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Objective: Carotid artery stenting (CAS) is a well-accepted treatment for atherosclerotic stenosis of carotid arteries. Since the occurrence of distal embolization with CAS is still a major concern embolus protection devices (EPD) are usually employed during the procedure. We examined two types of embolus protection filters (Angioguard XP (AG); Filterwire EZ (FW)) and evaluated the function. Thus, the filter was examined postoperatively and the cause of intraoperative flow impairment was evaluated. Materials and methods: CAS was performed for 54 patients with carotid artery stenosis (55 lesions: 25 AG; 27 FW; 3 others). After completing CAS the filter membrane was stained with hematoxylin-eosin (HE) solution and removed from the filter strut. Once mounted on a glass slide the filter was evaluated under a microscope. The area occupied with debris was measured and the relationship to intraoperative flow impairment was evaluated. Furthermore, the relationship between perioperative ischemic complications and intraoperative flow impairment was statistically analyzed. Results: Microscopic observation of the slide revealed the pore density of the FW was 1.5 times higher than that of the AG and the filter area of the FW was 2.5 times wider than than the AG. HE staining facilitated characterization of the debris composition. The area occupied with debris was significantly more in the AG (0.241 ±0.13 cm2) than in the FW (0.129 ±0.093 cm2). Thus, fibrin was significantly more precipitated in the AG. Flow impairment occurred in 6 AG cases (24.0 %) and 4 FW cases (14.8 %). It was induced by filter obstruction in the AG and by vasospasms in the FW. Three cases treated with AG (12.0 %) were complicated with cerebral infarction and all of them were related to flow impairment. One FW case (3.7 %) was complicated with cerebral infarction in presence of preserved flow throughout the intervention. Conclusion: Filter function is different according to each design. The cause of flow impairment was attributable to filter obstruction in the AG group and to vasospasms in the FW group. Filter obstruction tends to result in cerebral infarction., Acta Neurochirurgica, 156(9), pp.1721-1728; 2014

Parent artery occlusion for intractable aneurysms or sinus packing for dural arteriovenous fistulas (DAVFs) is sometimes difficult and requires many expensive coils to accomplish complete occlusion. To help solve these problems, we reviewed our experience using 0.035-inch coil (0.035 coil; Boston Scientific, San Leandro, CA, USA), which has been used in cardiovascular and abdominal lesions. These 0.035 coils were preferably used in addition to the detachable and fibered coils for patients with intractable aneurysms, traumatic vessel blowout, and DAVF. Our strategy was as follows: (1) detachable coils were deployed first for the ideal anchoring of the coils; (2) small fibered coils were additionally deployed to stabilize the coil mass; (3) 0.035 coils were deployed to complete the occlusion. From January 2012 to December 2013, seven consecutive patients were treated by endovascular embolization with 0.035 coils. Reasons for intervention were parent artery occlusion for carotid blowout (n = 1), internal carotid artery aneurysm (n = 2), traumatic vertebral artery injury (n = 2), vertebral AVF (n = 1), and transverse sinus-sigmoid sinus DAVF (n = 1). In our cases, a mean of 20.1 ± 8.5 coils per vessel were placed, and mean total coil length was 258.4 ± 91.5 cm per vessel. All procedures were safely performed and complete occlusions achieved. From our initial experience and treatment results, we believe endovascular parent artery occlusion or sinus packing with 0.035 coils to be useful in terms of reducing the number and expense of coils and also accomplishing immediate occlusion.

Here we describe a case of iliac artery injury during carotid artery stenting (CAS) treated by covered stent. A 74-year-old man underwent CAS for asymptomatic right carotid artery stenosis. Under local anesthesia, the right common femoral artery was punctured and an 8 Fr long sheath introducer was placed. However, the sheath kinked because the iliac artery was tortuous. We introduced the stylet to the sheath again and tried to extend the kinking. It failed, and the arterial dissection was identified at the lateral iliac artery. The kink was extended with triple coaxial system, i.e. guidewire, coaxial catheter, and a guiding catheter; CAS was performed with distal filter protection. Before removal of the sheath, the right iliac artery was examined, and extraversation of the contrast medium was observed. The balloon catheter was placed to the lesion and dilated for the hemostasis. However, it failed, and the covered stent was placed subsequently. Although blood tests revealed anemia and CT showed retroperitoneal hematoma after the treatment, further complication did not occur. Treatment with covered stent for the vessel injury was effective., Acta Neurochirurgica, 156(3), pp.561-564; 2014

The authors present the case of a 66-year-old female who developed progressive pulsating exophthalmos, a bruit, and conjunctival chemosis 7 months after a head injury. These symptoms, though highly suspicious of carotid cavernous fistula, were caused by an arteriovenous fistula (AVF) between the inferolateral trunk (ILT) and the ophthalmic veins. A direct AVF at the branch of the ILT without involvement of the cavernous sinus is extremely rare, but could occur in the case of acquired AVF since the ILT has some branches around venous structures outside the cavernous sinus. The clinical implications of this case are discussed in terms of the anatomical aspects.

Recently, endovascular management has been reported as a feasible option for Takayasu aortitis. However, few papers have focused on restenosis in the follow-up, and therefore, it is important to predict high-risk cases for restenosis after endovascular treatment. We herein report three cases with Takayasu aortitis showing repeated restenosis after endovascular percutaneous transluminal angioplasty (PTA)/stenting and discuss its clinical implications with a review of the literature. We should keep in mind that endovascular PTA/stenting for Takayasu aortitis does not always keep the patency of the affected vessels, and severity of the stenosis and/or uncontrollable systemic inflammation could be a risk factor for restenosis. Therefore, careful follow-up under strict control of inflammation is mandatory. Overall, this method is effective as an initial treatment since repeated PTA is available until collateral supply develops.

A 30 year old female with a fusiform aneurysm of the cervical vertebral artery causing nerve root compression and associated with neurofibromatosis-1 was successfully treated with endovascular methods which resolved the mass effect. This is the first report demonstrating the reduction of the mass effect of an aneurysm on a cervical nerve root with endovascular treatment by using MR neurography.

T2*-weighted gradient echo (GE) imaging is useful for detection of intracranial hemorrhage in the patients with diffusion axonal injury (DAI). However, the temporal changes in the DAI-related lesions on T2*-weighted GE images are not clear. We report two very rare cases with DAI in which lesions identified on T2*-weighted GE images resolved in less than ten days.