroke Scale (NIHSS) score of 14 points. Electrocardiography revealed atrial flutter. Three-dimensional computed tomography angiography revealed basilar artery (BA), right posterior cerebral artery (PCA), and right internal carotid artery (ICA) occlusions and indicated the presence of persistent primitive hypoglossal artery (PPHA). We performed intravenous tissue plasminogen activator and revascularization therapies for acute cerebral main trunk occlusion. We obtained recanalization of thrombolysis in cerebral infarction (TICI) grade 3 for both BA-PCA and ICA. An improvement of 2 points on the NIHSS was obtained on the 4^th hospital day. On the 30^th hospital day, he was transferred to another hospital for rehabilitation with a mRS score of 3 points. We report here a very rare case of successful treatment for embolic cerebral infarction of multiple major arteries with PPHA. Although PPHA is very rare and difficult to identify at the early stage of stroke, this rare anomaly should be considered in severe multiple cerebral infraction cases like that presented here.

Delayed spontaneous recanalization of a previously occluded internal carotid artery (ICA) has been occasionally reported. Here we describe five cases of delayed spontaneous recanalization of acute non terminal ICA occlusion (non-T ICA occlusion). In view of the mild neurological symptoms, all five cases received only medical treatment without thrombolytic therapy or surgical intervention for the occluded ICA in the acute phase. Initial ultrasound imaging showed a hypoechogenic plaque in two cases and a hypoechogenic clot in another two cases, all at the level of the carotid bifurcation. Spontaneous recanalization was observed within 39–859 (median; 69) days after the diagnosis of ICA occlusion. Though one patient suffered of asymptomatic cerebral infarction in the occluded side, none of the rest had subsequent cerebrovascular events in the interim period until recanalization. After spontaneous recanalization, carotid endarterectomy was performed for two patients with residual high-grade ICA stenosis. Delayed spontaneous recanalization of an occluded ICA may cause a second ischemic stroke. As such, it is important to closely follow-up patients with non-T ICA occlusion and mild clinical symptoms so that high-risk patients may be offered surgical intervention to prevent recurrence of an ischemic stroke.

We report a case of a 68-year-old woman who was diagnosed with isolated pulmonary arteriovenous malformation (PAVM) during follow-up of paradoxical cerebral embolism with patent foramen ovale (PFO). She developed acute cerebral infarction in left middle cerebral artery (MCA) territory with the occlusion of left MCA. Electrocardiogram showed a normal sinus rhythm. Transesophageal echocardiography revealed a PFO with right-to-left shunts, and Doppler ultrasound of venous system in the lower limbs revealed thrombosis in bilateral soleus veins. She was diagnosed with paradoxical cerebral embolism due to PFO, and started with an anticoagulant therapy. After 2 months, however, she developed upper gastrointestinal bleeding. The chest CT at the time revealed PAVM, and coil embolization was performed successfully. Although PAVM is rare and difficult to diagnose, we should take into account PAVM as a possible cause of cryptogenic stroke.

Traumatic pseudoaneurysms of the posterior inferior cerebellar artery (PICA) are rare. Here we report a pseudoaneurysm developed on the PICA after blunt head injury. A 35-year-old man hit the back of his head on the wall in a fight, and was admitted to our hospital. The computed tomography (CT) showed subarachnoid haemorrhage (SAH) at the foramen magna and an intraventricular hematoma accompanied by an acute hydrocephalus. 3D-CT angiography on admission did not show any aneurysm or other vascular abnormality. However, the left vertebral angiogram (Lt. VAG), 6 h after injury, revealed a saccular aneurysmal formation on the PICA slowly stained by pooled contrast medium, indicating a pseudoaneurysm. The patient underwent trapping and occipital artery-PICA (OA-PICA) bypass through a midlateral suboccipital approach. The bleeding point was identified as the laceration on the vessel wall of the lateral medullary segment of PICA surrounded by thick hematoma. Thus, the diagnosis was a pseudoaneurysm caused by the blunt head injury. Although the development of a traumatic pseudoaneurysm is usually delayed, this suggested that a pseudoaneurysm could be a different diagnosis of an acute traumatic SAH.

A 72-year-old woman presented with pain and visual loss in the left eye, and diplopia. Computed tomography demonstrated a soft tissue shadow at the left side of the posterior ethmoid sinus, then she was diagnosed as sinusitis. Ethmoidectomy, as well as administration of antibiotics and steroids, once improved her symptoms, but visual loss recurred and gradually worsened with repeating the process of transient improving by the administration of antibiotics and steroids, resulting in the orbital apex syndrome. The serum data of β-D-glucan and Aspergillus antigen showed both negative. Thus far the nasal biopsy had been performed twice but Aspergillus was not detected. Initial steroid responsiveness suggested a possibility of granulomatosis with polyangiitis, thus cyclophosphamide additionally administered, but had no effect. Consciousness disturbance developed and magnetic resonance imaging revealed brainstem infarction. At this time, β-D-glucan and Aspergillus antigen level were elevated in the serum and cerebrospinal fluid, and the diagnosis of invasive aspergillosis was confirmed. Vascular invasion by Aspergillus advanced to cerebral infarction one after another, and caused her to death. In case of the sinusitis advancing to orbital apex syndrome, if the possibility of invasive aspergillosis cannot be excluded, careful measures should be taken such as administrating of antifungal agent and performing repetitive biopsies.

A patient with recurrent episodes of transient dysarthria was described. The episodes with dysarthria were about 10 s in duration and occurred daily for a month and half. Neurologically constant fasciculation was observed in the lateral part of the tongue on the right side. Magnetic resonance cisternography revealed that the right hypoglossal nerve might be compressed by the right posterior inferior cerebellar artery (PICA) at the level of the hypoglossal canals. A daily medication of carbamazepine (400 mg/day) resulted in complete relief of symptoms. These findings support that the episodic dysarthria was due to a hypoglossal neurovascular compression syndrome by PICA.

Stroke is one of the main causes of long-term disability, and hemiparesis is a common disability following stroke. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that can modulate cortical and subcortical excitability by inducing a weak, direct current via electrodes placed over the scalp. Several studies, mainly performed in the chronic or subacute recovery phase after stroke, have reported a tDCS-induced functional motor improvement of the paretic hand. Various tDCS strategies, following a model of interhemispheric rivalry between the damaged and intact hemispheres, have been found to promote motor recovery. This suggests that motor recovery may be facilitated by upregulating the excitability of the affected motor cortex through anodal tDCS, down-regulating the excitability of the intact motor cortex through cathodal tDCS, or through bihemispheric anodal/cathodal tDCS. tDCS may facilitate stroke rehabilitation by restoring the balance between the hemispheres and combined with physical or occupational therapy can improve functional motor outcome. Several combination trials have been performed such as tDCS and robot-assisted arm-training, peripheral nerve stimulation, constraint-induced movement therapy, facilitating the beneficial effects in comparison with each intervention alone. Brain-derived neurotrophic factor (BDNF) plays an important role in neuronal plasticity and the pathophysiology of brain disorders. BDNF Val-66Met genotype may moderate the response to tDCS on post-stroke upper limb hemiparesis. Moreover, tDCS may alter BDNF and is therefore influenced by BDNF gene polymorphism.