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Mechanical thrombectomy using a stent retriever for acute large vessel occlusion is indispensable in stroke treatment, however, vasospasm may occur. The objective of this retrospective study was to investigate which cases are more likely to experience vasospasm after thrombectomy with stent retrievers.We included 29 patients diagnosed with acute cardiogenic cerebral embolism who were treated with stent retrievers at our facility from December 2014 to December 2017. Atherothrombotic brain infarction cases were excluded because it was difficult to evaluate for vasospasms. Vasospasm was defined as reversible arterial narrowing of80% of the normal vessel diameter after usage of the stent retriever. The age, sex, type of stent retriever, occlusion site, number of procedures, thrombolysis in cerebral infarction (TICI) grade, degree of vasospasm, intracranial hemorrhage by the procedure, and neurological outcomes were analyzed.Among the 29 cases, 12 (41.4%) resulted in vasospasm; nine cases were mild (20-50% stenosis) and 3 cases were severe (≥50% stenosis). Vasospasm frequently occurred in the distal part of the anterior circulation when compared to the proximal part. In addition, the frequency of vasospasm increased as the number of procedures increased. Pooled analysis showed significant difference in the intravenous tissue-type plasminogen activator group (P = 0.029). There was no significant difference in the other groups.Stent retrievers appear to cause vasospasm more than expected when including mild cases. Vasospasm tends to occur especially in cases with IV-tPA; prognosis is generally good, and it rarely requires any treatment.

Introduction Although cavernous sinus (CS) dural arteriovenous fistulas (d-AVFs) are usually treated with transvenous embolization (TVE) via the inferior petrosal sinus (IPS), IPSs are sometimes thrombosed and angiographically invisible. In such cases, the first obstacle to TVE is detecting the entry to the IPS. We report a new technique for TVE via IPS using intravascular ultrasonography (IVUS). Methods Three consecutive cases of CS d-AVF with ipsilateral or bilateral IPS occlusion were involved in this study. On TVE, the orifice of the IPS was investigated with IVUS placed in the jugular vein or jugular bulb. Results This technique has been successfully adapted in all three cases. In two of these cases, IPS was well visualized with the help of IVUS, and TVE was successfully performed. Conclusion To our knowledge, this is the first report to mention the usefulness of IVUS for detecting angiographically occult IPS.

Background and Purpose Among adults with posterior fossa tumors, an intraaxial location of the tumor is less common than an extraaxial location. Moreover, the differential diagnosis of a single cerebellar tumor in adults is sometimes difficult by conventional magnetic resonance imaging. We aimed to report the findings of positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) and methionine in adult patients with intraaxial and solitary metastatic brain tumors. Materials and Methods FDG-PET was performed on 12 patients with posterior fossa tumors: 4 had solid hemangioblastoma (HB), 3 had primary central nervous system lymphomas, 1 had a glioblastoma, and 4 had single metastatic brain tumors (METs). Methionine-PET was performed on 9 patients except for 1 patient with a MET. The maximum standardized uptake value (SUVmax) of the tumor was measured and compared with pathologic findings. Results The SUVmax of FDG in HB was lower compared with that of other tumors (P = 0.001). On the other hand, the SUVmax of methionine in the HB cases was almost the same as that in other tumors (P = 0.07). Conclusion FDG-PET was helpful in differentiating HBs from adult cerebellar tumors.

Carotid artery stenting (CAS) is an effective and less invasive alternative to carotid endarterectomy for internal carotid artery (ICA) stenosis, but the guiding catheter is often technically difficult to introduce into the common carotid artery (CCA) in patients with concomitant atherosclerotic disease in the peripheral vessels or aorta. A new pull-through technique between the superficial temporal artery (STA) and the brachial artery was used to deliver the guiding catheter into the CCA safely and steadily. An 83-year-old male presented with repeated transient left hemiparesis caused by severe stenosis of the origin of the right ICA. He also had severe systemic atherosclerotic disease with occlusion of the bilateral femoral arteries. The innominate artery branched at an acute angle from the aorta. Therefore, catheterization of the right CCA seemed to be impossible using a conventional approach. The guidewire introduced from the right STA was lassoed by a loop snare wire and pulled out of the left brachial artery, forming the pull-through system. The guiding catheter could be introduced into the CCA from the left brachial artery over this guidewire. Subsequently, successful stent placement was performed under the distal protection. This new technique may facilitate safe and stable CAS even in patients with a severely tortuous access route due to concomitant atherosclerotic disease.

A 61-year-old woman was admitted for head injury after a traffic accident. Two months later, she developed abducens nerve palsy, chemosis, and pulsatile tinnitus. Right internal carotid angiography demonstrated a high flow direct carotid-cavernous fistula (CCF) at the C(5) portion with reflux into the superficial and deep sylvian veins, superior ophthalmic vein, superior petrosal sinus, and inferior petrosal sinus. Intravascular ultrasonography (IVUS) revealed a large fistula at the C(5) portion of the internal carotid artery (ICA). Coil embolization via transarterial and transvenous approaches under IVUS monitoring was performed. During the procedure, IVUS accurately detected protrusion of a coil into the parent ICA, and the parent artery could be preserved. IVUS monitoring is useful for embolization of direct CCF with coils.

We report two rare cases of progressive congestive myelopathy caused by dural arteriovenous fistulae (DAVF) at the foramen magnum. The first, a 69-year-old male with a 2-year history of progressive myelopathy, had symptoms unrecognized due to a past history that included spinal caries and congenital dislocation of the hip. The second, a 60-year-old male, had a recurrence of the myelopathy three months after endovascular occlusion of the DAVF feeding artery. Both patients were successfully treated by direct microsurgical interruption of the arterialized medullary vein with functional and radiological improvement. The clinical manifestations of DAVF at the foramen magnum are nonspecific, mimicking those of cervical spondylotic myelopathy or cervical neoplasm. Accurate and early diagnosis followed by complete obliteration of the fistula is mandatory to avoid permanent neurological deficit.

We obtained the venograms using the two-dimensional digital subtraction angiography (2D DSA) images and three dimensional rotation venography (3D RV) images and investigated the potential usefulness of the 3D RV compared with venograms of 2D DSA using the newly developed three-dimensional rotation angiography unit with a flat-panel detector (FPD). This study included 26 sides (11 left, 15 right) in 20 cases (4 males and 16 females) who underwent radiographic examination for management of intracranial tumors and vascular diseases between May 2003 and December 2003. Each patient underwent diagnostic angiography performed on a DSA unit with a FPD. In all patients, the 2D DSA images, including anteroposterior view and lateral view of the carotid artery, were obtained in two stereoscopic views. The 3D RV was used to produce volume-rendered images. Two neuroradiologists investigated the venous configuration of 3D RV compared with that of 2D DSA about the relationship of the venous drainage system on the temporal lobe according to Guppy et al.'s classification. Twenty-four sides of the 26 sides enabled the precious visualization on 3D RV images. In investigation of 2D DSA, 9 sides (37.5%) were classified into type A, 13 (54.2%) into type B, two (8.3%) into type C, and no sides into types D, E, and F. In investigation of 3D RV images, 10 sides (41.7%) were classified into type A, 9 (37.5%) into type B, 1 (4.2%) into type C, 2 (8.3%) into type E, and 2 (8.3%) into type F. Seven of 24 sides demonstrated discrepancy in results between 2D DSA and 3D RV. The 3D RV could be performed by setting the adequate delay in between the injection of the contrast material and starting time of third rotation to acquire the opacified images. In Guppy et al.'s classification, the 3D RV images could demonstrate the precious venous drainage including the venous lakes with use of multiple views and variable reconstruction compared with 2D DSA. Our DSA system with FPD could provide good 3D RV images. These images are very useful for the skull-base surgery because we can understand the three-dimensional vascular anatomy preoperatively.

Glucocorticoids (GCC) generally are administered to patients with brain tumors to relieve neurological symptoms by decreasing the water content in a peritumoral zone of edema. We hypothesized that diffusion imaging and apparent diffusion coefficient (ADC) values could detect subtle changes of water content in brain tumors and in peritumoral edema after GCC therapy. The study consisted of 13 patients with intra-axial brain tumor, and ADC was measured in the tumor, within peritumoral edema, and in normal white matter remote from the tumor before and after GCC therapy. ADC also was measured in normal white matter in four control patients with no intracranial disease who were treated with GCC for other indications. Conventional MR images showed no visually evident interval change in tumor size or the extent of peritumoral edema in any subject after GCC therapy, which nonetheless resulted in a decrease in mean ADC of 7.0% in tumors (P0.05), 1.8% in peritumoral edema (P0.05, not significant) and 5.8% in normal white matter (P0.05). In patients with no intracranial disease, GCC therapy decreased mean ADC in white matter by 5.4% (P0.05). ADC measurement can demonstrate subtle changes in the brain after GCC therapy that cannot be observed by conventional MR imaging. Measurement of ADC proved to be a sensitive means of assessing the effect of GCC therapy, even in the absence of visually discernible changes in conventional MR images.

A 63-year-old man presented with subclavian steal syndrome associated with left internal mammary artery (IMA) bypass graft to a coronary artery. He was admitted with a history of oppressive sensation in the chest, dizziness, and light headedness on exertion for 2 weeks in March 2002. He had undergone myocardial revascularization consisting of a left IMA-to-left anterior descending coronary artery graft in April 1988. His blood pressure was 140/70 mmHg in the right arm and 80/64 mmHg in the left arm. Aortic arch arteriography revealed complete occlusion of the left subclavian artery proximal to the left IMA takeoff and subclavian steal with anterograde flow of the left IMA. Percutaneous angioplasty and stent placement with protection of the left IMA bypass graft using a balloon catheter was successfully performed without complication by cerebral or myocardial ischemia. Complete recanalization of the occluded left subclavian artery and anterograde flow of the left vertebral artery were achieved. His symptoms disappeared and blood pressure in the left arm recovered. This variant of coronary subclavian steal might require protection of the left IMA during angioplasty and stent placement.

Two cases of fibrous dysplasia in the skull base bone appeared hypointense on T1- and T2-weighted magnetic resonance imaging, with accumulation of [11C]methyl-L-methionine ([11C]Met) on positron emission tomography (PET). Fibrous dysplasia is a benign bone disorder which is identified by its distinctive radiography, computed tomography, and bone scintigraphy findings. [11C]Met PET may indicate the presence of viable tumor-like cells in fibrous dysplasia.

A 57-year-old woman presented with a dural arteriovenous fistula (AVF) involving the superior sagittal sinus (SSS) based upon serial radiological examinations. Her chief complaints were headache and vomiting. Cerebral angiography and magnetic resonance (MR) venography revealed the sinus thrombosis involving the SSS, the bilateral transverse sinuses (TSs), and the right sigmoid sinus. Her symptoms disappeared after anticoagulant therapy. Follow-up MR venography revealed almost complete recanalization of the occluded sinuses, followed by restenosis of the SSS and the left TS and occlusion of the right TS without symptoms. She developed transient right hemiparesis 13 months after the initial onset. Cerebral angiography revealed a dural AVF involving the SSS with cortical reflux into the left frontoparietal region. The dural AVF was occluded by transarterial and transvenous embolization. Her symptom disappeared during the follow-up period.

A 69-year-old woman had suffered from diplopia on right lateral gaze for the last 4 months due to right abducens nerve paresis. Right carotid angiography showed a cavernous internal carotid artery (ICA) aneurysm of 17 x 16 x 14 mm size and a primitive trigeminal artery (PTA) variant supplying the territory of the posterior inferior cerebellar artery. Intraluminal occlusion of the aneurysm was performed with 15 Guglielmi detachable coils. The flow of the PTA variant and the ICA was preserved. Right abducens nerve paresis improved partially. PTA variant is a primitive artery originating from the cavernous ICA supplying the cerebellum without opacification of the basilar artery. Only four of the 67 cases of PTA variant were associated with an aneurysm of the PTA variant. The possibility of this rare association should be considered when treating cavernous portion aneurysm because of the risk of cerebellar ischemia.

A 66-year-old female developed exophthalmos, impaired visual acuity (perception of light), and diplopia one day after sudden onset of headache. Neurological examination revealed proptosis, chemosis, impaired vision, and ophthalmoplegia. Carotid angiography showed direct carotid-cavernous sinus fistula concomitant with an intracavernous aneurysm on the right side. Intraaneurysmal embolization using the Guglielmi detachable coils (GDCs) via the transarterial route was performed and complete occlusion of the fistula successfully achieved. The neurological deficits resolved completely by 6 months after embolization. Intraaneurysmal GDC embolization via the transarterial route may be an alternative for the treatment of direct carotid-cavernous sinus fistula due to rupture of intracavernous aneurysm.

Pitfall during the embolization and evaluation after the embolization for skull base meningiomas supplied by meningeal arteries of internal carotid artery (ICA) are reported. This study includes 15 cases of skull base meningiomas (two males and 13 females) that supplied by meningeal branches of internal carotid artery. The preoperative embolization was performed by these feeders. MRI findings and serum levels of C-reactive protein (CRP) after the embolization were examined. In ten patients among 15 patients the meningeal branches of ICA were dominant feeders. In ten patients out of 15 patients, the embolization from the meningeal branches of ICA was possible. Eight patients out of these ten patients were suffered from high fever and increase of serum level of CRP after the embolization. During the embolization for skull base meningiomas, the existence of collateral pathways between the ICA system and external carotid artery system were identified. The increase of serum levels of CRP might be recognized in the patients that effective embolization were performed.

Dear Sir, We would like to report a rare complication after transvenous embolization (TVE) of an isolated transverse sigmoid sinus (TSS) dural arteriovenous fistula (dAVF). A 72-year-old male complaining of right pulsatile tinnitus was referred to our hospital. A bruit was identified in the post-auricular region on the right side. There were no neurological deficits. Diagnostic angiography demonstrated a dAVF fed by branches of the occipital and posterior auricular artery and ending in an isolated transverse sigmoid sinus (Fig. 1a). The venous phase of the right common carotid angiography demonstrated absence of opacification of the diseased sinuses and of the ipsilateral inferior petrosal sinus (IPS) and jugular Bulb (JB) (Fig. 1b). TVE was performed under general anesthesia. A microcatheter was navigated to the diseased sinus via contralateral approach. This segment of sinuses was packed with detachable microcoils (GDC®/Targets Therapeutics, Fremont, CA, USA). Final control angiography showed complete obliteration of the shunt (Fig. 2). The pulsatile tinnitus disappeared immediately after the procedure. On postoperative day 1, the patient complained of dizziness, but MR with diffusion weighted images showed no abnormal findings. The dizziness improved within 10 days. After 10 days of hospitalization, a sudden hearing loss occurred in the right ear. Puretone audiography revealed a sensory neural hearing loss (SNHL) of 40 dB. A tentative diagnosis of sudden SNHL (SSNHL) was made by the ENT specialists. Intravenous drip infusion of corticosteroids and low molecular dextrin was initiated. Two weeks later, hearing loss had improved with 15 dB. To the best of our knowledge, no previous reports have described SNHL after TVE of a dAVF. When considering the etiology of the hearing loss in our case, two aspects must be discussed. First it should be made out whether this SNHL occurred incidentally or as a consequence of the procedure. Secondly, if the embolization caused the SNHL, the potential pathogenesis and clinical significance of the SNHL should be investigated. If the hearing loss was coincidental, the diagnosis of SSNHL would be the most likely diagnosis. Nevertheless, in the literature, the incidence of SSNHL is reported as low as 5–20/100,000 person-years [1, 2]. Moreover, it is highly unlikely that ipsilateral SSNHL would occur incidentally within 10 days after TVE. Therefore, it seems more likely that this SNHL has arisen as a consequence of the procedure. Although various reports have described SNHL caused by anesthesia [3], radiation [4], and contrast medium administration [5], these potential causes of hearing loss seem not to match for our case. Therefore, we considered that TVE itself must be responsible for this SNHL. Anatomically, the inner ear has two main venous drainage routes: the vein of the vestibular aqueduct (VVAQ) draining into the vertical portion of the sigmoid sinus or superior petrosal sinus (SPS); and the vein of cochlear aqueduct (VCAQ) draining into the JB or the caudal end of the IPS (Fig. 3a) [6]. Watanabe et al. reported the precise venous drainage of the inner ear in guinea pigs [7]. They reported the presence of minor collateral vessels between the VCAQ and the mucoperiosteal veins of the middle ear, which act as collateral channels in the event of venous congestion of the inner ear [7]. S. Yamauchi (*) :A. Nishio Department of Neurosurgery, Hokuto Hospital, 7-5 Inada, Obihiro, Hokkaido 080-0033, Japan e-mail: ymailadd@silver.ocn.ne.jp

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.

The efficacy of selecting non-responders to intravenous recombinant tissue plasminogen activator (rt-PA) for mechanical clot disruption (MCD) was investigated based on cerebral angiography in the acute stage following rt-PA therapy. rt-PA therapy using 0.6 mg/kg was performed in eligible patients within 3 hours of onset. Patients who did not show recanalization on cerebral angiography 1 hour after rt-PA initiation immediately underwent MCD. Clinical outcome was evaluated by National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, and 1 month, and by modified Rankin scale (mRS) score at 3 months. Eighteen patients were initially treated with intravenous rt-PA, with mean time from stroke onset to rt-PA therapy of 120 +/- 27 minutes. Eight of these patients underwent MCD. Seven of these eight patients had complete recanalization. Time to recanalization by percutaneous transluminal angioplasty from stroke onset was 258 +/- 59 minutes. Final recanalization was achieved in 16 of the 18 patients. Baseline NIHSS score improved significantly at 1 month (median from 22.5 to 4). Twelve of the 18 patients treated according to our protocol were classified as independent (mRS scores 0-2). No patients had symptomatic hemorrhage. MCD for non-responders determined by cerebral angiography at the end of intravenous rt-PA infusion can decrease the time to recanalization and improve recanalization rates, leading to good clinical outcome after acute stroke.

The authors report a case of subarachnoid hemorrhage and spinal root injury caused by an acupuncture needle buried in the posterior neck about 30 years before onset. A 33-year-old female presented with sudden onset of severe occipital headaches. Plain x-ray films of the cervical spine revealed a fine gold needle, about 1.5 cm in length, between the C1 and C2 vertebrae. The needle was piercing the spinal nerve root through the dural vein, and was removed. Postoperatively, the pain exacerbated by neck movement disappeared.

In the management of skull base chordomas, surgical treatment is essential to achieve long-term control. A petroclival chordoma growing laterally in the skull base is one of the most challenging tumors for neurosurgeons. We have treated petroclival chordomas based on the principle of maximal surgical resection of the tumor with minimal morbidity. Lateral skull base approaches were used to approach petroclival chordomas in eight patients. The surgical procedure involved removal of soft tumor tissue and extensive drilling of adjacent bony structures. Gross total resection of the tumor was achieved in six patients. Subtotal resection in the remaining two patients was associated with acceptable morbidity. In cases of petroclival chordomas, lateral skull base approaches can be used as a primary procedure, although those approaches may be associated with high rates of morbidity and mortality.

We report a dural arteriovenous fistula (AVF) that developed at a site on the midline dorsal surface of the dura mater that had been damaged by repeated lumbar punctures. A 61-year-old male patient had undergone repeated lumbar punctures and discectomy for severe lumbago 40 years before the present admission. After surgery, the lumbago symptoms resolved. However, 30 years after the operation, he started to experience dysaesthesia, motor weakness in both legs, and urinary disturbance. Physical examination revealed bilateral leg weakness, diminished deep tendon reflexes in the patellar and Achilles tendons bilaterally, and decreased superficial sensation below L1. Magnetic resonance imaging revealed swelling with intramedullary high intensity and multiple flow voids around the conus and spinal cord on T(2)-weighted images, and adhesive arachnoiditis. Spinal angiography revealed an AVF between the left lateral sacral artery and the S1 radicular vein at the site of the previous operation. Surgery was conducted to carry out excision of the dural AVF at the shunting point, the arterialized intradural vein, and lysis of the arachnoiditis. This case of dural AVF may have been caused by repeated lumbar punctures.

Background: A dural arteriovenous fistula (AVF) involving the transverse-sigmoid (T-S) sinus which is occluded at its proximal and distal ends i.e., an isolated sinus, runs the risk of haemorrhaging or causing serious neurological deficits as a result of its retrograde leptomeningeal venous drainage. While lesions of this type have not been considered to be treatable by percutaneous, transvenous embolisation, this paper challenges this view. Case Presentation: Two middle-aged men with dural AVFs involving the isolated left T-S sinus presented with motor aphasia due to focal brain edema or haemorrhage. Under local anaesthesia, transfemoral, transvenous embolisation was performed with a microcatheter that was passed through the occluded proximal transverse sinus from the right (contralateral) side. The isolated sinus was then occluded with platinum coils. This embolisation resulted in angiographic and clinical cure of dural AVFs in both patients. Interpretation: Transfemoral, transvenous embolisation is a therapeutic alternative for the treatment of dural AVFs involving the isolated T-S sinus. Embolisation obviates the need for craniotomy and general anaesthesia, which are required for the established modes of treatment, i.e., direct surgery or direct percutaneous sinus packing.

Two patients with acute embolic occlusion of the intracranial internal carotid artery and the lenticulostriate arteries were treated by local intraarterial fibrinolysis using tissue plasminogen activator. Although fibrinolysis started within 2.5 hours from the ictus, extravasation of the contrast medium from the lenticulostriate arteries occurred in the region of the basal ganglia. Local intraarterial fibrinolysis for acute embolic occlusion of the internal carotid artery may be a high-risk therapeutic intervention even within the ultra-acute stage, especially when the lenticulostriate arteries are occluded by an embolus.

A 68-year-old man with acute, total thrombotic occlusion of the right cervical internal carotid artery, associated with embolic occlusion of the ipsilateral middle cerebral artery, was treated by the endovascular approach, i.e., intra-arterial fibrinolysis and balloon angioplasty. Endovascular treatment for a totally occluded internal carotid artery is indicated in the very early stage where there is no thrombus or a short thrombus that can be evacuated. Fibrinolysis of the associated embolus in the middle cerebral artery, if any, can be done in the same session, enabling an early restoration of the blood flow.

We have collected four cases of supergiant cerebral aneurysm, each greater than 6.0 cm in diameter. Two of these cases were saccular aneurysms of the anterior communicating artery and middle cerebral artery, of which the necks were clipped with resection of the aneurysms. Another patient had a fusiform aneurysm of the middle cerebral artery, which was resected accompanied by a reconstructive procedure of cerebral blood flow. The last patient had a fusiform aneurysm of the internal carotid artery. Following internal carotid artery occlusion surgery with superficial temporal artery-middle cerebral artery anastomosis, the aneurysm completely disappeared radiologically within several months.

We hereby report a case of a laterally situated sinus pericranii, which is rare. According to the articles regarding this kind of lesion, carotid angiograms revealed no pathological findings, and venograms taken with direct injection of contrast medium into the mass were useful. It should be stressed that the lesion could be demonstrated in the late phase of carotid angiograms, and digital subtraction angiography was especially useful for diagnosis. The literature is also reviewed