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Background and Purpose Because magnetic resonance imaging (MRI) focuses on the morphological characteristics of carotid artery plaques, its diagnostic value with respect to plaque vulnerability is limited. We examined the correlation between N e -(carboxymethyl)lysine (CML), a main chemical structure of advanced glycation end-products, and the vulnerability of plaques visualized on MRI scans. Materials and Methods We enrolled 43 patients who had undergone carotid artery stenting (CAS) for carotid artery stenosis; all underwent MRI studies, including black-blood MRI and diffusion-weighted imaging (DWI). The signal intensity ratio (SIR) of plaques to adjacent sternocleidomastoid muscle (P/M) on T1- and T2-weighted images (T1WI, T2WI) was calculated. Protein samples were extracted from debris trapped by a filter device. The concentrations of CML and myeloperoxidase (MPO) were measured by solid-phase enzyme-linked immunosorbent assay. Results The patients were classified into 2 groups based on their SIR-P/M on T1WI and T2WI scans. We observed a higher incidence of post-CAS DWI lesions in patients with a higher than a lower SIR-P/M on T1WI; the CML and MPO concentrations in their CAS debris were also higher. No such differences were seen in patients with a higher or lower SIR-P/M on T2WI scans. The concentration of CML in CAS debris correlated independently with the SIR-P/M on T1WI of the carotid plaques, and was related to the concentration of MPO in CAS debris. Conclusions Our findings suggest CML as a candidate molecular imaging probe for the identification of vulnerable plaques.

Background Black-blood magnetic resonance imaging (BB-MRI) is useful for the characterization and assessment of carotid artery plaques. The plaque-to-muscle signal intensity (SI) ratio (plaque/muscle ratio [PMR]) is used widely to evaluate plaques. However, the correlation between the PMR and the T1 relaxation time needs to be determined. We measured the T1 relaxation time of carotid plaques using T1 mapping and compared the results with the PMR on BB-MRI scans. Methods Between April 2014 and July 2015, 20 patients with carotid artery stenosis were treated by carotid artery stenting. All patients underwent preoperative magnetic resonance plaque imaging. The ratio of the plaque SI to the sternocleidomastoid muscle was calculated on T1-weighted BB-MRI scans. T1 mapping was performed in the region where the vessel was narrowest using the inversion recovery technique. The T1 relaxation time was recorded to determine whether there was a correlation with the PMR. Results The plaque T1 value was 577.3 ± 143.2 milliseconds; the PMR value obtained on BB-MRI scans was 1.23 ± .27. There was a statistically significant decrease in the T1 value as the PMR increased ( P Conclusions As the T1 relaxation time was well correlated with the PMR on BB-MRI scans, the evaluation of vulnerable plaques using the PMR was reliable and convenient.

Background Stent-assisted coil embolization is effective for intracranial aneurysms, especially wide-necked aneurysms; however, the optimal antiplatelet regimens for ischemic events that develop after coil embolization have not yet been established. We aimed to determine the onset time of such postoperative ischemic events and the relationship between these events and antiplatelet therapy. Methods We performed coil embolization using a vascular reconstruction stent for 43 cases of intracranial aneurysms and evaluated the incidence of postoperative ischemic events in these cases. Results Nine patients showed postoperative ischemic events during the follow-up period (13 ± 7 months). Two patients developed cerebral infarction within 24 hours. Five patients developed transient ischemic attack within 40 days while they were receiving dual antiplatelet therapy. In addition, 1 patient showed cerebral infarction 143 days postoperatively during single antiplatelet therapy, and a case of transient visual disturbance was reported 191 days postoperatively (49 days after antiplatelet therapy had been discontinued). We increased the number of antiplatelet agents in 4 of these patients. The other 5 patients were under strict observation with dual antiplatelet therapy. All these patients were shifted to single antiplatelet therapy 3-13 months postoperatively. No recurrence of ischemic events was noted. Conclusions Postoperative ischemic events are most likely to occur within 40 days postoperatively. For patients with postoperative ischemic events, additional ischemic events can be prevented by increasing the number of antiplatelet agents; subsequently, they can be shifted to single antiplatelet therapy after the risk of recurrence has decreased.

An 87-year-old man presented with extracranial vertebral artery (VA) occlusion and progressive vertebrobasilar ischemia despite maximal medical management. Cerebral angiography showed left proximal VA occlusion, termination of the right VA at the ipsilateral posterior inferior cerebellar artery, and hypoplastic bilateral posterior communicating arteries. Although the stump of the left VA ostium was not visualized, the distal patent artery was reconstituted via muscular branches from the left subclavian artery (SCA). Endovascular angioplasty with a stent for left VA occlusion was performed. The non-visualized VA ostium was extrapolated from the computed tomography angiography findings of the distal patent VA and the partial calcification of the SCA. The occluded VA was penetrated by the guide wire and revascularized by balloon angioplasty with the stent using the support of a snare wire inserted via the left brachial artery for stabilization of the guide catheter. This treatment resulted in resolution of the severe neurological findings.

Because magnetic resonance imaging (MRI) focuses on the morphological characteristics of carotid artery plaques, its diagnostic value with respect to plaque vulnerability is limited. We examined the correlation between NWe enrolled 43 patients who had undergone carotid artery stenting (CAS) for carotid artery stenosis; all underwent MRI studies, including black-blood MRI and diffusion-weighted imaging (DWI). The signal intensity ratio (SIR) of plaques to adjacent sternocleidomastoid muscle (P/M) on T1- and T2-weighted images (T1WI, T2WI) was calculated. Protein samples were extracted from debris trapped by a filter device. The concentrations of CML and myeloperoxidase (MPO) were measured by solid-phase enzyme-linked immunosorbent assay.The patients were classified into 2 groups based on their SIR-P/M on T1WI and T2WI scans. We observed a higher incidence of post-CAS DWI lesions in patients with a higher than a lower SIR-P/M on T1WI; the CML and MPO concentrations in their CAS debris were also higher. No such differences were seen in patients with a higher or lower SIR-P/M on T2WI scans. The concentration of CML in CAS debris correlated independently with the SIR-P/M on T1WI of the carotid plaques, and was related to the concentration of MPO in CAS debris.Our findings suggest CML as a candidate molecular imaging probe for the identification of vulnerable plaques.

Changes in the cerebral blood flow (CBF) are important for planning postoperative care in patients treated by carotid artery stenting (CAS). The relationship between intraprocedural changes in the angiographic cerebral circulation time (CCT) and perioperative CBF changes were retrospectively studied in 49 CAS procedures performed in 46 patients with carotid artery stenosis. The CCT, defined as the interval between the timing of maximal opacification at the terminal portion of the internal carotid artery and at the cortical vein, was determined by referring to time-density curves of data obtained from routine intraprocedural digital subtraction angiography. The intraoperative change in CCT (Delta CCT) was calculated for each of the 49 procedures. CBF studies, using dynamic perfusion computed tomography, were performed 10-2 days before and 2-4 days after CAS. Perioperative changes in the ratio of the CBF in the territory of the middle cerebral artery on the affected side to CBF on the contralateral side (%CBF) were calculated by subtracting pre- from postoperative %CBF (Delta%CBF) and the correlation between Delta CCT and Delta%CBF was evaluated. Mean CCT was shortened by 1.1 seconds from 5.3 to 4.2 seconds after CAS. Mean %CBF increased by 11.9% from 91.8% to 103.7% after the procedure. Delta CCT and Delta%CBF showed a significant positive correlation (r = 0.61, p = 0.008). Intraprocedural changes in angiographic CCT are predictive of postoperative CBF in patients with CAS.

We evaluate the efficacy of the coil embolization for tiny ruptured anterior communicating artery (ACoA) aneurysms. Of 21 ruptured ACoA aneurysms with a maximum diameter of 3 mm, coil embolization was successfully carried out in 20 (95%) as the first treatment option. Complete occlusion was achieved in 17 of 20 patients and nearly complete occlusion was realized in 3. There were no treatment-related complications. Seventeen of 20 patients were followed up angiographically for a mean 39.7 months (range 6-72 months), and none of them demonstrated reopening of aneurysm that required additional treatment. Even in tiny ruptured ACoA aneurysms, coil embolization can be a safe and feasible treatment with sophisticated techniques.

An 82-year-old man with an asymptomatic left high-grade carotid stenosis was treated with carotid artery stenting (CAS) under distal protection. The procedure consisted with predilation with a 5 x 40 mm percutaneous transluminal angioplasty (PTA) balloon, deployment of a 10 x 20 mm self-expandable stent, post-dilation with a 7 x 20 mm PTA balloon, and aspiration of debris with 60 ml of blood. The cervical carotid angiogram immediately after deflation of the distal blocking balloon demonstrated a small in-stent filling defect of the contrast medium that protruded from the anterior wall of the carotid artery. The following cranial carotid angiogram showed abrupt occlusion of the left middle cerebral artery (MCA). Because the in-stent lesion had vanished in the repeat study after recognition of this embolic event, it was suggested that an embolus had been liberated from the in-stent lesion, reaching the left MCA and obliterating it. In this case, the embolus was speculated to originate in the ruptured plaque, which protruded into the stent through the cells of the device and became liberated into the bloodstream. Attention should be paid so as not to overlook any plaque protrusion, which may be seen subsequently as a cerebral embolism on the angiogram obtained immediately after CAS.

Introduction Because of its high complication rate, the endovascular treatment (EVT) of anterior communicating artery (ACoA) aneurysms less than 3 mm in maximum diameter remains controversial. We evaluated EVT of tiny ruptured ACoA aneurysms with Guglielmi detachable coils (GDCs). Methods We treated 19 ruptured ACoA aneurysms with a maximum diameter of ≤3 mm with GDCs. The pretreatment Hunt and Hess score was grade 1 in four patients, grade 2 in six, grade 3 in six, and grade 4 in three. The patients were clinically assessed before and after treatment and with multiple angiographic follow-up studies. Results All EVTs were successful; there were no aneurysm perforations or any other treatment-related complications. In five patients older than 80 years the transfemoral approach was difficult, and the direct carotid approach was used. Complete and near-complete occlusion was achieved in 16 patients (84.2%) and 3 patients (15.8%), respectively. Of the 19 patients, 16 (84.2%) were followed angiographically for a median of 38.5 months (range 16–72 months). None demonstrated recanalization of the aneurysm requiring additional treatment. In 15 patients (78.9%) the final outcome was good (modified Rankin scale, mRS, score 0–2), and 3 patients (15.8%) died or suffered severe disability (mRS score 4–6). None of 18 patients who were followed clinically for a median of 39.5 months (range 17–84 months) experienced rebleeding. Conclusion Even tiny ruptured ACoA aneurysms can be safely treated by EVT by expert neurointerventionalists using advanced techniques.

The term “accordion effect” is used to describe a mechanical distortion of tortuous arteries mimicking spasm or dissection. This phenomenon has been reported in patients undergoing percutaneous coronary intervention. To our knowledge, this is the first documentation of the accordion effect during carotid artery intervention. Two patients who developed the accordion effect during carotid artery stenting (CAS) are described. Angiograms obtained just after CAS showed a stenosing lesion with wall irregularity at the distal part of the stent. This lesion disappeared and tortuosity of the internal carotid artery developed after withdrawing the guidewire until its floppy segment rested equally on the lesion. In another patient, the lesion did not disappear completely until the guiding catheter had been withdrawn to the proximal portion of the common carotid artery. We conclude that these stenosing lesions reflected the accordion effect. It is essential to differentiate the accordion effect from dissection, spasm, and thrombosis because the management is importantly different. We report our findings and present a review of the literature.

Carotid artery stenting for carotid bifurcation stenosis usually uses the transfemoral approach. However, in patients with proximal common carotid artery (CCA) stenosis, the guiding catheter is difficult to introduce into the narrow origin of the CCA without risking cerebral embolization before activation of the protection device. A technique of cerebral protection by internal carotid artery (ICA) clamping with or without simultaneous external carotid artery (ECA) clamping was used to treat patients with proximal CCA stenosis by the retrograde direct carotid approach. The carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the stenosis. The ICA was clamped during angioplasty and stenting to avoid cerebral embolization. The ECA was clamped simultaneously if any extracranial-intracranial anastomosis was present. None of five patients treated with this technique experienced ischemic complications attributable to this technique.

Background Stent-assisted coil embolization (SACE) is used to address wide-necked or complex aneurysms. However, as they may recanalize after SACE, predictors of recanalization are needed. We investigated the relationship between follow-up angiographic results and the morphology of sidewall (SW) aneurysms in patients treated by SACE. Methods Between September 2010 and September 2014, we performed 80 SACE procedures for SW intracranial aneurysms. Angiographic findings, obtained immediately after the procedure, 3-6 months thereafter, and when aneurysmal recanalization was suspected on MR angiogram scan, were recorded. Morphologically, the SW aneurysms were classified as “outside” (OS) and “partially inside” (PI) based on the curve of the axes of the proximal or distal parent artery with respect to the aneurysmal neck. Follow-up angiographic studies on OS- and PI SW aneurysms were compared. Results On the initial angiograms, we classified 42 aneurysms as OS and 38 as PI. Immediately after SACE, there was no significant difference in the angiographic findings on OS and PI aneurysms. However, on follow-up angiograms, there was a significant difference in the rate of spontaneous improvement (4 of 42 [OS] versus 21 of 38 [PI], P = .001). We performed additional coil embolization to treat 3 recanalized OS aneurysms. Conclusions SW aneurysms classified morphologically as PI tended to occlude progressively even after incomplete occlusion by SACE. In contrast, aneurysms classified as OS must be observed carefully after SACE.

Recent sporadic reports have described successful endovascular treatment of cerebral aneurysms associated with fenestration. We experienced an unruptured cerebral aneurysm case, with fenestration of the horizontal portion of the anterior cerebral artery that was successfully treated with coil embolization using an intracranial stent. An 80-year-old man presented with a chief complaint of gait disorder. Magnetic resonance imaging showed an incidental unruptured aneurysm. Three-dimensional digital subtraction angiography revealed a cerebral aneurysm associated with fenestration of the horizontal portion of the anterior cerebral artery. Endovascular surgery was performed at the patient's request. Conservation of the fenestrated vessels and perforators is important in the treatment of cerebral aneurysm associated with fenestration. Intracranial stents are reportedly useful for conserving not only parent vessels but also their perforators. In the present case, no postoperative perforator damage occurred. An endovascular approach is a potential treatment option with full evaluation of the relationship between the aneurysm and fenestrated vessels.

A 49-year-old female with a history of systemic hypertension and diabetes mellitus suffered transient right hemiparesis. Carotid angiography with arch-aortography detected severe stenosis of the proximal portion of the left common carotid artery. The left carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the proximal common carotid artery stenosis. The lesion was dilated with a balloon catheter and successfully stented without complications. The left internal carotid artery was clamped during the procedure to avoid embolism. Retrograde carotid stenting for stenosis of the proximal common carotid artery is a safe and effective alternative to conventional surgery in selected patients.

Three women older than 75 years presented with spontaneous superficial temporal artery (STA) pseudoaneurysms manifesting as a pulsatile mass in the preauricular region. None of the patients had a history of trauma. Histological examination of the surgically removed masses identified pseudoaneurysms based on the presence of connective tissue and adventitia. Spontaneous STA pseudoaneurysms are extremely rare. We suggest that all 3 aneurysms were associated with latent dissection and external force exerted by the frames of glasses.

Background Stent-assisted coil embolization is effective for intracranial aneurysms, especially for wide-necked aneurysms; however, the optimal antiplatelet regimens for postoperative ischemic events have not yet been established. We aimed at determining the efficacy and safety of a triple antiplatelet therapy regimen after intracranial stent-assisted coil embolization. Methods We retrospectively evaluated patients who underwent stent-assisted coil embolization for unruptured intracranial aneurysms or during the chronic phase of a ruptured intracranial aneurysm (≥4 weeks after subarachnoid hemorrhage onset). We recorded the incidence of ischemic and bleeding events 140 days postoperatively. Results We assessed 79 cases in patients who received either dual (n = 51) or triple (n = 28) antiplatelet therapy. The duration of triple antiplatelet therapy was 49 ± 29 days. Seven patients in the dual group experienced postoperative ischemic events. Compared to the dual group, the triple group had a similar incidence of postoperative bleeding events but a significantly lower incidence of postoperative ischemic events ( P Conclusions Triple antiplatelet therapy had a significantly lower incidence of postoperative ischemic events and a similar incidence of postoperative bleeding events 140 days postoperatively.

Background We investigated the incidence of embolic protection device retrieval difficulties at carotid artery stenting (CAS) with a closed-cell stent and demonstrated the usefulness of a manual carotid compression assist technique. Methods Between July 2010 and October 2013, we performed 156 CAS procedures using self-expandable closed-cell stents. All procedures were performed with the aid of a filter design embolic protection device. We used FilterWire EZ in 118 procedures and SpiderFX in 38 procedures. The embolic protection device was usually retrieved by the accessory retrieval sheath after CAS. We applied a manual carotid compression technique when it was difficult to navigate the retrieval sheath through the deployed stent. We compared clinical outcomes in patients where simple retrieval was possible with patients where the manual carotid compression assisted technique was used for retrieval. Results Among the 156 CAS procedures, we encountered 12 (7.7%) where embolic protection device retrieval was hampered at the proximal stent terminus. Our manual carotid compression technique overcame this difficulty without eliciting neurologic events, artery dissection, or stent deformity. Conclusions In patients undergoing closed-cell stent placement, embolic protection device retrieval difficulties may be encountered at the proximal stent terminus. Manual carotid compression assisted retrieval is an easy, readily available solution to overcome these difficulties.

Background No predictor of postoperative ischemic events has been identified in patients undergoing carotid artery stenting (CAS). We aimed to determine whether Ne-(carboxymethyl)lysine (CML) in debris trapped by an embolic protection filter device is a predictor of postoperative ischemic events. Methods We enrolled 27 patients (73.4 ± 7.2 years; 22 male, 5 female) who underwent CAS for carotid artery stenosis. Diffusion-weighted magnetic resonance imaging was performed before and after the procedure. Protein samples were extracted from the debris. CML and myeloperoxidase were examined by solid phase enzyme-linked immunosorbent assay and Western blot analysis. Results Seventeen patients had 0 or 1 new lesion (nonmultiple lesions) postoperatively, whereas 10 patients had 2 or more new lesions postoperatively (multiple lesions). The CML concentration of the protein sample was significantly higher in patients with multiple lesions than in those with nonmultiple lesions (6.26 ± 2.77 ng/mg protein and 3.36 ± 1.57 ng/mg protein, respectively; P = .010). Statin therapy for dyslipidemia was associated with a lower incidence of multiple lesions and a lower concentration of CML in the protein sample (P = .004 and P = .02, respectively). Receiver operating characteristic analysis showed that the area under the curve for CML was significantly greater than .5 (.877; 95% confidence interval, .742-1.00). Conclusions CML derived from debris may distinguish between patients with postoperative multiple ischemic lesions and those with postoperative nonmultiple lesions who undergo CAS.

Purpose Preventing cerebral embolism from debris produced during carotid artery stenting (CAS) is important. This study compared the treatment outcomes of CAS using two types of filter-based embolic protection devices currently in use in Japan. Materials and methods We assessed 121 consecutive cases of CAS performed with FilterWire EZ™ between July 2010 and November 2012 and 37 consecutive cases of CAS performed with the Spider FX™ between November 2012 and June 2013. A Carotid Wallstent™ was used in all cases. The incidence of positive lesions on diffusion-weighted magnetic resonance imaging (DWI) and stroke were compared between the groups. Results Postoperative DWI-positive lesions were observed in 38 (31.4%) and 14 (37.8%) patients in the FilterWire and Spider groups, respectively. In the FilterWire group, complications were transient ischemic attacks in 3 (2.5%) patients, cerebral infarction in 2 (1.7%) patients (1 patient each with minor and major stroke), and cerebral hemorrhage due to hyperperfusion syndrome in 1 (0.8%) patient. In the Spider group, except for cerebral infarction (minor stroke) in 1 (2.7%) patient, no complications were observed. No significant differences were observed in the incidence of complications between the groups. Conclusion FilterWire EZ and Spider FX are comparable in terms of treatment outcome.

A 38-year-old man presented with a dissecting aneurysm of the left proximal posterior inferior cerebellar artery (PICA) manifesting as Wallenberg's syndrome. The patient was treated by endovascular occlusion of the aneurysm and parent artery. Immediately after the treatment, the PICA territory was supplied by collateral circulation via the ipsilateral anterior inferior cerebellar artery. Seven days later, endogenous revascularization of the distal PICA territory had occurred via collateral circulation from the posterior meningeal artery (PMA). This unusual collateral circulation was thought to occur through a pre-existing anastomotic channel between the primitive vessels of the PICA and the PMA during sub-clinical hypoperfusion of the distal PICA territory. This unusual case demonstrates the potential for delayed development of collateral circulation from the PMA to the PICA territory.

An 87-year-old man presented with extracranial vertebral artery (VA) occlusion and progressive vertebrobasilar ischemia despite maximal medical management. Cerebral angiography showed left proximal VA occlusion, termination of the right VA at the ipsilateral posterior inferior cerebellar artery, and hypoplastic bilateral posterior communicating arteries. Although the stump of the left VA ostium was not visualized, the distal patent artery was reconstituted via muscular branches from the left subclavian artery (SCA). Endovascular angioplasty with a stent for left VA occlusion was performed. The non-visualized VA ostium was extrapolated from the computed tomography angiography findings of the distal patent VA and the partial calcification of the SCA. The occluded VA was penetrated by the guide wire and revascularized by balloon angioplasty with the stent using the support of a snare wire inserted via the left brachial artery for stabilization of the guide catheter. This treatment resulted in resolution of the severe neurological findings.

The pull-through angioplasty technique allows stable wire tension and stabilization of the device during the procedure. In this technique, a guide wire is passed from one sheath to another, usually with the aid of a snare device. We describe the treatment of occlusive subclavian artery disease and lesion at the origin of the vertebral artery employing a brachiofemoral pull-through technique without using a snare device. In this technique, the guide wire is advanced from the femoral artery to the brachial artery. The guide wire is directly inserted into the sheath placed at the brachial artery. The brachial artery is compressed proximal to the point of sheath insertion to prevent bleeding. The sheath is extracted temporally and the guide wire is caught outside of the body. The sheath is then introduced again through the guide wire. We used the pull-through technique without a snare device in seven cases, and we were able to build the pull-through system in six of these cases without a snare device. This pull-through technique without a snare device is not difficult to use, and may reduce the time and cost of angioplasty procedures.

Purpose: Stent coning is conular morphological changes at the distal end of wire-braided closed-cell stents. We discuss its incidence, predictors, and outcomes. Materials and Methods: We reviewed data on 178 carotid arteries (172 patients) that were treated by carotid artery stenting (CAS) with wire-braided stents. All patients were followed-up by carotid duplex ultrasound (DUS) studies to detect in-stent restenosis (ISR) and stent-edge stenosis. In patients manifesting stent coning, we also obtained neck radiographs. Results: Stent coning was detected in 11 arteries (6.2%). Internal carotid artery/common carotid artery ratio and use of a post dilation balloon were associated with coning (p50% (p=0.72). At clinical follow-up carried out a mean of 38.4 months after the procedure, none of our patients had developed new neurologic ischemic symptoms. Conclusions: While stent coning is self-curing, it may be associated with the late development of stent-edge stenosis.

This retrospective study aimed to compare the effectiveness of the embolization prevention mechanism of two types of embolic protection device (EPD)—a distal protection balloon (DPB) and a distal protection filter (DPF). Subjects were 164 patients scheduled to undergo carotid artery stenting: a DPB was used in 82 cases (DPB group) from April 2007 until June 2010, and a DPF was used in 82 cases (DPF group) from July 2010 to July 2011. Rates of positive findings on postoperative diffusion-weighted imaging (DWI) and stroke incidence were compared. Positive postoperative DWI results were found in 34 cases in the DPB group (41.4 %), but in only 22 cases in the DPF group (26.8 %), and there was only a small significant difference within the DPF group. In the DPB group, there was one case of transient ischemic attack (TIA) (1.2 %) and four cases of brain infarction (2 minor strokes, 2 major strokes; 4.9 %), compared to the DFP group with one case of TIA (1.2 %) and no cases of minor or major strokes. In this study, significantly lower rates of occurrence of DWI ischemic lesions and intraoperative embolization were associated with use of the DPF compared to the DPB.

Three women older than 75 years presented with spontaneous superficial temporal artery (STA) pseudoaneurysms manifesting as a pulsatile mass in the preauricular region. None of the patients had a history of trauma. Histological examination of the surgically removed masses identified pseudoaneurysms based on the presence of connective tissue and adventitia. Spontaneous STA pseudoaneurysms are extremely rare. We suggest that all 3 aneurysms were associated with latent dissection and external force exerted by the frames of glasses.

We assessed the morphological change of calcified plaque after carotid artery stenting (CAS) in vessels with heavily calcified circumferential lesions and discuss the possible mechanisms of stent expansion in these lesions.We performed 18 CAS procedures in 16 patients with severe carotid artery stenosis accompanied by plaque calcification involving more than 75% of the vessel circumference. All patients underwent multidetector-row computed tomography (MDCT) to evaluate lesion calcification before and within 3 months after intervention. The angiographic outcome immediately after CAS and follow-up angiographs obtained 6 months post-CAS were examined.The preoperative mean arc of the calcifications was 320.1 +/- 24.5 degrees (range 278-360 degrees ). In all lesions, CAS procedures were successfully carried out; excellent dilation with residual stenosisor=30% was achieved in all lesions. Post-CAS MDCT demonstrated multiple fragmentations of the calcifications in 17 of 18 lesions (94.4%), but only cracks in the calcified plaque without fragmentation in one (5.6%). Angiographic study performed approximately 6 months post-CAS detected severe restenosis in one lesion (5.6%) without fragmentation of calcified plaque.Excellent stent expansion may be achieved and maintained in heavily calcified circumferential carotid lesions by disruption and fragmentation of the calcified plaques.

A 50-year-old man presented with a symptomatic aneurysm arising from the right inferior cavernous sinus artery (ICSA) associated with a cerebral arteriovenous malformation (AVM) manifesting as a 3-month history of progressive right abducens nerve palsy. Cerebral angiography demonstrated a high-flow AVM and a saccular aneurysm arising from the right ICSA acting as a meningeal feeder. The symptom was thought to be attributable to aneurysmal mass effect rather than the AVM. The aneurysm was successfully treated with endovascular embolization and the symptom improved gradually. Hemodynamic stress in the ICSA may have resulted in the development of the aneurysm of the ICSA. Meningeal artery aneurysm presenting with cranial nerve palsy is extremely uncommon. The present case illustrates the need for detailed evaluation of the external carotid artery and internal carotid artery vasculature in patients with cerebral AVMs.

BACKGROUND AND PURPOSE: Our aim was to assess the feasibility of carotid artery stent placement (CAS) for calcified lesions. MATERIALS AND METHODS: Using embolic protection devices (EPDs), we performed 51 CAS procedures in 43 patients with severe carotid artery stenosis accompanied by plaque calcification. Before intervention, all lesions were subjected to multidetector-row CT. The arc of the circumferential plaque calcification was measured on axial source images at the site of maximal luminal stenosis, and the total volume of the plaque calcification was determined. The angiographic outcome immediately after CAS, and intra- and postoperative complications were recorded. RESULTS: The mean arc of calcification was 201.1 ± 72.3° (range, 76–352°), and the mean of the total calcification volume was 154.9 ± 35.4 mm(3) (range, 92–2680 mm(3)). Balloon rupture occurred in 1 procedure (2.0%) at predilation angioplasty; all 51 CAS procedures were successful without clinical adverse effects. Although there was a correlation between the arc of plaque calcification and residual stenosis (r = 0.6, P < .001), excellent dilation with residual stenosis ≤30% was achieved in all lesions. There was no correlation between the total volume of calcification and residual stenosis. None of the patients developed stroke or death within 30 days of the CAS procedure. CONCLUSION: CAS by using EPDs to treat lesions with plaque calcification is feasible even in patients with near-total circumferential plaque calcification.

A 38-year-old man presented with a dissecting aneurysm of the left proximal posterior inferior cerebellar artery (PICA) manifesting as Wallenberg's syndrome. The patient was treated by endovascular occlusion of the aneurysm and parent artery. Immediately after the treatment, the PICA territory was supplied by collateral circulation via the ipsilateral anterior inferior cerebellar artery. Seven days later, endogenous revascularization of the distal PICA territory had occurred via collateral circulation from the posterior meningeal artery (PMA). This unusual collateral circulation was thought to occur through a pre-existing anastomotic channel between the primitive vessels of the PICA and the PMA during subclinical hypoperfusion of the distal PICA territory. This unusual case demonstrates the potential for delayed development of collateral circulation from the PMA to the PICA territory.

This study retrospectively reviewed 227 patients with ruptured solitary cerebral aneurysm who underwent endovascular embolization with detachable coils between March 1997 and March 2006 to establish the incidence of rebleeding after endovascular treatment for ruptured cerebral aneurysm and identify the risk factors. The site and size of the aneurysm, the interval between treatment and rebleeding, and the outcome were investigated in six of the 227 patients (2.6%) who rebled after treatment. Four patients had large or giant aneurysms located on the internal carotid artery at the origin of the posterior communicating artery. The interval between treatment and rebleeding was less than 1 year in four patients (mean 394.2 days). Two patients died, and the survivors had modified Rankin Scale scores of 0, 2, 3, and 4. Re-embolization was performed in four patients and no further bleeding occurred during the mean follow-up period of 1.9 years after re-treatment. Patients with giant aneurysms of the internal carotid artery are at increased risk for rebleeding. Re-treatment should be considered if there is conventional and/or magnetic resonance angiographic evidence of dome filling. Patients with ruptured cerebral aneurysms must be followed up with diagnostic imaging closely during the first 12 months post-embolization because rebleeding frequently occurs within 1 year after initial treatment. Re-embolization is safe and effective in patients with recurrent hemorrhage from aneurysms previously embolized with detachable coils.

A 44-year-old male with right vertebral arteriovenous fistula accompanied with tinnitus, underwent endovascular treatment using GDC. A digital subtraction angiography clearly showed one fistula flowed from the right vertebral artery (VA) to the vertebral venous plexus, while the right VA close to the fistula was interupped with HyperForm. The tip of the micro catheter was placed in the vertebral venous plexus through fistula from the right VA, and the vertebral venous plexus around the fistula was embolized with 4 GDCs. Blood flow of the right VA was maintained. Follow-up angiography undertaken 6 months after the operation didn't show the recurrence of arteriovenous fistula.

Carotid artery stenting for carotid bifurcation stenosis usually uses the transfemoral approach. However, in patients with proximal common carotid artery (CCA) stenosis, the guiding catheter is difficult to introduce into the narrow origin of the CCA without risking cerebral embolization before activation of the protection device. A technique of cerebral protection by internal carotid artery (ICA) clamping with or without simultaneous external carotid artery (ECA) clamping was used to treat patients with proximal CCA stenosis by the retrograde direct carotid approach. The carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the stenosis. The ICA was clamped during angioplasty and stenting to avoid cerebral embolization. The ECA was clamped simultaneously if any extracranial-intracranial anastomosis was present. None of five patients treated with this technique experienced ischemic complications attributable to this technique.

The PercuSurge system is a distal balloon embolic protection device used for carotid artery stenting (CAS). We performed a retrospective study on the prognosis and clinical effects of spasms induced by the PercuSurge GuardWire system (PercuSurge-induced spasm). We performed CAS in 118 carotid stenoses using the PercuSurge system. Of the 118 procedures, 31 (26.3%) of the patients experienced PercuSurge-induced spasm, and all underwent postoperative follow-up studies by cerebral angiography and antiplatelet treatment. On follow-up angiograms obtained a mean of 5.2 months (range 3–10 months) after CAS, all 31 PercuSurge-induced spasms had disappeared, and no delayed stenosis was found at the sites where the spasms had occurred. No ischemic events due to the spasms occurred during a mean follow-up of 13 months (range 3–32 months). In the hands of physicians experienced in endovascular surgery, CAS using the PercuSurge system is a safe method with which to treat patients with carotid stenosis. Our study demonstrated that PercuSurge-induced spasms had no morphological or clinical adverse effects.

The authors herein report a case of a ruptured dissection of the superior cerebellar artery (SCA). A 68-year-old man presented with symptons of sudden headache and nausea. The CT scan revealed the presence of both a subarachnoid hemorrhage (SAH) and acute hydrocephalus. The left vertebral angiogram showed an fusiform dilatation in the cerebellomesencephalic segment of the left SCA. Endovascular embolization of the aneurysm and SCA was successfully performed using Guglielmi detachable coils (GDCs). No delayed ischemic deficits were observed after the treatment. A dissection of the distal segment of the SCA is a very rare occurrence. We believe endovascular embolization using GDCs to be an effective and less invasive therapy for the treatment of an SCA dissection with SAH.

We assessed the long-term follow-up examinations and complications of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic ostial vertebral artery (VA) stenosis. A retrospective study was done to evaluate 12 patients with symptomatic ostial VA stenosis who underwent PTAS. Six patients were treated with the Palmaz stent and six with a balloon-expandable coronary stent. Initial angiographic follow-up examination was conducted about 12 months after PTAS in all patients. Simple radiographic, ultrasonographic and clinical follow-up examinations were scheduled every 6 months. Excellent dilatation was achieved in all patients without any procedural complications. Initial angiographic follow-up obtained at a mean of 13 months after PTAS detected no restenosis. However, an asymptomatic severe restenosis was detected at 24 months after PTAS in one patient (8%). During a mean follow-up of 31.5 months, three stent fractures were detected in deployed coronary stents (50%). None of the stent fractures was associated with either recurrent stroke or restenosis. No patients developed recurrent symptoms during the follow-up period. PTAS for symptomatic ostial VA stenosis is effective in preventing recurrent stroke. As the open-cell single-joint type of stent is associated with the risk of fracture, long-term follow-up examinations including simple radiography are needed.

The purpose of our study was to investigate the frequency of hemodynamic instability in patients undergoing carotid artery stenting (CAS) under general anesthesia using sevoflurane and nitrous oxide in oxygen.A total of 97 consecutive CAS procedures were performed in 84 patients under sevoflurane anesthesia. The following hemodynamic variables were assessed: degree of systolic blood pressure change (deltaSBP) during CAS, hypotension, and bradycardia during and after CAS.During CAS, hypotension occurred in 43% of the patients, and bradycardia occurred in 14%. There was individual variation in the deltaSBP during CAS. Systolic blood pressure (SBP) change50 mmHg was not seen in this series. After CAS, hypotension occurred in 24%, and bradycardia occurred in 10%. Cerebral infarction occurred in three cases. The stroke rate was 3.1% in this series.General anesthesia using sevoflurane and nitrous oxide in oxygen depressed barorecepter reflex sensitivity, induced hemodynamic stability under CAS, and may decrease the rate of occurrence of complications.

A 49-year-old female with a history of systemic hypertension and diabetes mellitus suffered transient right hemiparesis. Carotid angiography with arch-aortography detected severe stenosis of the proximal portion of the left common carotid artery. The left carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the proximal common carotid artery stenosis. The lesion was dilated with a balloon catheter and successfully stented without complications. The left internal carotid artery was clamped during the procedure to avoid embolism. Retrograde carotid stenting for stenosis of the proximal common carotid artery is a safe and effective alternative to conventional surgery in selected patients.

We present an alternative endovascular approach to treat dural anterio-venous fistulas (AVFs) of the cavernous sinus that drain only into the superior ophthalmic vein. Two cases of dural AVFs of the cavernous sinus producing increased intraocular pressure and diminishing visual acuity are reported. The cavernous sinus was accessed via the direct superficial temporal vein approach through the superior ophthalmic vein. Successful embolization was documented radiographically and clinically.

The authors report a retrospective analysis of their experience in the endosaccular embolization of internal carotid aneurysms which caused mass effect symptoms of cranial nerves (CN) and review the efficacy and limitations of this technique.Between April 1997 and August 2002, 12 internal carotid aneurysms that caused mass effect symptoms of CN were treated by endosaccular GDC embolization with parent artery preservation. The locations were the cavernous internal carotid artery (CV) in six patients, carotid-ophthalmic artery (CO) in two patients, and posterior communicating artery (PCo) in four patients. The angiographical size of the aneurysms ranged from 6 to 20 mm, with a mean of 13.3 mm. Duration of symptoms ranged from 0.5 to 120 months, with a mean of 13.7 months. All aneurysms were treated by endosaccular guglielmi detachable coil (GDC) embolization with preservation of the internal carotid artery.Five patients (42%) had complete resolution of symptoms, four (33%) had significant improvement of symptoms, and three (25%) were unchanged. Immediate posttreatment angiographic studies revealed neck remnant (NR) in nine patients and dome filling (DF) in three patients. In one patient (case 10), the resolved symptoms became worse 29 months later. Follow-up angiograms were obtained in 10 patients, and recanalization was observed in four of them (40%). Transient thrombotic complication occurred in only one patient. The group with resolution or improvement of symptoms demonstrated a shorter duration of symptoms before GDC treatment (or = 12 months).Even subtotal endosaccular embolization of aneurysms may reduce mass effect symptoms of cranial nerves. However, careful follow-up is needed because subtotal occlusion carries a future risk of growth.

Clinical and angiographic evaluations were performed in 19 consecutive patients with anterior communicating artery (ACoA) aneurysms treated by Guglielmi detachable coil (GDC) embolization between March 1997 and April 1999.The angiographic criteria for endovascular treatment were 1) small (15 mm) aneurysm with a neck smaller than the fundus and 2) distinguishable aneurysm neck and relationship to the parent artery. Initially, we also included patients with anticipated surgical difficulties. These criteria were later expanded to include patients with conditions amenable to surgical clipping. Eleven patients presented with subarachnoid hemorrhage (SAH), and eight patients were asymptomatic. The most recent clinical follow-up was obtained by telephone interview with the patients and with their close relatives, to examine post-treatment personality changes.Complete obliteration (68%) or near-complete obliteration (neck remnant) (32%) of the ACoA aneurysm was achieved in all patients. Six-month follow-up angiography performed in 15 patients demonstrated no recurrence of aneurysms. The clinical outcome was good recovery in 15 (80%), moderately disabled in one (5%), vegetative survival in one (5%), and death in two (10%). The patients who had good recovery did not demonstarate significant personality or behavioral change. No late rebleeding had occurred at the time of writing, a minimum of 33 months postoperatively.The outcome of endovascular treatment of ACoA aneurysms was satisfactory, especially in post-treatment psychosocial sequelae.

A 50-year-old man presented with a symptomatic aneurysm arising from the right inferior cavernous sinus artery (ICSA) associated with a cerebral arteriovenous malformation (AVM) manifesting as a 3-month history of progressive right abducens nerve palsy. Cerebral angiography demonstrated a high-flow AVM and a saccular aneurysm arising from the right ICSA acting as a meningeal feeder. The symptom was thought to be attributable to aneurysmal mass effect rather than the AVM. The aneurysm was successfully treated with endovascular embolization and the symptom improved gradually. Hemodynamic stress in the ICSA may have resulted in the development of the aneurysm of the ICSA. Meningeal artery aneurysm presenting with cranial nerve palsy is extremely uncommon. The present case illustrates the need for detailed evaluation of the external carotid artery and internal carotid artery vasculature in patients with cerebral AVMs.