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BACKGROUND AND PURPOSE Artery-to-artery embolism generally occurs in patients with not only moderate to severe arterial stenosis but also plaque vulnerability. Two unique cases with free-floating thrombi at the distal side of the small plaque in the internal carotid artery without stenosis are presented and its clinical implications are discussed. RESULTS Two middle-aged men suffered embolic stroke. Initial duplex ultrasonography revealed small plaques and vortex flow without significant stenosis or plaque vulnerability in their internal carotid arteries. Continuous examination by duplex ultrasonography showed that free-floating thrombi developed and regressed at the distal side of the small plaques. Histological examination disclosed plaque erosion at the distal side of the plaques without lipid core rupture. CONCLUSIONS In these two cases, duplex ultrasonography revealed free-floating thrombi developed at the distal region of small plaques. Aggressive treatment should be considered in a patient with thromboembolic stroke who has the small plaque presenting “snake fang” sign even if there is no stenosis or plaque vulnerability.

A 63-year-old woman presented with right hearing disturbance and vertigo. Magnetic resonance (MR) imaging revealed the presence of right vestibular schwannoma (VS). Stereotactic radiosurgery (SRS) was performed with a tumor marginal dose of 14 Gy using two isocenters. She was followed up clinically and neuroradiologically using three-dimensional spoiled gradient-echo MR imaging. She experienced temporal neurological deterioration due to peritumoral edema in her right cerebellar peduncle and pons for a few months beginning 1.5 years after SRS, when she experienced transient right facial dysesthesia and hearing deterioration. Ten years after SRS, the patient presented with sudden onset of vertigo, gait disturbance, diplopia, dysarthria, and nausea. MR imaging demonstrated a new lesion in the right cerebellar peduncle, which was diagnosed as radiation-induced stroke. The patient was followed up conservatively and her symptoms disappeared within a few months.Multiple delayed onset radiation injuries are possible sequelae of SRS for VS., Neurologia medico-chirurgica, 52(12), pp.933-936; 2012

Traumatic pseudoaneurysms of the internal maxillary artery (IMA) are rare and difficult to treat. A 58-year-old man with a traumatic pseudoaneurysm of the IMA presented with intractable nasal and oral hemorrhage during dual antiplatelet therapy. Transcatheter artery embolization with N-butyl cyanoacrylate (NBCA) completely occluded the pseudoaneurysm. Transcatheter artery embolization with NBCA is a feasible and effective treatment because of its shorter treatment time and lower incidence of recurrence.

Blood blister–like aneurysms (BBAs) tend to have a more precipitous clinical course, enlarging rapidly and rebleeding frequently. Nevertheless, they often present a diagnostic challenge because of the characteristic morphological features of a wide neck and shallow outpouching of the medial wall. The authors present the case of a 34-year-old woman who suffered a subarachnoid hemorrhage whose cause could not be determined on the initial imaging with digital subtraction (DS) angiography and CT angiography. Interestingly, MR imaging studies obtained on the 7th day revealed an intramural hematoma on the dorsal wall of the left internal carotid artery, which helped in the diagnosis of BBA on the third DS angiography study obtained on the 8th day, and in the surgical intervention on the 10th day. This case supports the hypothesis that focal dissection contributes to the formation of BBAs. Use of MR imaging in the subacute stage, in addition to DS and CT angiography, might be helpful in the diagnosis of BBAs.

Background Leptomeningeal high signal intensity (ivy sign) on fluid-attenuated inversion-recovery (FLAIR) MR imaging is one of the features of Moyamoya disease. However, the correlation between ivy sign and cerebral perfusion status has not been fully evaluated. Purpose To characterize ivy sign on FLAIR images in Moyamoya disease and compare this finding with hemodynamic alterations on perfusion single-photon emission CT (SPECT) obtained before and after bypass surgery. Material and Methods Sixteen patients with angiographically confirmed Moyamoya disease who underwent superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis were included in the study. The presence of ivy sign on FLAIR images was classified as ‘negative’, ‘minimal’ and ‘positive’. We evaluated the relationship between ivy sign and findings of SPECT, including cerebral vascular reserve (CVR) before and after surgery. Results Minimal or positive ivy sign was seen in 13 (81%) of 16 patients, and 21 (66%) of 32 hemispheres. CVR in the areas with positive or minimal ivy sign was lower than that in the areas with negative ivy sign. After STA-MCA anastomosis, ivy sign disappeared or decreased in all 21 hemispheres demonstrating ivy sign. SPECT demonstrated apparent hemodynamic improvement in areas demonstrating disappearance or decrease of ivy sign. Conclusion Ivy sign on FLAIR image is seen in areas with decreased cerebral perfusion. The sign is useful for non-invasive assessment of cerebral hemodynamic status before and after surgery.

【目的】頚動脈ステント留置術（carotid artery stenting；CAS）は主にフィルターデバイスを用いて行われる．我々は術後にフィルターをHematoxylinEosin（HE）染色し，回収されたデブリスを観察している．本研究では頚動脈内膜剥離術（carotid endarterectomy；CEA）病理標本とデブリスを比較し，デブリスの性状の同定を試みた．【対象と方法】当科にてCASを施行した27例（28病変）とCEAを施行した49例（49病変）を対象とした．デブリスの観察はフィルターをHE染色し，filter membraneをstrutより離断し，プレパラートを作成後に観察した．CEAで摘出されたプラークは固定後に包埋し，切片を作成した．HE染色および特殊染色し，観察した．【結果】CEA標本にはプラーク内出血，血栓，石灰化，コレステリン結晶，線維性被膜，炎症細胞浸潤，平滑筋増殖などが観察された．CASで回収されたデブリスは血栓性デブリス，石灰化デブリス，脂質性デブリス，線維性デブリス，細胞性デブリスなどと同定された．【結論】CASで回収されたデブリスはCEA病理標本と比較することで，その性状を同定できた．〈第26回日本脳神経血管内治療学会学術総会優秀演題推薦論文〉

Background and purpose: T2*-weighted magnetic resonance angiography (SWAN) detects hemodynamic insufficiency as hypointense areas in medullary or cortical veins. We therefore investigated whether SWAN can help predict ischemic penumbra-like lesions in patients with acute ischemic stroke (AIS). Materials and methods: Magnetic resonance imaging (MRI) records?including SWAN, diffusion-weighted imaging (DWI), and magnetic resonance angiography (MRA)?of consecutive patients with major vessel occlusion within 6 h from AIS onset were analyzed. Acute recanalization was defined as an arterial occlusive lesion score of 2?3. A modified Alberta Stroke Program Early CT Score (mASPECTS) was used to evaluate ischemic areas revealed by SWAN and DWI. SWAN- and DWI-based mASPECTSs were calculated, and correlations between DWI-SWAN mismatches with final infarct lesions or clinical outcomes were evaluated. Results: Among the 35 patients included in this study, we confirmed cardioembolic stroke in 26, atherothrombotic stroke in 4, and unknown stroke etiology in 5. Overall, recanalization was achieved in 23 patients, who showed a higher follow-up DWI-based mASPECTS and lower modified Rankin Scale (mRS) score at 90 days than patients without recanalization. Initial SWAN- and follow-up DWI-based mASPECTSs were significantly higher for atherothrombotic stroke than for cardioembolic stroke. Of 12 patients without recanalization, DWI-SWAN mismatch was significantly correlated with infarct growth. Patients with recanalization showed no such correlation. In the assessment of clinical outcome, follow-up DWI-based mASPECTS and patient's age were significantly correlated with mRS at 90 days after stroke. A multivariate logistic regression analysis revealed that the follow-up DWI-based mASPECTS was independently associated with a favorable outcome 90 days after stroke. Conclusions: For patients with AIS, DWI-SWAN mismatch might show penumbra-like lesions that would predict infarct growth without acute recanalization. Assessment of ischemic lesions from the venous side appears to be useful for considering the etiology and revascularization therapy., PLoS ONE, 13(4), e0195554; 2018

BACKGROUND: Although aneurysm formation accompanying parenchymal hemorrhage is one of devastating complications in the central nerves system (CNS), imaging studies of the brain are not routinely warranted in patients with infective endocarditis (IE). To assess the clinical importance for detecting silent lesions in the central nervous system, we investigated hypointense signal spots detected on the brain T2*-weighted MR imaging in patients with IE. METHODS AND RESULTS: Eleven patients with IE were retrospectively reviewed. Seven patients (63.6%) showed hypointense signal spots on T2*-weighted MR images. The number of hypointense signal spots increased within only a few weeks in five patients. CONCLUSION: The brain T2*-weighted MR imaging in patients with IE may have a potential role to detect CNS lesions with clinical significance of potentially high risk of intracranial hemorrhage. T2*-weighted hypointense signal spots may be specific to brain involvement, and be quite useful in monitoring CNS lesions associated with IE, even if they are asymptomatic., Clinical neurology and neurosurgery, 112(5), pp.436-440; 2010

BACKGROUND: Diffusion-weighted imaging (DWI) has been reported to be a useful technique for diagnosing Creutzfeldt-Jakob disease (CJD). The present study reported DWI results in cases of familial CJD with a V180I mutation (CJD180) in the prion protein gene as well as neurological findings. METHODS: A retrospective analysis of 3 patients with V180I was performed. Cerebrospinal fluid (CSF) analysis, brain MRI, single-photon emission computed tomography (SPECT), and magnetic resonance spectroscopy (MRS) were included. CSF was analyzed for biochemical markers, and each patient underwent brain MRI, SPECT, and MRS analysis. A brain biopsy from the frontal cortex, which corresponded to the area of increased DWI signals, was utilized for neuropathological analysis. RESULTS: CSF analysis results revealed elevated total tau protein and the absence of 14-3-3 protein, as well as decreased concentrations of neuron-specific enolase, S100 protein, and prostaglandin E(2). All patients presented with unique MRI features. Brain biopsy showed severe spongiform morphology, but comparatively preserved neurons and mild astrocytic gliosis. Accumulations of PrP(Sc) were not detected using the 3F4 antibody, and microglial activation was subtle. SPECT revealed hypoperfusion throughout both hemispheres. MRS revealed a reduced N-acetyl aspartate/creatine ratio. CONCLUSION: Results from this study suggested that increased DWI signals could reflect severe spongiform changes in CJD180 patients., Dementia and geriatric cognitive disorders, 28(6), pp.550-557; 2009

OBJECTIVES: As endovascular treatment becomes more prevalent, aneurysm recurrence from neck remnants, recanalization, incomplete obliteration and bleeding remain major concerns. In the current analysis, we attempted to identify factors related to disease progression and clinical outcome in patients treated with coil embolization. METHODS: This study included 58 patients who underwent endovascular coil embolization for treatment of intracranial aneurysm. The result of embolization was evaluated with three-dimensional time-of-flight magnetic resonance angiography (TOF MRA) and classified as a complete occlusion, a residual neck (minor, central and marginal types), a residual dome (central and marginal types). Patients were followed up clinically and radiologically. Statistical analyses were performed to establish factors that influenced the occurrence of adverse events such as recurrence of aneurysm. RESULTS: Overall, the complete occlusion rate was 18.8%, the occurrence of a residual neck was 67.2%, and the residual dome rate was 14.1%. The mean clinical follow-up was 31.2 months. Recurrences were found in 18 aneurysms, and major recurrences were retreated with coiling or surgery. The post-treatment study revealed that the marginal-type aneurysm filling has a significant impact on outcome. Thus, perianeurysmal edema was correlated with recurrence of the aneurysm. CONCLUSIONS: Three-dimensional TOF MRA was a sensitive tool for visualizing residual filling of embolized aneurysm and is useful for long-term follow-up of patients., Neurological research, 31(7), pp.674-680; 2009

BACKGROUND AND PURPOSE: Identifying the precise hemodynamic features, including the fistulous point, is essential for treatments of dural arteriovenous fistulas (DAVFs). This study illustrates the efficacy of DynaCT digital angiograms obtained from a 3D C-arm CT to directly visualize the location of the fistulous points in DAVFs. MATERIALS AND METHODS: This retrospective study observed 14 consecutive patients with DAVFs, which included 7 cavernous sinuses, 4 transverse-sigmoid sinuses, 2 convexity-superior sagittal sinuses, and 1 tentorial sinus. In the assessment of the practical applicability for the diagnosis of DAVFs, images obtained from 2D digital subtraction angiography (DSA) and DynaCT were comparatively evaluated. RESULTS: In all patients, DynaCT digital angiography could clearly demonstrate the feeding arteries, the fistulous points, and the draining veins. Significant anatomic landmarks for the fistulous points with relationships to osseous structures were also provided. Compared with 2D DSA, DynaCT digital angiograms demonstrated 12 additional findings in 8 patients (57%), including the detection of the fistulous points (n = 7), the feeders (n = 1), the retrograde leptomeningeal drainage (n = 1), the draining veins (n = 1), and the venous anomaly (n = 2). CONCLUSIONS: In comparison with 2D DSA, DynaCT may provide more detailed information to evaluate DAVFs. DynaCT digital angiograms have a high contrast and isotropic spatial resolution, allowing a reliable visualization of small vessels and fine osseous structures. Such detailed information, especially for the location of the fistulous points, could be very useful for either the endovascular or the surgical treatments of DAVFs., AJNR. American journal of neuroradiology, 30(3), pp.487-491; 2009

A MicroNester coil (MNC) was developed from the Nester coil with a 0.018-in microcatheter. The most specific feature of the MNC is the extended length of 14 cm. Neurointervention involving the MNC was undertaken in 11 patients. Intervention procedures were transvenous embolization for a dural arteriovenous fistula in 4 patients, transarterial embolization for a dural arteriovenous fistula in 2, parent artery occlusion for a cerebral aneurysm in 4, and stent-assisted embolization for a carotid artery dissection in 1. A push technique through microcatheter was used to deploy the MNCs. The MNCs were successfully placed into the venous sinus lesion, feeding artery, parent artery of the aneurysm, and the pseudoaneurysm. There were no major technical complications resulting in morbidity. The postoperative course was uneventful except in 2 cases in which the occluded vessel recanalized. Use of MNCs was safe and feasible for embolization of cerebrovascular lesions. Fewer coils are required in embolization when using MNCs.

Percutaneous transluminal angioplasty with stenting (PTA/stenting) for intracranial atherosclerotic stenoses is usually performed without any protection devices. We report a unique case of atherothrombotic stenosis with the vulnerable plaque in the cavernous portion of the internal carotid artery (ICA), which was successfully treated by PTA/stenting under cerebral protection with the flow reversal system. A 68-year-old woman presented repetitive transient ischemic attacks in the right ICA territory. Cerebral angiography revealed 80% stenosis in the cavernous portion of the right ICA. High-resolution magnetic resonance imaging (HR-MRI) demonstrated lipid-rich plaques at this lesion. PTA/stenting was performed with a proximal protection device under flow reversal. A filter device captured much amount of atherothrombotic debris with lipid-rich macrophages and leukocytes, which was consistent with HR-MRI findings. Some selected cases of intracranial atherothrombotic ICA stenoses may need endovascular treatment with cerebral protection system. HR-MRI is useful to evaluate plaque characteristics even in the cavernous portion of the ICA., Clinical neurology and neurosurgery, 110(10), pp.1031-1034; 2008

We present a unique case of a cavernous sinus (CS) dural arteriovenous fistula (DAVF), which recurred at adjacent sinuses following repeated transvenous embolizations (TVEs). A 68-year-old woman presented with progressive left conjunctival chemosis and diplopia. Cerebral angiography revealed a left CS DAVF, which was completely obliterated by TVE via the left inferior petrosal sinus (IPS). Two years later, the DAVF recurred in the left IPS, and again in the left sigmoid sinus (SS) 3 years after the initial treatment in spite of a second TVE. Moreover, the left SS and the left internal jugular vein, which had been previously stenotic, had been occluded. The third TVE resulted in the complete obliteration of the SS DAVF. CS DAVFs may recur at adjacent sinuses even after complete obliteration by TVE. Careful follow-up is necessary to check for the recurrence of DAVFs, especially in cases with venous flow changes, such as sinus occlusion, following endovascular treatment., The original publication is available at www.springerlink.com, Radiation medicine, 26(7), pp.431-437; 2008

Endovascular occlusion has been accepted as a safe, minimally invasive, and reliable treatment for ruptured dissecting aneurysms. Occlusion of the entire affected area is ideally the most complete treatment for such lesions. However, it is difficult to occlude the entire dissected lesion when it involves side branches due to the short-term risk of side branch occlusion, emboli dislodgement, and the long-term risk of parent artery recanalization. We herein present an extremely rare case where recanalization occurred after endovascular occlusion of a ruptured dissecting aneurysm of the posterior cerebral artery, and discuss its clinical implications. There are three mechanisms of recanalization: coil compaction due to loose or short segment packing, secondary dissection and occlusion of the false lumen. In endovascular occlusion of dissecting aneurysms that involve side branches, it is important to consider the risk of both recanalization and ischemic complications. We should attempt to insert the microcatheter into the true lumen and maintain dense packing as long as possible, unless the coils occlude the side branches following the procedure. Careful follow-up is necessary in all patients that received endovascular treatment.

Macrophages and by-products are important in plaque destabilization in atherosclerosis. Ultra-small superparamagnetic particles of iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging may be suitable for the detection of macrophages in atherosclerotic plaques. The present study investigated the potential of MR plaque imaging using SPIO in 10 patients scheduled for carotid endarterectomy before and 24-43 hours after administration of SPIO (fercarbotran, 0.016 ml/kg). Three-dimensional gradient recalled acquisition in the steady state (3D-GRASS) was used for detecting macrophages within plaques. Signal loss on the post-contrast 3D-GRASS images was found in 5 of 10 cases, and accumulation of SPIO particles in the vessel wall was confirmed in 4 of these 5 cases. Intracytoplasmic localization of SPIO particles within recruited macrophages was verified by double staining analysis. A correlation between MR plaque imaging using SPIO and localization of macrophages was demonstrated in 6 of 10 patients. This study indicates that MR plaque imaging using SPIO is a potential functional imaging tool to detect infiltration of macrophages in human atherosclerotic carotid plaque., Neurologia medico-chirurgica, 48(4), pp.157-162; 2008

Giant fusiform aneurysms at the basilar trunk tend to have a poor natural history, and the surgical management for these aneurysms remains controversial. For these aneurysms, basilar trunk occlusion may offer a potentially long-lasting cure. However, the strategy for these aneurysms is difficult when the collateral supply from the carotid circulation is poor. The authors herein present a successful case of a thrombosed giant fusiform aneurysm at the basilar trunk with a poor collateral supply using repeated balloon test occlusion (BTO) and a second bypass surgery.A 46-year-old female was admitted to our institute because of progressing double vision. A radiologic examination revealed a thrombosed giant fusiform aneurysm at the upper basilar trunk, and the collateral supply from carotid circulation was poor. We attempted to perform a second bypass surgery before the basilar trunk coil occlusion due to intolerance after the repeated BTO. After confirmation of her tolerance against the third BTO, the aneurysm was successfully trapped using the endovascular technique.Various kind of bypass surgery should be tried for endovascular trapping of giant fusiform basilar trunk aneurysms, and repeated BTO is necessary to confirm the tolerance after bypass surgery especially for the complex aneurysms without a sufficient collateral supply.

Background Early detection of vulnerable plaques at risk of causing thromboembolic events is very important, and many investigators report the usefulness of high-resolution MRI. The purpose of this study was to determine whether the detection of atherosclerotic carotid plaques can be enhanced after administration of contrast agents and, if so, to evaluate the potential for functional information. Methods We studied 9 patients (10 subjects) who underwent a high-resolution MRI examination using a gadolinium-based contrast agent before CEA. Pre- and postcontrast-enhanced T1-weighted images were reviewed, and their histopathologic characteristics evaluated in the corresponding tissue slices. Results Strong contrast enhancement patterns were found in 6 of 10 subjects. For 5 of 6 subjects, many microvessels with inflammatory cells or intraplaque hemorrhages were demonstrated in their corresponding tissue slices. Contrast enhancement patterns were noted to be focal, diffuse, and along the luminal surface or the vessel adventitial boundary. Moreover, some plaques were clearly demonstrated by using contrast agent, and others were clearly divided into fibrous and lipid regions. Conclusion Gadolinium-based contrast agent can penetrate human atherosclerotic carotid plaques. The extent or size of neovascularization and the endothelial permeability are likely related to the mechanism of enhancement, and contrast-enhanced MRI may be essential for the identification of plaque neovascularization which is an important factor of vulnerable plaques. In addition to morphologic information, with the functional information provided using various contrast agents, we may expect a more correct diagnosis of carotid plaques at risk of causing thromboembolic events.

Background Echography is a convenient and noninvasive method of characterizing carotid artery plaques. However, recent reports suggest that multisequential MR imaging may yield better data regarding the instability of asymptomatic carotid artery plaques. Therefore, the goal of the present study was to show the useful information for asymptomatic carotid artery plaque. Methods A total of 6 patients (5 men, 1 woman; age range, 62-76 years; mean age, 69.2 years) with carotid artery plaques, which were detected during medical check-up using carotid MR angiography and/or echography, underwent MR imaging. Two-dimensional TOF MR angiography, T1WI, and fat-suppressed, cardiac-gated, black-blood proton density image, and T2WI were obtained with a 1.5-T MR imager. All plaques underwent carotid endarterectomy and histological examination. Results The MR imaging demonstrated high signals in at least one modality in 4 of 7 plaques. In the remaining 3 patients, MR imaging detected partial-high signals, which corresponded to histologically confirmed partial lipid core or hemorrhagic components in the fibrous tissues The TOF MR imaging showed 2 cases of thin fibrous caps, and MR imaging also showed a large mural thrombus in 1 patient. Conclusions Magnetic resonance imaging was useful in characterizing factors associated with plaque instability in patients with asymptomatic carotid artery plaques and may help guide therapeutic strategies for asymptomatic carotid artery plaques.

Acute ischemic stroke with major intracranial vessel occlusion is commonly due to cardioembolic or atherosclerosis-related in situ stenosis/occlusion, and immediate identification of these subtypes is important to establish the optimal treatment strategy. The aim of this study was to clarify the differences in clinical presentation, radiological findings, neurological temporal courses, and outcomes between these etiologies, which have not been fully evaluated. Consecutive emergency patients with acute ischemic stroke were retrospectively reviewed. Among them, patients with stroke with major intracranial vessel occlusion were analyzed with a focus on clinical and radiological findings, and a comparison was performed for those with cardioembolic or atherosclerosis-related in situ stenosis/occlusion. Of 1053 patients, 80 had stroke with acute major intracranial vessel occlusion (45 with cardioembolic and 35 with atherosclerosis-related in situ stenosis/occlusion). Interestingly, the susceptibility vessel sign (SVS) on T2-weighted MR angiography was more frequently detected in cardioembolic stroke (80.0%) than in atherosclerosis (in situ stenosis: 5.9%, chronic occlusion: 14.3%). Moreover, the proximal intra-arterial signal (IAS) on arterial spin labeling MRI and the distal IAS on fluid attenuated inversion recovery MRI was less frequently detected in chronic occlusion (27.3% and 50.0%, respectively) than in acute occlusion due to cardioembolic or in situ stenosis. Multivariate regression analysis showed that the SVS was significantly related to cardioembolism (adjusted odds ratio (OR): 21.68, P=0.004). Clinical characteristics of acute stroke with major intracranial vessel occlusion differ depending on the etiology. The SVS and proximal/distal IAS on MRI are useful to distinguish between cardioembolic and atherosclerotic-related in situ stenosis/occlusion.

Background and Purpose: Neovascularization of carotid plaques is associated with plaque vulnerability. However, the role of neovascularization in the development of intraplaque hemorrhage (IPH) and the clinical contribution of neovascularization to IPH and symptomatic presentation remain undetermined. Methods: Consecutive patients with moderate to severe carotid atherosclerosis who underwent carotid endarterectomy were prospectively analyzed from 2010 to 2014. The neovessel appearance was categorized into three groups based on dynamic intraoperative indocyanine green videoangiography: neovessels derived from the endothelium (NVe), neovessels derived from the vasa vasorum (NVv), and no neovessels. Each neovessel pattern was evaluated with respect to clinical, radiological, and pathological findings. Results: Of 57 patients, 13 exhibited NVe, 33 exhibited NVv, and 11 exhibited no neovessels. There were no significant differences in baseline characteristics among the three groups with the exception of a higher percentage of symptomatic presentations among patients with NVe. Moreover, patients with NVe exhibited larger infarctions than did those with NVv (P=0.04). Pathologically, patients with NVe had more severe IPH (P=0.002), hemosiderin spots (P=0.04), neovessels (P=0.11) and inflammation (P=0.26), all of which were correlated with hyperintensity on time-of-flight magnetic resonance imaging. Interestingly, inflammation was significantly correlated with neovessel formation (R=0.43, P=0.008), hemosiderin spots (R=0.62, P Conclusions: Luminal neovascular sprouting with inflammation and lumen communication could clinically contribute to IPH and symptomatic presentation in patients with carotid stenosis. This condition may thus be a key therapeutic target against neovessel formation and inflammation.

Introduction: T2 star weighted MR angiography (SWAN) can detect slight changes of susceptibility caused by microbleeds. It has also been reported that SWAN can detect hemodynamic insufficiency as hypointensity area in the medullary or cortical veins. In this study, we investigate whether SWAN can help to detect ischemic penumbra in the acute stage. Materials and methods: Patients showing acute major vessel occlusion (internal carotid artery and middle cerebral artery) within 4.5 hours from onset were consecutively analyzed with MR imaging including SWAN, diffusion weighted imaging (DWI) and MR angiography. To evaluate ischemic area in SWAN and DWI, modified Alberta Stroke Program Early CT score (mASPECTS) was used as follows; M1~6 and basal ganglion including caudate, insula, lentiform or internal capsule. SWAN based mASPECTS was calculated with DWI based ASPECTS, and correlation between DWI-SWAN mismatch and final infarct area or outcome was evaluated. Result: Of 30 patients (mean age: 72.7 ± 13.3 years). Cardioembolic stroke was confirmed in 24 patients, atherothrombotic stroke was in 3 patients, and others had unknown etiology. Intravenous t-PA was performed in 17 patients, and endovascular therapy was performed in 17 patients. Overall, recanalization was achieved in 70% (21 patients) with lower modified Rankin Scale at 90 days compared with no recanalization (P=0.0004). Interestingly, SWAN based mASPECTS was significantly correlated with mRS at 90 days (R=-0.4382, P=0.02) regardless of recanalization. Of 9 patients showing no recanalization, DWI-SWAN mismatch was significantly correlated with new infarction (R=0.8221, P=0.0065). On the other hand, patients showing recanalization showed no correlation between mismatch and new infarct. Conclusion: DWI-SWAN mismatch could simply predict ischemic penumbra requiring immediate reperfusion. Assessment of ischemic penumbra from venous side using SWAN is quite useful without contrast media.

Background: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy. Although it was considered to be a poor prognostic disease, modern treatment protocols (aggressive chemotherapy and prophylactic cranial irradiation) have resulted in dramatically improved survival rates. In a group of low-risk ALL patients, the 5-year survival rate is estimated to be 85%. However, ALL patients who undergo this treatment are at risk of developing secondary neoplasms related to treatment, which has become an increasingly recognized problem. Case Description: A 3-year-old boy with ALL was successfully treated with chemotherapy (vincristine, prednisolone, mercaptopurine and methotrexate) and prophylactic cranial irradiation (total 18 Gy). At the age of 23, he was admitted to our hospital for weakness in the right leg. Computed tomography and magnetic resonance imaging revealed a parasagittal tumor of the left frontoparietal lobe with perifocal edema. The tumor was completely removed surgically and pathohistologically diagnosed as atypical meningioma. Conclusion: Long-term survivors who received radiotherapy for ALL in childhood are at risk for late complications, including radiation-induced meningioma. Therefore, careful follow-up neurological examinations, for example magnetic resonance imaging, are indicated in these patients. In addition, late complications should be taken into account during the initial planning of prophylactic radiotheraphy dosage, which has implications for informed consent of the patient.

Purpose: To determine whether the signal changes on magnetic resonance imaging (MRI), including fluid attenuated inversion recovery (FLAIR), T2*-weighted gradient echo (GE) imaging, and diffusion-weighted imaging (DWI) in diffuse axonal injury (DAI) patients correlate with the clinical outcome. Material and Methods: We diagnosed patients with DAI based on the following criteria: 1) a loss of consciousness from the time of injury that persisted beyond 6 h; 2) no apparent hemorrhagic contusion on computed tomography (CT); 3) the presence of white matter injury on MRI. Twenty-one DAI patients were analyzed (19 M, 2 F, mean age 34 years) with MRI (FLAIR, T2*-weighted GE imaging, and DWI). Results: 325 abnormalities were detected by MRI within a week after injury. The T2*-weighted GE imaging was significantly more sensitive than FLAIR and DWI in diagnosing DAI. DWI detected only 32% of all lesions, but could depict additional shearing injuries not visible on either T2*-weighted GE imaging or FLAIR. The mean number of lesions in brainstem detected by DWI in the favorable group (good recovery/moderately disabled) was significantly smaller than in the unfavorable group (severely disabled/vegetative survival/death). This trend was not observed on the T2*-weighted GE imaging and FLAIR findings. Conclusion: DWI cannot detect all DAI-related lesions, but is a potentially useful imaging modality for both diagnosing and assessing patients with DAI.

Objective We report our experience using high-resolution magnetic resonance imaging (MRI) to identify carotid plaques and also discuss these MRI findings while comparing them with carotid endarterectomy specimens. Methods Eighteen carotid plaques from 17 different patients were observed using plaque MRI. The patients included 14 men and 3 women, aged 53 to 75 years (mean, 68.6 yr). Eight patients experienced a stroke and four patients experienced transient ischemic attack. The remaining five patients did not experience any neurological symptoms. Two-dimensional time-of-flight (TOF) MR angiography; T1-weighted imaging; fat-suppressed, cardiac gated, black-blood proton density imaging; and T2-weighted imaging were obtained with a 1.5-T MRI. Results Symptomatic plaques showed either vast or partially dotted high signals for each contrast. The high signal intensity on time-of-flight and T2-weighted imaging predicted the instability of the plaques (100% sensitivity and specificity). In particular, time-of-flight imaging predicted intraplaque hemorrhaging with 100% sensitivity and 80% specificity. MRI revealed that three of four asymptomatic lesions were unstable plaques. Conclusion High-resolution MRI was able to detect various signal patterns related to the plaque components, and it was thus considered to be very useful for evaluating plaque instability. The application of plaque MRI therefore may positively affect the decision-making process when selecting optimal therapeutic strategies to treat with carotid plaques.

In carotid arterial stenting (CAS), ischemic complications and cerebral hyperperfusion are recognized as devastating complications. To detect these complications in early stages, we assessed the feasibility for real-time measurement of regional oxygen saturation (rSO2) of the brain in 24 patients with symptomatic extracranial carotid artery stenosis in CAS. The rSO2 changes were easy to evaluate and significantly correlated with the ischemic neurological symptoms as well as postoperative hyperperfusion detected by single-photon emission computed tomography (SPECT). Moreover, the pattern of changes in rSO2 was significantly correlated with the asymmetry index and the cerebral vasoreactivity examined by preoperative SPECT. Therefore, simultaneous monitoring of rSO2 is feasible in detecting early hemodynamic complications in CAS.

Elective carotid stent implantation using a distal protection is increasing. In this article we describe an observation method for carotid plaque debris collection during carotid stenting.Endovascular stenting for the right internal carotid artery (ICA) stenosis was performed under distal balloon protection. During balloon protection, 30 ml of blood containing debris was aspirated followed by vigorous saline irrigation flushing any residual debris out into the ipsilateral external carotid circulation. Post-operatively, the aspirated blood was filtered and the debris remained on the membrane. The membrane was stained with hematoxylin-eosin (HE) solution and then mounted onto a glass slide for visualization.Microscopic observation of the slide revealed several debris such as atheromatous plaques and intimal strips. HE staining facilitates the characterization of the debris composition. In addition to the histological evaluation, this technique revealed the particle size as well as the quantity of debris. The resulting HE slide is also suitable for permanent storage. In addition to the qualitative and quantitative qualities, this simple technique requires neither specific instrumentation nor equipment.Carotid plaque debris aspirated during carotid artery stenting under distal protection can be filtered and visualized on a permanent glass slide. This simple method allows us to better understand quantity, particle size, and composition of debris.

We report a case of proximal vertebral artery restenosis following stent placement. Intravascular ultrasound study helped delineate its characteristics. A 69-year-old man was admitted because of dysarthria and dysphagia. Angiography revealed hypoplasia of left vertebral artery (VA) and remarkable stenosis of the proximal right VA with inadequate collateral flow from the anterior circulation. Balloon angioplasty and stent placement at the VA was performed to an excellent angiographic result with recovery of neurological symptoms. His condition deteriorated six months later due to intimal hyperplasia, which we evaluated by intravascular ultrasound (IVUS). Balloon angioplasty was then performed. Stent placement may induce intimal hyperplasia and IVUS is useful to assess the lesion.

The authors present the case of a 78-year-old man who presented with a subarachnoid hemorrhage due to rupture of an aneurysm at the origin of the persistent primitive olfactory artery (PPOA). Interestingly, the PPOA was originating from the A1 segment of the anterior cerebral artery and coursed anteromedially along the olfactory tract. Moreover, the PPOA in this case had 2 branches: the branch making a hairpin turn and supplying the distal part of the anterior cerebral artery territory (Type 1), and the branch extending to the cribriform plate to supply the nasal cavity (Type 2). To the best of the authors' knowledge, this is a new variant (Type 3) of PPOA associated with a ruptured aneurysm. The clinical implications of this case are discussed in terms of the embryological aspects.

Mucus released from goblet cells is important in intestinal mucosal defence, and mucin glycoproteins are thought to be major components of mucus. Recently, we identified and cloned another component of human colonic mucus, IgG Fc binding protein (Fc gamma BP). Fc gamma BP is immunologically distinct from known Fc gamma receptors and its structure contains repeated cysteine rich unit sequences resembling those present in mucins. In this work, we assessed the tissue distribution of Fc gamma BP, its binding activity in various body fluids, and its ability to inhibit complement mediated haemolysis.Immunohistochemical localisation of Fc gamma BP, using monoclonal antibodies against Fc gamma BP (K9 or K17) and labelled IgG, was conducted in various mucin producing tissues: colon, small intestine, stomach, gall bladder, cystic duct, choledochus, bronchus, submandibular gland, conjunctiva, and cervix uteri. The binding activity of Fc gamma BP in mucus extracted from colon, gastric juice, bile, nasal discharges, saliva, sputum, and tears was also examined by immunodotblot and immunoprecipitation using these monoclonal antibodies. Inhibition of complement mediated haemolysis by Fc gamma BP was investigated using sheep red blood cells (SRBC) and anti-SRBC IgG.The immunohistochemical study revealed that mucin secreting cells in the colon, small intestine, gall bladder, cystic duct, choledochus, bronchus, submandibular gland, and cervix uteri contained Fc gamma BP, and immunodotblot and immunoprecipitation analysis using IgG and monoclonal antibodies demonstrated that the fluids secreted by these cells were capable of binding IgG. Mucin producing cells of the conjunctiva did not express Fc gamma BP molecules or bind to IgG. The surface mucus cells in the stomach were variably positive for Fc gamma BP. Perhaps because of proteolytic degradation, Fc gamma BP in gut lavage fluid did not have IgG binding activity, although this activity was present in the mucus covering the colon. Fc gamma BP suppressed complement mediated haemolysis of SRBC.Fc gamma BP is widely expressed on mucosal surfaces and in external secretions. It is functionally intact in several fluids. These findings lend support to the concept that Fc gamma BP is an important component of mucosal immunological defences.

We determined the apparent diffusion coefficients of normal and dysfunctional salivary glands.A diffusion-weighted single-shot spin-echo type of echoplanar MR imaging was performed on the parotid or submandibular glands, or both, in 36 healthy subjects, 20 patients with Sjögren's syndrome, and six patients with sialoadenitis. The apparent diffusion coefficient of the salivary gland was calculated using two b factors (b = 500 and 1,000 sec/mm(2)).The apparent diffusion coefficient was lower in the parotid glands (0.28 x 10(-3) mm(2)/sec) than that of the submandibular glands (0.37 x 10(-3) mm(2)/sec). The apparent diffusion coefficient was increased in sialoadenitis, whereas it decreased with abscess formation. The apparent diffusion coefficients of the parotid glands in patients with Sjögren's syndrome correlated with the salivary flow rates but not with the sialographic gradings of the glands. We also found a correlation of the decreases in apparent diffusion coefficients with the severity of gland damage as assessed on T1-weighted MR images.Diffusion-weighted echoplanar MR imaging may reveal diseased states of the salivary glands.

Here we report a case of carotid blowout syndrome (CBS) treated with parent artery occlusion using pushable coils.A 68-year-old man with a history of surgery and chemoradiation therapy for esophageal cancer 9 years prior presented with a massive hemorrhage from a skin defect in the neck. Angiography revealed encasement of the right common carotid artery by radiation necrosis, and CBS was diagnosed. We performed emergent endovascular treatment, and the right common carotid artery was occluded using pushable coils and a detachable coil. The patient's postoperative course was uneventful. However, he died of esophageal cancer recurrence 6 months later.Pushable coils were useful for occluding the parent artery in this case of CBS.

Here we report a case of radiation-induced carotid stenosis treated with carotid artery stenting and proximal and distal protection. A 62-year-old man with a history of radiation therapy for cervical malignant lymphoma at 31 years of age was diagnosed with left radiation-induced carotid stenosis. Angiography revealed left common carotid artery severe stenosis, and T1-weighted magnetic resonance imaging showed plaque hyperintensity. He was treated with carotid artery stenting and proximal and distal protection. Postoperative carotid ultrasonography showed moderate dilatation of the left common carotid artery and his postoperative course was uneventful. Carotid artery stenting and proximal and distal protection for radiation-induced carotid stenosis may be an effective treatment.

Introduction: Postoperative cerebral hyperperfusion (HP) is a notable complication that occurs more frequently in moyamoya disease (MMD) than in atherosclerosis of unknown etiology. This study aimed to clarify the characteristics of intraoperative indocyanine green (ICG) videoangiography in MMD and atherosclerotic disease in terms of postoperative HP. Methods: This prospective study included 47 patients with 60 sides that underwent superior temporal artery (STA)-middle cerebral artery (MCA) single bypass. ICG videoangiography was performed after revascularization. The ICG time intensity curve was recorded in the STA, proximal MCA, distal MCA, and superficial Sylvian vein, and the angiographic differences among adult MMD, pediatric MMD, and atherosclerosis were analyzed. Results: Twenty two patients (27 sides) had adult MMD, 14 patients (22 sides) had pediatric MMD, and 11 patients (11 sides) had atherosclerosis. Postoperative HP was significantly higher in adult MMD (40.7%) than in pediatric MMD (18.2%) and atherosclerosis (0%). Adult MMD with HP was associated with a longer ICG peak time (P Conclusions: ICG videoangiography provides different characteristics of bypass flow among adult MMD, pediatric MMD, and atherosclerosis. Poor distribution and run-off of blood flow from the STA might contribute to postoperative HP in MMD. The occurrence of postoperative HP in MMD could depend on two factors: host STA size and recipient MCA integrity.

The authors present an extremely rare case of a 54-year-old female patient with subarachnoid hemorrhage due to a rupture of a dissecting internal carotid artery (ICA) aneurysm, who developed de novo vertebral artery dissection in the spasm period after endovascular trapping of the ICA. Interestingly, postoperative cardiopulmonary monitoring showed high global end-diastolic volume index and mean arterial pressure, which could contribute to this de novo dissection via hemodynamic stress in the cerebral circulation. Spontaneous intracranial artery dissection of more than two arteries is rare, and we believe this is the first case of de novo dissection occurring on a circulating vessel different from that of the initial dissection. The clinical implications are discussed in relation to postoperative hemodynamic stress with a review of the literature.

Accurate neuroimaging grading of gliomas is useful for management, but techniques such as MRI and CT are not sufficiently reliable. Necrosis is a consistent, decisive prognostic factor and the key diagnostic criterion for glioblastoma multiforme. MR spectroscopy (MRS) allows noninvasive measurement of metabolites in brain tumours and mobile lipids reflect necrosis. However, short echo-time (TE) spectroscopy has been required for reliable assessment of lipids, since their relaxation times are very short. Recent advances have made it possible to perform short-TE MRS. We attempted to evaluate the significance of short TE spectroscopy as part of routine imaging for diagnosis and grading of gliomas. We performed TE 30 ms MRS in 25 patients with gliomas (grade II six; grade III three; grade IV, 16) and in 19 areas of healthy white matter using proton brain examination/single voxel (PROBE/SV) and point-resolved spatially localised spectroscopy (PRESS). With short-TE spectroscopy, lipid signals were detected in all 16 tumours of grade IV, one grade II (P = 0.0002) and none of grade III (P = 0.001). TE 136 ms MRS, carried out in 20 of these cases, showed lipid signals in only four of 14 grade IV tumours and in none of the other six. N-acetylaspartate/choline (NAA/Cho) ratios were always more than 1.0 in healthy tissues and less than 1.0 in all but one of the gliomas. The mean creatine (Cr)/Cho ratio in each tumour grade was significantly lower than in the healthy tissues. The mean Cr/Cho ratio was also significantly lower in grade IV than in grade II tumours (P < .0005). Considerable overlap in Cr/Cho ratio was observed between grade II and grades III and IV gliomas at long but less so at short-TE MRS. We conclude that short-TE MRS with PROBE/SV and PRESS is of value in grading gliomas.

Fifteen patients, who had tumors in or near the precentral gyrus, underwent functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) combined with surface anatomy scanning (SAS) for presurgical mapping of the sensory motor cortex. TMS activated the motor cortex in all patients and fMRI demonstrated task activation of sensory motor cortex in 14 of the 15 patients. The marker of TMS superimposed on SAS and fMRI activation agreed within 0.5 cm in 11 of the 14 patients. In the remaining three, the distance of these mapped sites ranged from 1 cm to 1.5 cm, and SAS showed a deformity of the central sulcus which may cause the deviation of activated site with TMS. The cortical surface projection of TMS using SAS and fMRI has good spatial relationship and is useful in identifying a primary motor cortex in presurgical planning.

The migration inhibitory factor-related proteins (MRPs) MRP-8 and MRP-14 were detected in differentiated human leukemia cell lines (THP-1 and HL-60) by immunocytochemical analysis. They were induced and colocalized in the cytoplasm and in lesser amounts in the nucleus when THP-1 and HL-60 cells were induced to differentiate by 1alpha,25-dihydroxyvitamin D3 or retinoic acid. In a search for a protein capable of binding MRPs, both MRPs were individually produced in insect cells (Sf21) infected with recombinant baculovirus. The purified recombinant MRPs were electrophoretically and antigenically indistinguishable from the native proteins, and their ability to form the MRP8/14 complex was retained. The presence of MRP binding sites was investigated by a binding assay using recombinant MRPs and specific monoclonal antibodies. MRP binding sites were detected on the cell membrane of the human leukemia cell lines THP-1, Raji, and MOLT-4. HL-60 cells treated with 1alpha, 25-dihydroxyvitamin D3 did not express MRP binding sites on the cell membrane, but a high level of MRPs accumulated in the cells. The occurrence of MRP binding sites on the cell surface of leukemia cell lines of monocyte and lymphocyte origin suggests that MRPs, released from neutrophils under certain conditions, may contribute to the activation and recruitment of effector cells to inflammatory lesions.

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

Background and Purpose— Malignant middle cerebral artery (MCA) infarction is one of the most devastating forms of ischemic stroke, and identification of predictors of a malignant course of the MCA or internal carotid artery (ICA) infarction is exceedingly important. Here, we investigated whether thrombus component defined with MR imaging could predict malignant changes in the acute stage of the cerebral infarction. Methods— We retrospectively analyzed 468 consecutive patients with cerebral infarction in our institute from 2007 to 2011. In all the patients, initial MR imaging including T2 star (T2*), diffusion weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR) and MR angiography were performed and susceptibility vessel sign (SVS) on T2* was evaluated in relation to the brain swelling on CT 24 hours after the initial imaging. Correlation of the thrombus component between MRI and CT was also evaluated. Results— One hundred and twelve patients showed MCA main trunk or carotid T occlusion. Among them, 38 patients were t-PA failed or did not undergo endovascular treatment. Twenty eight patients had ICA occlusion and 10 patients had MCA main trunk occlusion. SVS was apparent in 17 (45%) patients, and there was no significant difference between SVS positive and SVS negative group in age (75.6 vs. 72.3 years old), time to arrival (84.4 vs. 106.9 min) and NIH stroke scale (19.5 vs. 18.7). On the other hand, DWI area was significantly larger in SVS positive group (189.3 vs. 107.6 ml). DWI area was also significantly correlated with brain swelling 24 hour later regardless of SVS. Most SVS positive patients showed MCA dense sign on CT performed 24 hours later (85.7% vs. 29.4%). Conclusions— Susceptibility vessel sign on MRI, which suggests RBC rich thrombus, indicates early maturation of the infarct in the MCA area, but could not predict following malignant change.

Human Fc gamma receptor IIIA (hFc gamma RIIIA) cDNA was introduced into mouse macrophage/monocyte cell line P388D1, and several stable cell clones expressing hFc gamma RIIIA were isolated. This facilitated the study of the biological function of Fc gamma RIIIA in monocytes/macrophages. The cloned cells showed the high phagocytic activity mediated by hFc gamma-RIIIA, while the original P388D1 cells did not. In order to examine the phosphorylation of proteins involved in hFc gamma RIIIA signal transduction, these receptors were stimulated by cross-linking. The cross-linking of hFc gamma RIIIA induced a rapid increase in tyrosine phosphorylation of several proteins, including PLC-gamma 1, Syk, HS1, and p21rasGAP-associated p190 and p60 proteins. Immunoblotting with a polyclonal antibody specific for the GAP-associated p62 protein, which was originally found in fibroblasts and is homologous with an RNA-binding protein, revealed that the p60 phosphorylated after cross-linking of hFc gamma RIIIA seemed to represent a novel GAP-associated protein unrelated to the known GAP-associated p62 protein, which was also present in the P388D1 cells.

Our previous work has shown that the amino acid residues around 62-67 located in the connecting loop between helix I and II of human growth hormone (hGH) are important in eliciting the differentiation of preadipose 3T3-F442A cells to adipocytes. In this study, we evaluated the role of the charged residues around 62-67 in receptor binding and biological activity. Eight artificial mutant variants of hGH were prepared in Escherichia coli by site-directed mutagenesis. Replacement of Arg64 with Tyr (R64Y variant) resulted in a significant loss of binding to the somatogenic receptors on 3T3-F442A cells, but retained full adipose conversion activity on these cells. Replacement of Arg64 with Glu (R64E) produced a considerable loss in receptor binding and a significant loss in biological activity. hGH variants in which either Glu65 or Glu66 was replaced with Asp (E65D and E66D) and with Gln (E65Q and E66Q) showed a slight loss in binding activity and retained almost a full adipogenic activity. An E65P variant (replacement of Glu65 with Pro) possessed the same binding activity as hGH, although it failed to induce full biological activity. The insertion of Ala between Asn63 and Arg64 (63NAR) caused a marked loss in both activities. These results indicate that the positively charged Arg64 is important for receptor binding and thereby in eliciting the biological activity of hGH, while negatively charged Glu65 and Glu66 are less important. In addition, our findings confirm that the conformation and size of the loop region around Arg64 is important for the adipose conversion activity of hGH.

Coil migration during cerebral aneurysm embolization is rare, but one of the most troublesome events. A 65-year-old woman was referred to our hospital for the treatment of a cerebral aneurysm. Angiography showed the aneurysm at the C3 portion of the right internal carotid artery. The neck of the aneurysm was wide. A detachable coil was placed into the aneurysm using the balloon neck plasty technique and was detached after confirmation of its stability. However, after detachment, the coil started to migrate. The balloon was inflated to prevent coil migration and another coil was inserted into the aneurysm to stabilize the migrated coil. Finally, the aneurysm was subtotally embolized with 9 coils. The postoperative course was uneventful. Coil migration may occur especially in a wide-neck aneurysm. Appropriate coil selection is important to prevent such migration. Subsequent coil insertion, retrieval of the migrated coil, and stent placement are the treatment options for coil migration.