Stroke occurring while driving may not be uncommon. While some elderly drivers sustaining large vessel occlusion (LVO) and subsequent severe stroke may be brought to emergency departments after causing traffic accident (TA), there were few reports on whether mechanical thrombectomy (MT) can be safely performed in that population. Between 2010 and 2019, we treated two elderly drivers who had caused TA secondary to LVO-induced stroke by MT. While MT established good recanalization within 6 h of TA in both patients, the outcomes had not been favorable: a hemispheric infarction developed in a patient with an MCA occlusion and a large hemorrhage developed in the other patient with an ICA occlusion, creating doubt that their outcomes might have been different if MT had been performed earlier. Their therapeutic timelines were critically analyzed to identify what had been the medical/social activities causing delay. The interval between TA and recanalization was trichotomized: (1) between TA and arrival, (2) between arrival and arterial puncture, and (3) between arterial puncture and recanalization. During (1), securement of an injured driver to a backboard in one and accident investigation by police in the other were found to have consumed extra time. During (2), performing bodily CT and abdominal ultrasound was found to have consumed extra time. Coordinated effort by emergency physicians and strokologists to shorten the door-to-needle-time is warranted to improve the outcomes of drivers sustaining large vessel occlusion and causing traffic accident.

We report the case of a 77-year-old female patient with symptomatic cervical internal carotid artery stenosis associated with persistent primitive proatlantal artery (PPPA) type I. She was admitted with total aphasia and severe right hemiparesis. Diffusion-weighted imaging revealed multiple infarctions in the watershed area of the left cerebral hemisphere. Digital subtraction angiography revealed severe carotid stenosis just proximal to the PPPA in the left internal carotid artery. The lesion had a massive unstable plaque, and the stenosis exhibited marked progression; therefore, carotid artery stenting (CAS) was planned. Due to concerns regarding debris migration to the vertebrobasilar system via the PPPA, CAS was performed after the intentional PPPA occlusion with coils. Risk of posterior-circulation ischemia during CAS should be considered in patients with primitive carotid–basilar anastomoses.

Tentorial dural arteriovenous fistula (DAVF) usually manifests as parenchymal brain injury, such as intracranial hemorrhage or subarachnoid hemorrhage, and very rarely as single onset of acute subdural hemorrhage (ASDH). We describe a case of tentorial DAVF manifesting as ASDH in the posterior fossa with a favorable outcome after early direct surgery. A 29-year-old man suffered from sudden onset of severe headache and vomiting, and was transferred to our emergency department. Head computed tomography and magnetic resonance imaging showed ASDH in the right posterior fossa. Cerebral angiography showed tentorial DAVF with a shunting point in the right tentorial notch, with evidence of venous reflux and varicose vein formation. We attempted endovascular embolization, but guidance of the microcatheter to the shunting point was difficult. Therefore, we performed surgical venous transection, resulting in complete occlusion of the shunting point. Tentorial DAVF manifesting as ASDH, not associated with parenchymal brain damage, benefits from direct surgery, which allows simultaneous radical hematoma removal and venous transection.

Double origin of the posterior inferior cerebellar artery (DOPICA) is a rare anatomical variant that is frequently associated with aneurysms. In this report, we describe a case of coil embolization of a ruptured aneurysm of the posterior inferior cerebellar artery (PICA), and despite occlusion of the entire PICA during the procedure, the patient survived ischemia due to collateral blood flow from another origin of the PICA. A 35-year-old man with dizziness, nausea, and headache presented with subarachnoid hemorrhage on head computed tomography (CT). Digital subtraction angiography (DSA) showed side-wall-type aneurysm in the right PICA and coil embolization was performed. The parent artery was spared and only the aneurysm was embolized successfully. The patient had no postoperative complications or symptoms. Seven days after the surgery, MRI showed no new cerebral infarction, but a magnetic resonance angiogram (MRA) showed occlusion at the origin of the PICA and the aneurysm. DSA showed that a second origin of the PICA functioned as collateral circulation to supplement the perfusion of the distal PICA. In PICA aneurysms in patients with DOPICA, a second PICA origin may serve collateral circulation after coil embolization.

A 78-year-old woman was diagnosed with cerebral infarction due to left hemiplegia by her family physician and was transferred to our hospital. On arrival, she had the NIHSS score of 15, right M1 occlusion on head MRA taken by her family physician, and a DWI-Alberta stroke program early CT score (DWI-ASPECTS) of 8. A white thrombus was retrieved by thrombectomy, and recanalization of thrombolysis in cerebral infarction (TICI) grade 3 was obtained, but the left hemiplegia did not resolve. On day 2, there was progression of impaired consciousness, the NIHSS score was 19, right M1 occlusion was observed again on head MRA, and the DWI-ASPECTS was 5. A white thrombus was retrieved again by the second thrombectomy, leading to TICI grade 2b recanalization. Postoperative contrast-enhanced CT of the trunk showed advanced pancreatic cancer. Based on elevated D-dimer levels and characteristics of the thrombi, we determined that the mechanism of the first M1 occlusions was cancer-associated embolism. The patient died of the primary disease on day 39. Cancer-associated occlusion of the major cerebral artery requires careful follow-up because of the possibility of reocclusion of recanalized sites with vascular endothelial damage due to hypercoagulable conditions in a short time period after mechanical thrombectomy.

A 60-year-old man was admitted to our hospital for 12 days with acute cerebral infarction due to occlusion of the right anterior cerebral artery A2 approximately two months previously. He presented with mild right hemiparesis and executive dysfunction at work, and was readmitted for acute cerebral infarction due to occlusion of the left proximal middle cerebral artery (MCA) M1. High-resolution magnetic resonance vessel wall imaging (VWI) revealed concentric wall thickening at the site of occlusion of the left proximal MCA M1. A sample of his cerebrospinal fluid was subjected to a FilmArray Meningitis/Encephalitis panel for the diagnosis of central nervous system vasculitis, and varicella-zoster virus (VZV) nucleic acid was detected. Although no preceding rash was observed, VZV vasculopathy was suspected, and the patient was treated with intravenous acyclovir and oral prednisolone. His symptoms improved after treatment. Contrast-enhanced magnetic resonance VWI revealed wall thickening and enhancement at the site of occlusion of the left proximal MCA M1. Follow-up VWI nine weeks after the treatment revealed decreased wall thickening and enhancement. Furthermore, follow-up magnetic resonance angiography three and a half months after the treatment revealed recanalization of the left proximal MCA M1. The FilmArray Meningitis/Encephalitis panel was useful for earlier diagnosis, and VWI findings were also useful for diagnosis and prognosis prediction.

Distal anterior inferior cerebellar artery (AICA) aneurysms are extremely rare and are typically treated using clipping, trapping, or parent artery occlusion. In this case report, we present a patient who received endovascular treatment for a ruptured AICA aneurysm in the meatal loop, which resulted in a favorable outcome. The patient was a 51-year-old male who presented with a sudden headache. A CT scan of the brain revealed a thick subarachnoid hemorrhage in the posterior cranial fossa and suggested the presence of a right distal AICA aneurysm dissection. Endovascular treatment was performed with the intention of parent artery occlusion, resulting in intra-aneurysmal coil embolization. Postoperatively, the patient did not experience any neurological deficits, such as hearing dysfunction or facial paralysis. Follow-up angiography revealed no aneurysm recurrence, and blood flow in the right AICA was maintained. When treating peripheral aneurysms of the AICA, intra-aneurysmal coil embolization is an effective method for preserving the function of the facial and auditory nerves while reducing the incidence of new cerebral infarctions. However, periodic vascular evaluation is essential due to the high likelihood of recurrence.

We report an autopsy case of the elderly patient with invasive Aspergillus sinusitis that developed brain abscess and mycotic aneurysm causing subarachnoid hemorrhage (SAH). A 83-year-old woman with a history of left facial pain and fever over 3 months was admitted with disturbed consciousness. CT and MRI disclosed left sphenoid sinus opacification with erosion of lateral wall, and extension into the left temporal lobe and posterior horn of left lateral ventricle with hydrocephalus. Second CT revealed SAH and left internal carotid artery aneurysm nearby abscess of the temporal lobe. Ventricular drainage and antifungal therapy by voriconazole were performed but subsequent CT showed the recurrence of SAH and internal carotid artery aneurysm was enlarged. Although antifungal therapy was continued, severe heart failure and renal dysfunction developed, and the patient eventually died. A pathological autopsy identified the hyphae consistent with Aspergillus species located in abscess at the temporal lobe, sphenoid sinus, and the aneurysmal vessel wall. That confirmed left brain abscess and mycotic aneurysm resulting from invasive Aspergillus sphenoid sinusitis pathologically.

A 90-year-old woman, being treated with apixaban for chronic atrial fibrillation, was transferred to our hospital with consciousness disturbance and right hemiplegia. Head MRI/A revealed acute cerebral infarction in the whole territory of the left posterior cerebral artery and occlusion at the P1 segment of the artery. Chest roentgenogram showed the right-sided aortic arch and the following contrast-enhanced CT revealed a Kommerell’s diverticulum (KD) complicated with aberrant left subclavian artery. From the filling defect in the diverticulum, we suspected that the thrombus in the KD was the cause of the embolic cerebral infarction. KD is a congenital malformation formed in the process of aortic arch formation and is often found incidentally when searching concomitant anomaly of the right-sided aortic arch. When KD causes symptoms due to its expansion and compression to adjacent organs, it eventually leads to fatal complications, rupture or dissection, and swift surgical repair is recommended. Although cerebral complications may occur secondary to rupture or dissection, ischemic stroke due to thrombus in the KD has not been reported. We present a very rare case of high-aged cerebral infarction caused by KD and treated with another direct oral anticoagulant, rivaroxaban.