Objective: The purpose of this study was to evaluate the effectiveness and neurologic outcome of patients treated with the Penumbra system (PS) in the setting of acute ischemic stroke.

Methods: A total of 45 patients with acute ischemic stroke due to large-vessel occlusion were treated with the only PS. In 27 patients, mechanical recanalization was combined with iV t-PA thrombolysis. Recanalization was accessed with the thrombolysis in Cerebral Infarction (TICI) score.

Results: The mean patient age was 75.5 years. The average NIHSS score at hospital admission was 18.3. Successful recanalization (TICI score > IIb) was achieved in 73% of patients, whereas recanalization rates of M2 & ICA occlusion was 56% and 67%, respectively. Median time from onset to recanalization was 350 minutes (90–360 minutes) and puncture to recanalization time was 28.9 minutes (13–54 minutes). At follow-up, 36% of patients showed a mRS of < 2 at discharge, whereas only 11% of the patients with ICA and M2 occlusion had a favorable result. One patient died during hospitalization due to hemorrhagic infarction, and none of the deaths was device-related.

Conclusion: In this study, the PS was an effective device for mechanical recanalization. Successful recanalization with the PS was associated with significant improvement of functional outcome in patients experiencing ischemic stroke. For the patients with ICA and M2 occlusion, it is necessary to evaluate how to recanalize occlusive site.

Objective: No therapeutic strategy has been established for in-stent thrombosis that occurs during the perioperative period of neuro-intervention. Herein, we report two cases who suffered from in-stent thrombosis and were effectively treated by prasugrel administration.

Case presentations: Case 1: In-stent thrombosis occurred just after stent-assisted coil embolization for an unruptured cerebral aneurysm. The thrombus kept growing during the neuro-intervention procedure despite the infusion of heparin, ozagrel, and argatroban. Next, when prasugrel was administered, the in-stent clot was immediately eradicated.

Case 2: In-stent thrombosis was revealed 5 days after carotid stent placement. The thrombus grew steadily and caused ischemic stroke despite antithrombotic therapies including strict heparinization. Prasugrel was subsequently administered, and the in-stent clot was immediately eradicated. The disappearance of the clot was confirmed by three-dimensional CT angiography (3D-CTA).

Conclusion: These cases demonstrate that prasugrel administration was effective for in-stent thrombosis relevant to neuro-intervention procedures. Prasugrel should be considered for in-stent thrombosis when other therapeutic methods are ineffective.

Objective: We report a case of very late in-stent thrombosis occurred 15 months after an incomplete stent-assisted coil embolization.

Case Presentation: A 54-year-old woman presented with two unruptured aneurysms in the left internal carotid artery (ICA) and the left anterior cerebral artery (ACA). At first, a left ICA aneurysm was treated by balloon-assisted coil embolization with rescue stenting using the enterprise vascular reconstruction device (VRD) for the protruding coil into the left ICA. Postoperetive dual-energy CT demonstrated the wall apposition of Enterprise VRD. Dual antiplatelet therapy was continued for 6 months after coil embolization. Post 12 months, antiplatelet therapy was terminated. Subsequently, a clipping surgery was performed for a left ACA aneurysm 15 months after the coil embolization. Two hours after the surgery, she presented with right hemiparesis and aphasia. MRI-diffusion weighted image (MRI-DWI) showed early ischemic sign at the left hemisphere. CT angiography showed an in-stent thrombosis. Thrombolysis was performed immediately, however, postoperative MRI-DWI demonstrated infarction-related neurological deficits.

Conclusion: It is possible that the activation of platelet aggression, blood coagulation due to operative stress, and incomplete stent apposition of Enterprise VRD might cause very late in-stent thrombosis. This case may provide the considerable order of therapies, including endovascular treatment and clipping surgery, for cerebral aneurysms.

Objective: In 2015, the usefulness of mechanical thrombectomy for cerebral infarction was clarified. However, the usefulness of angioplasty for cerebral infarction with intra/extra-cranial major artery stenosis is still unclear. We report a patient with acute cerebral infarction who was successfully treated with thrombolytic therapy, mechanical thrombectomy, and angioplasty with stenting with a review of the literature.

Case presentation: A 62-year-old male was diagnosed with cerebral infarction associated with right internal carotid artery occlusion (ICA) in the previous hospital and transported to our hospital 158 minutes after onset. After intravenous thrombolysis with recombinant tissue plasminogen activator, endovascular treatment was performed, and imaging showed occlusion at ICA origin. When manual aspiration was performed using a 9Fr Optimo catheter inserted into the ICA, stenosis in the foramen lacerum could be confirmed. After percutaneous transluminal angioplasty (PTA) at the foramen lacerum of the ICA, mechanical thrombectomy was performed for M1 occlusion using Penumbra 5MAX ACE, and complete recanalization was achieved. For residual stenosis in the foramen lacerum of the ICA, a coronary stent was placed, and the procedure was completed. Head magnetic resonance angiogram (MRA) on the next day revealed improvement in the visualization of the anterior circulation, and the clinical findings also markedly improved.

Conclusion: We report a patient who showed a favorable course after manual aspiration in the internal carotid artery, intracranial PTA, mechanical thrombectomy in the right M1, and stenting for the residual stenosis in the intracranial internal carotid artery.

Objective: We report a case of cavernous sinus dural arteriovenous fistula (CS-DAVF) in which another feeder in the other compartment became apparent just after selective transvenous embolization (TVE).

Case presentation: A 76-year-old woman complained of tinnitus and diplopia, proptosis, and conjunctival injection of right eye. Cerebral angiography showed CS-DAVF with fistulous points around right cavernous sinus (CS), posterior intercavernous sinus and left CS, draining to the right CS and right superior ophthalmic vein via basilar sinus. Although selective TVE including the affected left CS was performed via right inferior petrosal sinus, another feeder in the right CS became apparent just after embolization, and additional embolization was required.

Conclusion: It is important to recognize that another feeder in the other compartment may become apparent just after selective TVE of CS-DAVF.

Objective: A case of acute ischemic stroke involving intracranial middle cerebral artery and extracranial internal carotid artery (tandem lesions) requires some ingenuity to select appropriate revascularization devices in treatment. A case of tandem lesions treated by means of carotid artery stenting and revascularization devices was reported.

Case Presentation: A 66-year-old man was found lying on the floor, and was transferred to our hospital. The scores of neurological evaluation were as follows: Japan Coma Scale (JCS) 100, Glasgow Come Scale (GCS) 9 (E1V3M5) and National Institute of Health Stroke Scale (NIHSS) 31. The patient presented with left hemiparesis (Manual Muscle Test [MMT] 0/5). CT revealed no intracranial hemorrhage and cerebral infarction. MRI revealed no acute cerebral infarction, however, MRA revealed an occlusion of the right internal carotid artery (ICA). Within two hours after the onset of stroke, rt-PA was administered. NIHSS was improved to 11. Angiogram revealed an occlusion of the origin of the right ICA and the right middle cerebral artery. Recanalization (TICI IIb) was achieved by means of carotid artery stenting (CAS) and revascularization devices. Although the patient presented with dysarthria and left incomplete hemiparesis (MMT 3/5~4/5) after treatment, he could complete personal care. A modified Rankin Scale at the time of discharge was two.

Conclusion: Recanalization for an ischemic stroke due to tandem lesions by means of CAS and revascularization devices was useful, however, appropriate selection of patient and appropriate selection of revascularization devices were required.

Objective: We report a novel technique of the proximal balloon protection (PBP) during internal carotid artery stenotic lesion crossing, and the following total distal balloon protection (TDBP) for transbrachial carotid artery stenting (TB-CAS) with 7Fr-guiding sheath.

Case presentation: A 83-year-old male patient presented with an asymptomatic severe stenosis in the right internal carotid artery (ICA) complicated with ipsilateral occipital-vertebral artery anastomosis and severe aortic arch atherosclerosis. A 7Fr-guiding sheath was inserted into the right brachial artery and navigated into the right common carotid artery (CCA). The PBP was obtained by inflating the separately advanced GuardWire in the external carotid artery (ECA) and the 5.2Fr Selecon MP Catheter in the distal CCA. The TDBP was achieved with the following process; (1) a second GuardWire was navigated into the distal ICA under the PBP through the Selecon MP Catheter, and then inflated to achieve the distal protection, (2) The Selecon MP Catheter was deflated and withdrawn, (3) the inflated GuardWires in the ICA and ECA complete the TDBP. Then TB-CAS was performed under TDBP without any complication.

Conclusion: This protection technique enables the PBP and the subsequent TDBP with a 7Fr-guiding sheath and may be useful when performing TB-CAS.