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A subgroup analysis of puncture site-related complications listed in the Japanese Registry of NeuroEndovascular Therapy 3, based on retrospective studies, was performed. Puncture site-related complications occurred in 315 (0.73%, average age: 65.2) of 36,708 patients out of all 43,303 registered cases. Carotid artery stenting (CAS, 95 patients, 1.1%, P

Background Near-infrared spectroscopy (NIRS) is an alternative monitoring method during carotid artery stenting (CAS). NIRS has been reported to be effective in emergency care; however, it is unknown whether it can predict intraoperative ischemic intolerance and cerebral hyperperfusion during CAS. Perioperative ischemic intolerance and cerebral hyperperfusion are potential events during CAS for carotid artery stenosis. We evaluated whether perioperative monitoring of the tissue oxygenation index (TOI) using NIRS with the NIRO system can predict the occurrence of ischemic intolerance and cerebral hyperperfusion. Methods The TOI of 27 patients was measured during CAS. The relationship between the TOI and ischemic intolerance or cerebral hyperperfusion was analyzed, and the cutoff TOI was calculated to predict their occurrence. Results Ischemic intolerance occurred in 5 patients during balloon protection. The TOI in the presence of ischemic intolerance was significantly lower than that without ischemic intolerance. The cutoff TOI to detect ischemic intolerance was 50% and that of the TOI change rate before and after balloon protection was 80%. The ischemic symptoms in all patients had resolved immediately after balloon deflation. The cerebral hyperperfusion phenomenon was detected using single-photon emission computed tomography in 4 patients. These patients showed a transient increase in the TOI immediately after CAS; however, none of these patients showed symptomatic cerebral hyperperfusion phenomenon. The cutoff TOI to detect cerebral hyperperfusion was 109% compared with the TOI before CAS. Conclusion Monitoring of the TOI using the NIRO system could be useful for the detection of ischemic intolerance and cerebral hyperperfusion during CAS and to prevent perioperative adverse events.

Background Flow diverters (FDs) have marked the beginning of innovations in the endovascular treatment of large unruptured intracranial aneurysms, but no multi-institutional studies have been conducted on these devices from both the clinical and economic perspectives. Objective To compare retreatment rates and healthcare expenditures between FDs and conventional coiling-based treatments in all eligible cases in Japan. Methods We identified patients who had undergone endovascular treatments during the study period (October 2015-March 2018) from a national-level claims database. The outcome measures were retreatment rates and 1-yr total healthcare expenditures, which were compared among patients who had undergone FD, coiling, and stent-assisted coiling (SAC) treatments. The coiling and SAC groups were further categorized according to the number of coils used. Retreatment rates were analyzed using Cox proportional hazards models, and total expenditures were analyzed using multilevel mixed-effects generalized linear models. Results The study sample comprised 512 FD patients, 1499 coiling patients, and 711 SAC patients. The coiling groups with ≥10 coils and ≥9 coils had significantly higher retreatment rates than the FD group with hazard ratios of 2.75 (1.30-5.82) and 2.52 (1.24-5.09), respectively. In addition, the coiling group with ≥10 coils and SAC group with ≥10 coils had significantly higher 1-year expenditures than the FD group with cost ratios (95% CI) of 1.30 (1.13-1.49) and 1.31 (1.15-1.50), respectively. Conclusion In this national-level study, FDs demonstrated significantly lower retreatment rates and total expenditures than conventional coiling with ≥ 9 coils.

BackgroundEndovascular treatment is recommended in clinical practice in Japan. However, its utilization and comprehensiveness are less well described.AimsTo report endovascular treatment utilization and overall geographical coverage in Japan and to analyze regional differences in the number of endovascular treatments, specialists, and endovascular treatment-capable hospitals.MethodsA national survey of members of the Japanese Society for NeuroEndovascular Therapy (JSNET) was conducted in 2017 and 2018. The total number of endovascular treatment cases per year was estimated, and the number of endovascular treatment cases per 100,000 people was calculated using the 2015 census. The distribution of treatment hospitals and JSNET specialists was mapped and the population coverage rate was determined.ResultsThe total number of endovascular treatment cases in Japan increased by 34.5% from 2016 (7702) to 2017 (10,360). The number of endovascular treatment-capable hospitals in Japan increased from 597 in 2016 to 693 in 2017, with an average annual caseload of 14.9 in 2017. The number of JSNET specialists per hospital decreased from 1.81 in 2016 to 1.76 in 2017 because of the increase in endovascular treatment-capable hospitals. Only 50 (7.2%) hospitals had > 40 endovascular treatment cases annually. The majority (97.7%) of the Japanese population lives within a 60-min drive of any endovascular treatment-capable hospital. However, only 70.4% live within a 60-min drive of a high-volume center (>40 cases annually).ConclusionsUtilization of endovascular treatment in Japan is increasing; however, the number of cases per hospital remains low, as is the number of specialists per endovascular treatment-capable hospital. Increased number of specialists and centralization of endovascular treatment services may improve patient outcomes.

The purpose of this study was to investigate the dose distribution and lens doses associated with C-arm cone-beam computed tomography (CBCT), using a head phantom, and to estimate the contribution ratio of C-arm CBCT to each patient’s lens dose during interventional neuroradiology (‘lens dose ratio’) in 109 clinical cases. In the phantom study, the peak skin doses and respective right and left lens doses of C-arm CBCT were as follows: 63.0 ± 1.9 mGy, 19.7 ± 1.4 mGy and 21.9 ± 0.8 mGy in whole brain C-arm CBCT and 39.2 ± 1.4 mGy, 4.7 ± 0.9 mGy and 3.6 ± 0.3 mGy in high-resolution C-arm CBCT. In the clinical study, the lens dose ratios were 25.4 ± 8.7% in the right lens and 19.1 ± 9.8% in the left lens. This study shows that, on average, ~25% of patients’ total lens dose was contributed by C-arm CBCT.

The Tama-REgistry of Acute endovascular Thrombectomy (TREAT) is a multicenter registry of endovascular thrombectomy in the Tama area of Tokyo. The objective of this study was to confirm the real-world status of 2 paradigms of transportation.This was a retrospective analysis of data from TREAT. Patients were divided into 2 groups and 2 periods: directly admitted to an endovascular thrombectomy-capable center (ECC; group D)/secondary transfer from a non-ECC (group S), and the first period/the second period. Transfer distance, workflow metrics, and clinical outcomes were analyzed.A total of 326 patients, including 264 in group D and 62 in group S, were analyzed. The median distance from the onset-to-ECC was 3.62km for group D and 7.87km for group S (P.001). The median onset-to-needle (OTN) time was longer for group S (168 minutes) than group D (138 minutes; P = .006). The median onset-to-reperfusion (OTR) time was significantly shorter for group D (247 minutes) than for group S (304 minutes; P = .029). With respect to the 2 periods, there was no significant difference in onset-to-puncture time between the 2 groups in the first period (207 minutes versus 243.5 minutes, respectively, P = .50), while there was one in the second period (164 minutes versus 246.5 minutes, respectively, P = .02).This region-wide registry study showed longer OTN and OTR times, with no improvement of the time course over time in patients transported via non-ECCs. These results should be used to create a regional medical policy for the management of acute ischemic stroke.

Background: When severe aortic stenosis (AS) is concomitant with carotid stenosis, carotid artery stenting (CAS) will become a high-risk procedure because baroreceptor reflex-induced bradycardia and hypotension may cause irreversible circulatory collapse. When carotid stenosis-related misery perfusion is present, the risk of cerebral hyperperfusion syndrome increases after carotid revascularization. We report a case of severe carotid disease concomitant with severe AS successfully treated by a combination of staged angioplasty (SAP) and transcatheter aortic valve implantation (TAVI). Case Description: An 86-year-old man presented with transient deterioration of mental status and sluggish responsiveness continuous from the previous day. Magnetic resonance imaging of the brain revealed a right putaminal infarction, occlusion of the right internal carotid artery (ICA), and severe stenosis of the left ICA. Severe AS was diagnosed and single-photon emission computed tomography showed misery perfusion at the bilateral ICA territories. We performed a staged treatment consisting of SAP for the left carotid stenosis and TAVI. A first-stage carotid angioplasty was performed, followed by TAVI 2 weeks later and second-stage CAS 1 week after that. There were no apparent periprocedural complications throughout the clinical course. Conclusion: Combining SAP and TAVI may be an effective treatment option for severe carotid stenosis with misery perfusion concomitant with severe AS.

In patients undergoing percutaneous coronary intervention (PCI) with a stent, high on-treatment platelet reactivity may be associated with an increased risk of stroke. This post hoc analysis of the PENDULUM registry compared the risk of post-PCI stroke according to on-treatment P2Y12 reaction unit (PRU) values. Patients aged ≥ 20 years who underwent PCI were stratified by baseline PRU (at 12 and 48 h post-PCI) as either high (HPR, > 208), optimal (OPR, > 85 to ≤ 208), or low on-treatment platelet reactivity (LPR, ≤ 85). The incidences of non-fatal ischemic and non-ischemic stroke through to 12 months post-PCI were recorded. Almost all enrolled patients (6102/6267 [97.4%]) had a risk factor for ischemic stroke, and most were receiving dual antiplatelet therapy. Of the 5906 patients with PRU data (HPR, n = 2227; OPR, n = 3002; LPR, n = 677), 47 had a non-fatal stroke post-PCI (cumulative incidence: 0.68%, ischemic; 0.18%, non-ischemic stroke). Patients with a non-fatal ischemic stroke event had statistically significantly higher post-PCI PRU values versus those without an event (P = 0.037). The incidence of non-fatal non-ischemic stroke was not related to PRU value. When the patients were stratified by PRU ≤ 153 versus > 153 at 12–48 h post-PCI, a significant difference was observed in the cumulative incidence of non-fatal stroke at 12 months (P = 0.044). We found that patients with ischemic stroke tended to have higher PRU values at 12–48 h after PCI versus those without ischemic stroke.Clinical trial registration: UMIN000020332.

We successfully established a chordoma cell line, designated TSK-CHO1, derived from the clival chordoma. Currently, there is only one skull base chordoma cell line, UM-chor1, freely available to researchers. The established TSK-CHO1 cells were neoplastic, exhibited pleomorphic features, and secreted brachyury, as revealed by immunocytochemical staining or ELISA of conditioned medium (CM). Cells also secreted SOX9, which enhanced brachyury production. The CM of TSK-CHO1 cells promoted the production of hyaluronic acid and type II collagen during differentiation of human dental pulp stem cells (DPSCs) into fibrocartilage cells. Culture of DPSC pellets in a growth medium supplemented with 10% CM of TSK-CHO1 cells for 2 weeks resulted in the induction of fibrocartilage tissue under normoxic conditions. Brachyury produced by TSK-CHO1 cells promoted the production of collagen type II, peculiar to cartilage, in a dose-dependent manner. The newly established skull base chordoma cell line, TSK-CHO1, is expected to be used for elucidating the pathogenesis of skull base chordoma and for investigating the mechanism underlying the production of fibrocartilage.

BACKGROUND Extracranial arteriovenous malformations (AVMs) are rare clinical entities and on rare occasions cause neurological symptoms. The authors report a case of an extracranial pterygoid AVM and a subsequent contralateral cavernous sinus dural arteriovenous fistula (dAVF) presenting with abducens nerve palsy. OBSERVATIONS An 80-year-old woman was referred to the authors’ hospital with left abducens nerve palsy followed by right ophthalmalgia. Magnetic resonance imaging (MRI) showed abnormal vessel staining in the left pterygoid and the right inferior petrosal sinus (IPS). Cerebral angiography revealed a left pterygoid AVM draining into the right IPS via the cavernous sinus (CS). A dAVF in the right CS was also revealed. The right ophthalmalgia disappeared spontaneously, and, 4 months later, the left abducens nerve palsy also disappeared after conservative management. Follow-up MRI showed spontaneous regression of the AVM and dAVF. The disappearance of the dAVF was considered to be due to spontaneous regression of the left pterygoid AVM and the consequent decrease in venous pressure of the CS, and the symptoms eventually disappeared. LESSONS The authors treated an extremely rare case of extracranial AVM with dramatic changes in vascular structure and symptoms. Understanding of the pathophysiology between symptoms and dynamic changes in the vascular structure is essential for providing the appropriate treatment.

Cell therapy for peripheral nerve injury is a promising strategy as regenerative medicine that restores neurological function. However, challenges remain in producing suitable and sufficient amounts of autologous cells for promoting nerve regeneration. This study aimed to identify the characteristics of neural lineage cells (NLCs) differentiated from dental pulp stem cells (DPSCs) and reveal their effect on functional recovery and nerve regeneration after cell transplantation into an immunodeficient rat using a nerve guide conduit. Here we report a protocol of neural induction in monolayer culture and characterize NLCs in vitro. Furthermore, NLCs were transplanted into an immunodeficient rat model with a 10-mm sciatic nerve defect, and cell survival and differentiation were investigated in vivo. Outcomes of nerve regeneration were also assessed using the remyelinated axon numbers, myelin sheath thickness, electrophysiological activities, and gastrocnemius muscle mass. NLCs comprised neuronal, astrocyte, oligodendrocyte, and neural crest lineage cells. NLCs enhanced the activities of endothelial cells, Schwann cells, and neurons in a paracrine-dependent manner in vitro. At 2 weeks post-transplantation, numerous transplanted NLCs differentiated into platelet-derived growth factor receptor alpha (PDGFRα) + oligodendrocyte progenitor cells (OPCs) and a few PDGFRα + /p75 neurotrophin receptor + Schwann cell-like cells derived from OPCs were observed. At 12 weeks post-transplantation, human Schwann cell-like cells survived, and axon growth, remyelination, electrophysiological activities, and muscle atrophy were improved. This study demonstrates the broad application of our protocol of neural induction of DPSCs and portrays the efficacy of transplantation of NLCs derived from human DPSCs as a promising strategy for peripheral nerve regeneration.

To investigate the effect of alteplase, either combined with stent-retriever thrombectomy or a direct aspiration first pass technique (ADAPT), in patients with large-vessel occlusion stroke. This was a retrospective post hoc analysis of data from The Direct Mechanical Thrombectomy in Acute LVO Stroke (SKIP) study. Patients were divided into two groups according to the first-line thrombectomy technique: stent-retriever and ADAPT. Each group was further divided into two subgroups, namely MT and MT + alteplase. The procedural outcomes, such as first pass effect (FPE) ratio and number of passes, were evaluated. The clinical outcomes included mRS score at 3 months. A total of 180 patients were included (116 in the stent-retriever group and 64 in the ADAPT group). No interaction was detected between the first-line technique and alteplase administration. In the stent-retriever group, after adjusting for factors associated with FPE, the adjusted odds ratio (95% confidence interval) of FPE of the MT + alteplase subgroup versus the MT subgroup was 3.57 (1.5–8.48) and in the ADAPT group it was 1.35 (0.37–4.91). With alteplase, the number of passes decreased with adjusted odds ratios of 0.59 (0.37–0.93) in the stent-retriever group but not in the ADAPT group. In both first-line technique groups, clinical outcomes did not differ between subgroups. In the SKIP study, alteplase administration was associated with increased FPE when combined with stent-retriever thrombectomy, but not with ADAPT. We found no differences in the clinical outcomes.

The first coil should be as thick, long, and large as possible. A retrospective study at the Toranomon Hospital revealed that if the volume of the first coil is 1/3rd or more of the total coil volume, there are less chances of retreatment. Thus, a thick and long first coil contributes to stable long-term anatomical results. The length of the first coil should be approximately 8% of the volume of the aneurysm. After the placement of the first coil, a smaller and shorter coil should be placed sufficiently close to it to complete the procedure. The goal is to achieve prevention of acute re-rupture in ruptured acute aneurysms and life-long prevention of rupture in unruptured asymptomatic aneurysms. If the coil does not detach, check the position of the detachment point, and replace the power supply. In addition, refer to the direction for use of the device for prevention of coil disconnection failure and countermeasures. Although it is not a recommended method, a method of rotating the delivery wire at the detached position to thread the coil and a method of reconstructing the electric circuit with a crocodile clip has been reported.

Background Statins have been associated with reduced recurrence and better functional outcomes in patients with acute ischemic stroke. However, the effect of statins in patients with acute large vessel occlusion (LVO) is not well scrutinized. Methods and Results RESCUE (Recovery by Endovascular Salvage for Cerebral Ultra‐Acute Embolism)‐Japan Registry 2, a physician‐initiated registry, enrolled 2420 consecutive patients with acute LVO who were admitted to 46 centers across Japan within 24 hours of onset. We compared patients with and without statin use after acute LVO onset (statin group and nonstatin group, respectively) in terms of the modified Rankin scale at 90 days. We estimated that the odds ratios for the primary outcome was modified Rankin scale and we estimated the odds ratios for a 1‐scale lower modified Rankin scale adjusting for confounders. After excluding 12 patients without LVO and 9 patients without follow‐up, the mean age of 2399 patients was 75.9 years; men accounted for 55% of patients. Statins were administered to 447 (19%) patients after acute LVO onset. Patients in the statin group had more atherothrombotic cerebral infarctions (34.2% versus 12.1%, P P P P =0.02). The mortality at 90 days was lower in the statin group (4.7%) than the nonstatin group (12.5%; P P =0.02). Conclusions Statin administration after acute LVO onset is significantly associated with better functional outcome and mortality at 90 days.

Internal trapping (IT) is a treatment option for intracranial vertebral artery dissecting aneurysms (VADAs). Medullary infarction (MI) is a complication linked to this treatment. This study aims to clarify the outcomes of IT for VADAs and the risk factors for MIs. We retrospectively reviewed the databases from 2010 to 2017 to identify patients with VADAs treated by IT at seven collaborating institutions. Radiological findings, clinical courses, and outcomes were analyzed. Perforating arteries were classified into terminal or longitudinal types using preoperative angiography. IT was completed in 90 patients (74 ruptured and 16 unruptured VADA). Postoperative rebleeding did not occur in any ruptured VADA patients. Postoperative MRI detected MIs in 26 patients (28.9%). The incidence of MIs in the ruptured VADA (32%) was higher compared with that in the unruptured VADA (13%), though it was not significant. In the MI group, the occlusion or blind alley of the terminal-type and longitudinal-type perforator was confirmed in 23 patients (88%) and 11 patients (42%), respectively. The occlusion or blind alley of the terminal-type perforator was an independent risk factor for MIs in the logistic regression analysis (OR 5.81; 95% CI 1.34–25.11; p = 0.018). In ruptured VADA, postoperative MI (OR 12.2; 95% CI 3.19–64.55; p = 0.0001) and high-grade SAH (OR 8.02; 95% CI 2.32–37.70; p = 0.0006) were independent risk factors of an unfavorable clinical outcome. In conclusion, MIs were an independent risk factor for unfavorable outcomes after IT, especially for a ruptured VADA. The occlusion or blind alley of the terminal-type perforator caused by the IT was associated with postoperative MIs.

Background Although, thrombectomy for stroke more than 6 hours after onset supported by automated perfusion computed tomography (CT) software (RAPID, iSchemaView) is effective, this software is not available in Japan. This study aimed to elucidate the efficacy of thrombectomy 6-24 hours after onset in our patient cohort using conventional imaging mismatch. Methods Of 586 ischemic stroke patients who underwent thrombectomy registered from January 2015 to December 2017, patients with occlusion of the intracranial internal carotid artery or middle cerebral artery, who had last been known to be well 6-24 hours earlier and who had a prestroke modified Rankin scale (mRS) score 0 or 1 were enrolled. Clinical outcomes were the scores of the utility-weighted (UW) mRS, which ranges from 0 (death) to 10 (no symptom or disability), and the rate of functional independence (mRS score of 0-2) at 90 days. Results This study sample included 31 patients. The median baseline National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 13-20), and the median Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score was 7 (IQR, 5-8). The median interval between the time that the patient was last known well and revascularization was 741 (IQR, 641-818) minutes. The mean UW mRS score at 90 days was 5.3, the rate of functional independence was 32%, and the 90-day mortality rate was 13%. Conclusions Thrombectomy 6-24 hours after onset which can be performed with conventional imaging mismatch might be secured for improving functional independence in stroke patients.

Endovascular trapping of the vertebral artery dissecting aneurysms (VADAs) carries a risk of medullary infarction due to the occlusion of the perforating arteries. We evaluated the detectability and anatomical variations of perforating arteries arising from the vertebral artery (VA) using three-dimensional DSA. In 120 patients without VA lesions who underwent rotational vertebral arteriography, the anatomical configurations of perforating arteries from the VA were retrospectively evaluated on the bi-plane DSA and reconstructed images to reach the consensus between two experienced reviewers. The images were interpreted by focusing on the numbers and types of perforating arteries, the relationships between the number of perforators and the anatomy of the VA and its branches. Zero, 1, 2, 3, 4, and 6 perforators were detected in 2, 51, 56, 9, 1, and 1 patient, respectively (median of 2 perforators per VA). The 200 perforators were classified into 146 terminal and 54 longitudinal course types and into 32 ventral, 151 lateral, and 17 dorsolateral distribution types. All ventral type perforators were also terminal type. In contrast, the longitudinal type was seen in 28.5% of lateral types and in 65% of dorsolateral types. Regarding the difference in the origin of the posterior inferior cerebellar artery (PICA), non-PICA type VAs gave off larger number of perforators than the other types of VAs. Non-PICA type VAs give off a significantly larger number of perforators than other types, indicating that the trapping of non-PICA type VAs is associated with a risk of ischemic complications.

Objective Mechanical thrombectomy (MT) is the recommended treatment for patients with acute ischemic stroke due to large cerebral vessel occlusion (LVO). However, few studies have investigated long-term outcomes after MT. The aim of this study was to investigate functional outcomes at long-term follow-up (1 year after MT) in patients undergoing MT for anterior circulation LVO in real-world clinical practice. Methods This was a retrospective and prospective observational study using data from TREAT (Tokyo/tama-Registry of Acute Endovascular Thrombectomy), a multicenter registry of MT for acute LVO in the Tokyo metropolitan area. All subjects emergently transferred and treated with MT from January 2015 to December 2018 were selected. Patients' baseline characteristics and stroke-related parameters were evaluated. The primary outcome was the modified Rankin Scale (mRS) score 1 year after MT. The secondary outcomes were risk factors for long-term good outcomes (mRS score 0–2); transfer system (stroke bypass vs. secondary transfer) was also evaluated as a potential factor associated with good long-term outcomes. Results A total of 162 cases (mean age 73.0 years, age range 30–97 years; 59.9% male) whose mRS scores at 1 year were obtained were analyzed. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 17. Overall, 42.6% of the patients achieved functional independence at 1-year follow-up. Lower initial NIHSS score and mRS score 0–2 at 90 days were the independent predictors for good long-term outcomes. Stroke bypass was associated with a higher initial NIHSS score and mRS score 0 at 1 year. Conclusions A significant number of patients experience a good long-term outcome after MT.

To optimize the radiation protection of patients, we investigated the possibility of constructing the diagnostic reference levels (DRLs) by imaging objective/disease group using display value of the blood vessel imaging apparatus (air kerma-area product: PKA, air kerma at the patient entrance reference point: Ka, r) in cerebral angiography. We used PKA and Ka, r recorded during surgery of 997 patients at our hospital, and classified them according to the purpose of imaging (diagnostic cerebral angiography or neuro interventional radiology) and disease group. Neuro interventional radiology (PKA: 268±155 Gy・cm2, Ka, r: 2420±1462 mGy) was significantly higher than that of diagnostic cerebral angiography (PKA: 161±70 Gy・cm2, Ka, r: 1112±485 mGy), (Mann-Whitney test, P

A subgroup analysis of spinal vascular lesions registered in the Japanese Registry of Neuroendovascular Therapy 2 (JR-NET2) and JR-NET3 was performed. About 172 analyzable cases of spinal dural arteriovenous fistula (SDAVF) were assessed, including the characteristics, treatment strategy, and treatment outcome. SDAVF was more common in middle-aged and older males. The most commonly affected area was the thoracolumbosacral region (83.7%), and most cases had a non-hemorrhagic onset (89.0%). Complete obliteration was achieved in 54.7%. Treatment-related complications occurred in three patients (7.0%). Post-treatment neurological improvement was achieved in 48.3%. The primary endpoint [modified Rankin Scale (mRS) score of 0-2 on postoperative day 30] was achieved in 60.5% of the cases. As a new discovery, the incidence of cervical SDAVF increased from 1.8% in JR-NET2 to 19.7% in JR-NET3. Compared with non-cervical SDAVF, cervical SDAVF was characterized by a higher proportion of hemorrhagic onset (P

Thrombectomy has demonstrated clinical efficacy against acute ischemic stroke caused by intracranial occlusion of the internal carotid artery (ICA), even if performed 6–24 h after onset. This study investigated the outcomes of thrombectomy performed 6–24 h after stroke onset caused by extracranial ICA occlusion. Of 586 stroke patients receiving thrombectomy during the past 3 years and registered in the Tama Registry of Acute Endovascular Thrombectomy database, 24 were identified with ICA occlusion (14 extracranial and 10 intracranial), known to be well 6–24 h before presentation, and with pre-stroke modified Rankin Scale (mRS) score of 0 or 1. Clinical outcomes measured were the rate of functional independence at 90 days according to mRS score of 0–2 and 90 day mortality rate. Of patients with extracranial ICA occlusion, two received additional carotid stenting with thrombectomy. The median interval between the last time the patient was known to be well and hospital arrival was 601 (interquartile range, 476–729 min). Both the rate of functional independence at 90 days and 90 day mortality were comparable between patients with extracranial or intracranial ICA occlusion (36% vs. 40% and 7% vs. 10%, respectively). No symptomatic intracranial hemorrhages occurred within 24 h following treatment of extracranial ICA occlusion. Thrombectomy performed 6–24 h after extracranial ICA results in acceptable functional outcome. Further clinical study is warranted to better define the temporal window of thrombectomy for acceptable functional outcome in patients with extracranial ICA occlusion.

Background: Vertebrobasilar dolichoectasia (VBD) is a vasculopathy characterized by the elongation, widening, and tortuosity of a cerebral artery. Rarely, hydrocephalus results when the extended basilar artery impairs communication of the cerebral ventricle and cerebrospinal fluid dynamics. We experienced such a case when a patient underwent endoscopic third ventriculostomy (ETV) for noncommunicating hydrocephalus with VBD. Case Description: A 54-year-old man presented with cognitive dysfunction and was diagnosed with VBD by magnetic resonance imaging (MRI). Seven years later, he exhibited subacute impaired consciousness due to acute noncommunicating hydrocephalus, undergoing external ventricular drainage (EVD) that improved consciousness. After EVD removal, the noncommunicating hydrocephalus did not recur; however, 7 months later, subacute consciousness impairment due to noncommunicating hydrocephalus was again observed. MRI showed a significant dilation of both lateral ventricles and ballooning of the third ventricle while the right posterior cerebral artery shifted slightly posteriorly. The patient underwent ETV and clinical symptoms improved. One year after the treatment, MRI observed a patent ETV fenestration and no deleterious changes in clinical symptoms were observed. Conclusion: ETV can be an effective treatment for the noncommunicating hydrocephalus with VBD when performed with preoperative assessment of vascular anatomy and attention to vascular injury.

Background Parent artery occlusion (PAO) is an effective treatment for hemorrhagic diseases associated with the internal carotid artery. There are several reports of long-term cerebral infarction or the formation of de novo cerebral aneurysms following PAO. Materials and methods We retrospectively reviewed these complications in 38 patients who underwent PAO for therapeutic treatment. We investigated perioperative cerebral infarctions, long-term cerebral infarctions, and de novo aneurysms. Results The mean age of the patients was 64.0 years, and 25 patients (65.8%) were female. The causative diseases were unruptured (n = 19; 50.0%) and ruptured (n = 8; 21.1%) aneurysms. PAO was performed after ischemic tolerance was assessed with balloon test occlusion (BTO), and BTO was performed in 34 patients, of whom 25 (73.5%) had ischemic tolerance. Twenty-six patients (68.4%) were treated with PAO alone, eight (23.5%) with low-flow bypass, and six (17.6%) with high-flow bypass. Perioperative complications occurred in five patients (13.2%): two of the 26 patients (7.7%) who underwent scheduled treatment and three of the 12 patients (25.0%) who underwent emergency treatment. One patient (2.6%) had long-term de novo aneurysm, and none developed cerebral infarction. Conclusions These results showed that the assessment of ischemic tolerance by performing BTO and appropriate revascularization in scheduled treatments are important to reduce perioperative and long-term cerebral infarctions. PAO must be performed with greater caution in emergency treatment.

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are not appropriate treatment procedure for internal carotid artery stenosis (ICAS) in some patients. The importance of plaque vulnerability and the treatment risk evaluation has been reported. We analyzed whether treatment selection contributes to the outcome. We retrospectively examined 121 patients who underwent CEA or CAS. Treatment was selected based on plaque vulnerability and the treatment risk evaluation. We selected CAS for patients with stable plaques and CEA for patients with unstable plaques, and considered the other treatment for high-risk patients. The patients were classified as the stable plaque (Stable: n = 42), the unstable plaque and CEA low risk (Unstable/Low: n = 30), and the CEA high-risk (Unstable/High: n = 49). Frequency of perioperative stroke, myocardial infarction, death, and systemic complications was examined. CEA and CAS were performed in 35 and 86 patients, respectively. One patient (2.9%) had a stroke in CEA and five patients (5.8%) in CAS (P = 0.50). Systemic complications were observed in two patients (5.7%) in CEA and six (7.1%) in CAS (P = 0.80). There were no differences in stroke (Stable; 2.4%, Unstable/Low; 3.2%, and Unstable/High; 8.2%) and systemic complications (Stable; 9.5%, Unstable/Low; 3.3%, and Unstable/High; 6.1%) among three groups (P = 0.44 and P = 0.59, respectively). The treatment selection based on plaque vulnerability and the treatment risk evaluation could provide good treatment outcome for high-risk patients. It is ideal to select an appropriate treatment for ICAS by one neurovascular team.

Background: Identification of causative pathogen for fungal aneurysm is frequently difficult. We reported the case of a fungal aneurysm caused by Mucor arising in segment P4 of the posterior cerebral artery (PCA) detected only by histopathological examination. Case Description: A 50-year-old female complained of nausea and vomiting. Computed tomography showed an intracranial hemorrhage in the left occipital lobe and acute hydrocephalus due to intraventricular hemorrhaging. Digital subtraction angiography performed after external drainage showed a cerebral aneurysm in segment P4 of the left PCA. Surgical excision of the aneurysm and end-to-end anastomosis of the PCA were performed. A histopathological examination revealed that the aneurysm had been caused by a Mucor infection. Conclusion: In fungal aneurysm cases, especially those involving Mucor infections, it is difficult to identify the causative fungal infection based on cultures, imaging, and serological tests. Therefore, surgical excision and histopathological diagnosis are important for diagnosing such cases if possible.

Background: Hemorrhagic stroke is caused by various vascular abnormalities, such as aneurysms, arteriovenous malformations, and dural arteriovenous fistulas (DAVF). Magnetic resonance angiography (MRA) and three-dimensional computed tomography angiography (3DCTA) are used as efficient initial diagnostic modalities in assessing the etiology of hemorrhagic stroke. We describe the unusual case of a false-positive aneurysm on MRA and 3DCTA. Case Description: A 65-year-old nonhypertensive woman was brought to our hospital with a sudden onset of headache and left hemiparesis. She also had chemosis in the right eye. CT and magnetic resonance imaging showed an intracerebral hemorrhage in the right temporal lobe. MRA and 3DCTA showed a rounded mass suggestive of an aneurysm arising from the bifurcation of the middle cerebral artery (MCA) and also demonstrated an abnormal tortuous vessel contacting with a rounded mass. Digital subtraction angiography showed a transversesigmoid sinus DAVF with a varix in contact with the MCA bifurcation. Hematoma evacuation and venous drainage disconnection through the right frontotemporal craniotomy were performed. Conclusion: This case is very instructive and clinicians should keep in mind that detailed neurological and radiological examinations are essential in obtaining an accurate diagnosis, especially if the bleeding source is similar in shape and location to common lesions (such as a cerebral aneurysm).

Objective: Due to the recent increase in the availability of cone-beam CT (CBCT), delineation of blood vessels and intracranial stents using CBCT has been well-reported, but reports using 3D-rotational angiography (3D-RA) have been few. We evaluated delineation of carotid artery stents using 3D-RA with diluted contrast medium. Methods: We prepared simulated blood vessel phantoms covered by carotid artery stents different in material and shape. The phantoms were encapsulated with different concentration of contrast medium, and scanned using 3D-RA. The appropriate concentration of contrast medium was evaluated. Results: The appropriate concentrations of diluted contrast medium were 50–17% for the Carotid Wall Stent (Boston Scientific, Natick, MA, USA) and 20%–10% for PRECISE (Johnson & Johnson, Miami, FL, USA) and PROTÉGÉ (Covidien, Irvine, CA, USA). Conclusion: The appropriate concentration of contrast medium varied with carotid artery stent. By selecting an appropriate degree of dilution, the stent shape, plaque, intimal thickening, and vascular lumen in the stent can be visualized. Therefore, it is possible to evaluate vascular lumen after carotid artery stenting.

Background: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. Methods: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 – ≤180 min; category 2, > 180 – ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. Results: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. Conclusions: In MT for elderly patients, effective recanalization improved the patients’ outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

Objective: We report endovascular treatment of a patient with acute basilar artery occlusion considered to be due to an embolus from radiation-induced vertebral artery stenosis. Case Presentation: The patient was a 46-year-old male with a history of neck irradiation. He developed basilar artery occlusion. Temporary recanalization achieved by intravenous alteplase therapy and revascularization was followed by relapse. The origin of the vertebral artery was stenosed, and basilar artery was considered to have been embolized by a thrombus formed on the proximal side of the vertebral artery, where blood flow was stagnated due to reduced antegrade flow from the distal side of the stenotic vertebral artery and the increased collateral flow from the deep cervical artery. Recurrence of cerebellar infarction could be prevented by revascularization and occlusion of the parent artery. Conclusion: Acute basilar artery occlusion considered to be due to an embolus from radiation-induced vertebral artery stenosis is a rare condition, but it must be recognized as a possible cause of posterior circulation infarction.

Supplemental Digital Content is available in the text., Background and Purpose— The purpose of this study is to compare the angiographic and clinical characteristics of spinal epidural arteriovenous fistulas (SEAVFs) and spinal dural arteriovenous fistulas (SDAVFs) of the thoracolumbar spine. Methods— A total of 168 cases diagnosed as spinal dural or extradural arteriovenous fistulas of the thoracolumbar spine were collected from 31 centers. Angiography and clinical findings, including symptoms, sex, and history of spinal surgery/trauma, were retrospectively reviewed. Angiographic images were evaluated, with a special interest in spinal levels, feeders, shunt points, a shunted epidural pouch and its location, and drainage pattern, by 6 readers to reach a consensus. Results— The consensus diagnoses by the 6 readers were SDAVFs in 108 cases, SEAVFs in 59 cases, and paravertebral arteriovenous fistulas in 1 case. Twenty-nine of 59 cases (49%) of SEAVFs were incorrectly diagnosed as SDAVFs at the individual centers. The thoracic spine was involved in SDAVFs (87%) more often than SEAVFs (17%). Both types of arteriovenous fistulas were predominant in men (82% and 73%) and frequently showed progressive myelopathy (97% and 92%). A history of spinal injury/surgery was more frequently found in SEAVFs (36%) than in SDAVFs (12%; P=0.001). The shunt points of SDAVFs were medial to the medial interpedicle line in 77%, suggesting that SDAVFs commonly shunt to the bridging vein. All SEAVFs formed an epidural shunted pouch, which was frequently located in the ventral epidural space (88%) and drained into the perimedullary vein (75%), the paravertebral veins (10%), or both (15%). Conclusions— SDAVFs and SEAVFs showed similar symptoms and male predominance. SDAVFs frequently involve the thoracic spine and shunt into the bridging vein. SEAVFs frequently involve the lumbar spine and form a shunted pouch in the ventral epidural space draining into the perimedullary vein.

Purpose Recent reports have posed doubts about the effect of preradiosurgical embolization in brain arteriovenous malformation (AVM) because it makes the planning of stereotactic radiosurgery (SRS) difficult and has the risk of recanalization out of the target. We investigated whether the performance and quality of embolization may influence the success of SRS based on a retrospective case cohort study. Materials and Methods Seventy-three patients who underwent embolization followed by SRS between 2003 and 2012 in eight institutes with neurointerventionists were considered. They were divided into the following two groups at 3 years of follow up after the final SRS: “successful occlusion group” (S group), with radiologically complete occlusion of AVM; and “non-successful occlusion group” (N group) with persistent remnant nidus or abnormal vascular networks. Patient background, AVM profile, embolization performance grade and complications were compared in each group. The quality of embolization was evaluated with the new grading system: embolization performance grade (E grade), specializing the achievement of nidus embolization. E grade A was defined as sufficient nidus embolization with more than half of the total number of feeders achieving nidus penetration. E grade B was defined as less than half achievement of nidus embolization, and E grade C was defines as failure to perform nidus embolization. Results Forty-three patients were included in the S group, and 29 patients were included in the N group. The size and Spetzler-Martin grade of AVM and the rate of diffuse type was higher in the N group without statistical significance. The embolization performance level according to E grade indicated a significantly higher rate of successful embolization with more than 50% of nidus penetration in the S group (P

Background and Purpose— Reperfusion therapy by mechanical thrombectomy is used to treat acute ischemic stroke. However, reactive oxygen species generation after reperfusion therapy causes cerebral ischemia–reperfusion injury, which aggravates cerebral infarction. There is limited evidence for clinical efficacy in stroke for antioxidants. Here, we developed a novel core-shell type nanoparticle containing 4-amino-4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl (nitroxide radical-containing nanoparticles [RNPs]) and investigated its ability to scavenge reactive oxygen species and confer neuroprotection. Methods— C57BL/6J mice underwent transient middle cerebral artery occlusion and then received RNPs (9 mg/kg) through the common carotid artery. Infarction size, neurological scale, and blood-brain barrier damage were visualized by Evans blue extravasation 24 hours after reperfusion. RNP distribution was detected by rhodamine labeling. Blood-brain barrier damage, neuronal apoptosis, and oxidative neuronal cell damage were evaluated in ischemic brains. Multiple free radical-scavenging capacities were analyzed by an electron paramagnetic resonance–based method. Results— RNPs were detected in endothelial cells and around neuronal cells in the ischemic lesion. Infarction size, neurological scale, and Evans blue extravasation were significantly lower after RNP treatment. RNP treatment preserved the endothelium and endothelial tight junctions in the ischemic brain; neuronal apoptosis, O 2 − production, and gene oxidation were significantly suppressed. Reactive oxygen species scavenging capacities against OH, ROO, and O 2 − improved by RNP treatment. Conclusions— An intra-arterial RNP injection after cerebral ischemia–reperfusion injury reduced blood-brain barrier damage and infarction volume by improving multiple reactive oxygen species scavenging capacities. Therefore, RNPs can provide neurovascular unit protection.

In Japan, the era of thrombectomy for acute stroke started when the Merci retriever was approved in 2010 and the Penumbra system in 2011. New-generation Penumbra catheters (MAX series) and stent retrievers were introduced in 2013 and 2014, respectively. The aim of this study was to clarify the general status and trends in endovascular reperfusion therapy for stroke in Japan from 2010 to 2014. We extracted a total of 3705 patients (72.1 ± 12.2 years, 1482 women) from a nationwide study of patients receiving any neuroendovascular treatment, the Japanese Registry of NeuroEndovascular Therapy 3. Reperfusion therapy resulted in a successful reperfusion rate of 59%, and 31% of patients achieved a favorable outcome at 30 days of onset. The frequency of Merci-including procedures increased to 52% in the first half of 2011, but conversely decreased to 1% in the second half of 2014. The frequency of Penumbra-including procedures increased from 18% in the second half of 2011 to 67% in the first half of 2014, decreasing to 38% in the second half of 2014. The reperfusion rate and 30-day clinical outcomes remained almost unchanged until June 2013, and started to improve thereafter, coincident with the introduction and spread of newer-generation devices. The rate of successful reperfusion reached 71-76%, and 36-38% of patients achieved a favorable outcome in 2014. After multivariate adjustment for preprocedure variables, the calendar period from 2013 to 2014 was significantly associated with improvement in reperfusion rates and clinical outcomes.

Cerebral arteries are developed from the primitive carotid artery derived from brachial arch and longitudinal neural artery (future vertebrobasilar artery) derived from segmental arteries. In embryonic periods, the longitudinal neural artery is supplied by the carotid-vertebrobasilar anastomoses (homologue of the segmental arteries in spinal arterial system). The ascending pharyngeal artery and the occipital artery are derived from remnant of the carotid-vertebrobasilar anastomoses of the primitive hypoglossal artery and the pro-atlantal artery [1–2]. Therefore, the both arteries give off branches supply cranial nerves, and they have potential anastomoses with the vertebral arterial system (Fig. 3.1). The longitudinally adjacent segmental arteries in the spinal level have anastomoses via paravertebral, epidural, and dural branches. Similarly, the ascending pharyngeal artery has anastomoses with anterior meningeal artery from the vertebral artery, meningohypophyseal trunk (derived from the remnant of primitive trigeminal artery, a carotid-basilar anastomosis) of the internal carotid artery via the clival branches and the carotid branch. Because embolization from the ascending pharyngeal artery and the occipital artery has a potential risk of cranial nerve injury or cerebral infarction, knowledge of imaging anatomy of the two arteries is essential for safe procedure.

The purpose of this study was to measure the peak skin dose (PSD) and bilateral lens doses using radiophotoluminescence glass dosimeters and to determine the factors influencing the radiation dose in cases of cerebral aneurysm treated with pipeline embolization devices (PEDs). The cumulative dose, PSD and right and left lens doses were 3818.1 ± 1604.6, 1880.0 ± 723.0, 124.8 ± 49.2 and 180.7 ± 124.8 mGy, respectively. Using multivariate analysis, body mass index (p

Background We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. Methods and results We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. Conclusions We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.

We hypothesized that a single-leg version of the Hybrid Assistive Limb (HAL) system could improve the gait and physical function of patients with hemiparesis following a stroke. In this pilot study, we therefore compared the efficacy of HAL-based gait training with that of conventional gait training (CGT) in patients with acute stroke. Patients admitted to the participating university hospital were assigned to the HAL group, whereas those admitted to outside teaching hospitals under the same rehabilitation program who did not use the HAL were assigned to the control group. Over 3 weeks, all participants completed nine 20 min sessions of gait training, using either HAL (i.e., the single-leg version of HAL on the paretic side) or conventional methods (i.e., walking aids and gait orthoses). Outcome measures were evaluated before and after the nine training sessions. The Functional Ambulation Category (FAC) was the primary outcome measure, but the following secondary outcome measures were also assessed: National Institutes of Health Stroke Scale, Fugl–Meyer Assessment (Lower Extremity), comfortable walking speed, step length, cadence, 6-min walk distance, Barthel Index, and Functional Independence Measure. In total, 22 post-stroke participants completed the clinical trial: 12 in the HAL group and 10 in the CGT group. No serious adverse events occurred in either group. The HAL group showed significant improvement in FAC after nine sessions when compared with the CGT group (P = 0.014). However, secondary outcomes did not differ significantly between the groups. Our results demonstrate that HAL-based gait therapy may improve independent walking in patients with acute stroke hemiplegia who are dependent on ambulatory assistance. A larger-scale randomized controlled trial is needed to clarify the effectiveness of single-leg HAL therapy. Clinical Trial Registration: UMIN Clinical Trials Registry, identifier UMIN000022410.

Precautious balloon test occlusion (BTO) is sometimes performed in cases of high-risk intraoperative internal carotid artery injury. We investigated whether magnetic resonance angiography (MRA) findings could predict BTO results to thus avoid the use of precautious BTO. This retrospective study, included 96 patients who underwent BTO, eight of whom underwent bilateral BTO. The relationship between the BTO results for 104 internal carotid arteries and the MRA findings obtained in 96 patients were retrospectively evaluated. On MRA, anterior cerebral artery (A1)–anterior communicating artery–A1 was defined as anterior collateral circulation (ACC), and posterior cerebral artery–posterior communicating artery was defined as posterior collateral circulation (PCC). BTO was tolerated in all 27 sides with thick ACC regardless of PCC thickness. In 31 of 44 cases with a thin ACC, the tested sides were BTO-tolerant (70.5%). Of these 44 tested sides, all five with a thick PCC were BTO-tolerant, but eight with a thin PCC and 31 with an invisible PCC showed results other than tolerance. Among cases with an invisible ACC, 10 of 33 tested sides were BTO-tolerant (30.3%). Among these 33 tested sides, outcomes other than tolerance were observed regardless of PCC thickness. Thick, thin, and invisible ACCs were assigned 3, 1, and 0 points, respectively; and thick, thin, and invisible PCCs were assigned 2, 1, and 0 points, respectively. A sum of 3 points in the ACC and PCC indicated that all sides were BTO-tolerant. In conclusion, a thick ACC or a thin ACC with a thick PCC indicates BTO-tolerance. The BTO prediction score is useful for predicting results of BTO.

Background After subarachnoid hemorrhage (SAH), headache management is often difficult owing to the need to use multiple analgesic drugs. Fentanyl is an opioid we can use after surgery, and it can decrease pain post SAH. The aim of this study was to investigate the effectiveness and safety of fentanyl for management of headache after SAH. Methods Twenty-two patients who underwent surgical clipping for ruptured intracranial aneurysms and complained of severe headache after the surgery were enrolled. Among them, 9 patients were given fentanyl combined with other analgesic drugs. The numeric rating scale score and dietary intake were measured in the acute phase after the SAH. Results The numeric rating scale scores were significantly lower in the fentanyl (+) group. The maximum numeric rating scale decreased to 7.7 ± 3.8 days in the fentanyl (+) group. At day 14, the fentanyl (+) group showed significantly better dietary intake than that of the fentanyl (−) group. Conclusions Using fentanyl after surgical clipping for ruptured intracranial aneurysms might decrease headache and produce few adverse effects. Adequate headache control showed improved dietary intake after SAH.

Background: Optic neuropathy due to an aneurysm is relatively rare, with only a few small case series on this topic, and no randomized trials having been published until now. As such, the functional prognosis and treatment for aneurysm-induced optic neuropathy remain controversial. Objective: We quantified optic nerve injuries using an objective index (the visual impairment score) and evaluated prognostic factors of postoperative visual function. Materials and Methods: Of 960 patients treated for an unruptured intracranial aneurysm, 18 (1.9%) patients had optic neuropathy. Visual acuity and visual field were assessed before surgery and 6 months' postoperatively. Cases were classified on the basis of treatment modality (coil embolization or flow alteration [FA]) and prognostic factors of the two treatment groups. Results: Of the 18 patients with an intracranial aneurysm and optic neuropathy, 12 (67%) were treated using coil embolization and 6 (33%) were FA. Visual function improved after surgery in 8 patients (44%), 5 (42%) in the coil embolization group, and 3 (50%) in the FA group. The visual function remained stable after surgery in 6 (33%) patients and worsened in 4 (22%). Patients with an aneurysms

The efficacy of mechanical thrombectomy in the treatment of occlusions of the second segment of the middle cerebral artery (M2) has not been firmly established. This study analyzed data from patients who had undergone mechanical thrombectomy for the first segment of the middle cerebral artery (M1) and M2 occlusion from the Tama-REgistry of Acute endovascular Thrombectomy (TREAT) between January 2015 and March 2017, which is a multicenter database in the Tama area of Tokyo, Japan. The M1 and M2 occlusions were compared in order to evaluate the safety and efficacy of M2 thrombectomy. A total of 515 patients were registered, whereby 160 patients with M1 occlusion and 51 patients with M2 occlusion were included. While the puncture-to-reperfusion time was longer in the M2 occlusions (median 43 min, range 30–61 min vs. median 60 min, range 38–79 min, p = 0.01), no significant differences were seen in the proportion of patients with successful reperfusion, postoperative hemorrhagic complications and good outcome (modified Rankin scale ≤2 at 90 days). Younger age was the only independent factor associated with good outcome in patients with M2 occlusions as determined by the multivariate analysis (p = 0.033, odds ratio 0.91, 95% confidence interval 0.83–0.99). The outcome and the safety profile of mechanical thrombectomy for M2 occlusions are favorable and comparable to those of the M1 occlusion thrombectomy.

Characterization of vessels distal from occluded site is important when considering endovascular revascularization therapy (EVT) for acute ischemic stroke. The goal of this study was to assess the clinical value of intra-arterial contrasted high-resolution cone-beam computed tomography from the ascending aorta (Ao-CBCT) for visualization of the vessels distal from occluded site. Acute ischemic stroke patients with large vessel occlusion who were to undergo EVT were evaluated. In EVT, digital subtraction angiography (DSA) and Ao-CBCT were performed with local anesthesia. Ao-CBCT images were acquired in a 20-second rotational scan. Contrast medium was injected (1 mL/s for a total of 30 seconds using a 4-Fr catheter and an imaging delay of 10 seconds) from the ascending aorta. We assessed the image quality of Ao-CBCT and compared the visualization of the vessels distal from occluded site among magnetic resonance angiography (MRA), DSA and Ao-CBCT. We analyzed 14 patients (mean age, 66 years; three female patients). Stroke subtypes were cardiogenic (n = 6), atherothrombotic (n = 5) and others/unknown (n = 3). Occluded sites were middle cerebral artery (MCA) M1 (n = 8), MCA M2 (n = 2), internal carotid artery (ICA) (n = 2), MCA M4 (n = 1) and basilar artery (BA) (n = 1). All obtained Ao-CBCT images successfully characterized the vessels distal from occluded site, and 11 images (79%) were excellent. In all cases, Ao-CBCT images could depict distal vessels with more detail when compared with MRA and DSA. Ao-CBCT is an efficient method to obtain detailed information regarding vessels distal from occluded site when compared with conventional examination methods.