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Background: Arteriovenous malformation (AVM) and developmental venous anomaly (DVA) rarely coexist. Developing a surgical strategy to treat this co-occurrence is difficult due to the unclear pathogenesis. We report the use of super-selective digital subtraction angiography (DSA) and Three-dimensional (3D) rotational digital subtraction venography (DSV) to develop a surgical strategy for complex AVM draining into a DVA., Case Description: A 58-year-old woman presented with left hemiparesis and unconsciousness. Plain and contrast computed tomography showed a right frontal subcortical hematoma and a heterogeneous contrast lesion anterior to the hematoma, leading to a dilated vessel. The hematoma was removed due to worsening unconsciousness. DSA revealed a right frontal AVM of Spetzler-Martin grade 2 with superficial drainage into a DVA, and 3D-DSV revealed that the intermediate part of the DVA involved normal parenchyma. Interventional transarterial embolization and surgical nidus removal were planned. Preoperative super-selective DSA showed two medullary veins draining from the AVM into the DVA. Thus, we decided to separate the two medullary veins from the nidus. Postoperative angiography revealed complete removal of the AVM and preservation of the DVA., Conclusion: Treating a complex AVM draining into a DVA is challenging; surgeons have to remove only the AVM portion and preserve the DVA. Super-selective DSA and 3D rotational DSV were performed to develop the surgical strategy., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Background: Catheter shaping is vital in cerebral aneurysm coil embolization; however, understanding three-dimensional (3D) vascular structures on two-dimensional screens is challenging. Although 3D-printed vascular models are helpful, they demand time, effort, and sterility. This study explores whether mixed-reality (MR) devices displaying 3D computer graphics (3D-CG) can address these issues., Methods: This study focused on magnetic resonance imaging (MRI) of seven cases of cerebral aneurysms. Head-mounted display (HMD) and spatial reality display (SRD) MR devices were used, and applications for 3D-CG display at a 1:1 scale and a 3D-CG control panel were developed. Catheters shaped using a 3D printer, HMD, and SRD were inserted into hollow models to assess their accessibility and positioning., Results: The concordance rate of the 3D printer and HMD groups in terms of accessibility to the aneurysm was 71.4 %, while that of the 3D printer and SRD group was 85.7 %, and that of the HMD and SRD group was 85.7 %. The concordance rates of positioning in the 3D printer and HMD groups, 3D printer and SRD groups, and HMD and SRD groups were 85.7 %, 85.7 %, and 100 %, respectively., Conclusions: MR devices facilitate catheter shaping in cerebral aneurysm coil embolization and offer a time-efficient, precise, and sterile alternative to traditional 3D printing methods., Competing Interests: Declaration of Competing Interest None, (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Dolichoectasia is a rare arterial condition characterized by the dilatation, tortuosity, and elongation of cerebral blood vessels. The vertebrobasilar artery and internal carotid artery are the common sites of dolichoectasia. However, dolichoectasia of the branch arteries, such as the ophthalmic artery (OA), is extremely rare. To the best of our knowledge, this is the first case of ophthalmic dolichoectasia that was successfully treated with endovascular internal coil trapping., Case Presentation: A 54-year-old female patient presented with transient left ophthalmalgia and visual disturbance. Magnetic resonance imaging revealed a dilated and elongated left OA compressing the optic nerve at the entrance of the optic canal. However, a previous image that was taken 17 years back revealed that the OA was normal, which suggested the change in dolichoectasia was acquired. Cerebral angiography showed that the dilated and tortuous OA was running from the ophthalmic segment of the left internal carotid artery into the orbit. The symptoms could have been attributed to the direct compression of the dolichoectatic OA in the optic canal. A sufficient anastomosis between the central retinal artery and the middle meningeal artery was identified on external carotid angiography with balloon occlusion of the internal carotid artery. Endovascular treatment with internal trapping of the OA was performed due to ophthalmic symptom progression. Internal coil trapping of the OA was performed at the short segment between the OA bifurcation and the entrance of the optic canal. As expected, the central retinal artery was supplied via the middle meningeal artery after the treatment. The transient visual disturbance was immediately resolved. Ophthalmalgia worsened temporarily after the treatment. However, it completely resolved after several days of oral corticosteroid therapy. Postoperative angiography showed that the origin of the OA was occluded and that the OA in the optic canal was shrunk. The flow of the central retinal arteries via the middle meningeal artery was preserved., Conclusions: OA dolichoectasia is rare, and its pathogenesis and long-term visual prognosis are still unknown. However, endovascular therapy can improve symptom by releasing the pressure site in the optic canal., (© 2024. The Author(s).)

Objective: This study aimed to improve the reachability of large lumen catheter for contact aspiration during acute ischemic stroke by a new delivery assist catheter., Methods: This study included 58 patients with large-vessel stroke treated using endovascular procedures at our institution and affiliated hospitals between July 2021 and January 2023. Contact aspiration, especially contact aspiration using nonpenetrating of thrombus (CANP) technique, was adopted as first-line thrombectomy for localized internal carotid artery, middle cerebral artery proximal (M1 segment), and basilar artery without tandem occlusion in acute stroke. The new delivery assist catheter (AXS Offset catheter, Stryker, Fremont, CA, USA) was standardized after its release. Results of this improved contact aspiration technique using the new delivery assist catheter, including reachability, procedure time, and first-pass effect, were compared with conventional catheters., Results: Of the 58 patients, 43 underwent only thrombectomy for acute embolic stroke. CANP technique was attempted on 25 patients (25/43, 58.1%). Of these, a normal inner catheter (inner diameter: 0.021 or 0.027 inches) and the new delivery assist catheter were used on 10 (10/25, 40%) and 15 (15/25, 60%) patients, respectively. An aspiration catheter reached the thrombus for 5 patients (5/10, 50%) and 14 patients (14/15 93.3%) in the normal and new delivery assist catheter groups, respectively (P = 0.023). There was no significant difference in the results of contact aspiration due to the delivery catheter., Conclusions: The new delivery assist catheter improved the reachability of the aspiration catheter to the thrombus and is an effective device for performing CANP technique., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT., Methods: We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0-2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups., Results: The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group ( p  < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group ( p  < 0.05)., Conclusion: The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

Background: Although the relationship between dural arteriovenous fistula (dAVF) and cerebral venous thrombosis (CVT) has been reported, the etiology has not been clarified. Here, we report a case of de novo dAVF after mechanical thrombectomy for CVT and discuss the underlying mechanism., Case Description: A 61-year-old woman presented with a gradually worsening headache and was diagnosed with severe CVT. Mechanical thrombectomy was performed for the CVT because of progressive neurological deterioration despite anticoagulation therapy. Two years after the initial treatment, angiography revealed a de novo dAVF with a direct shunt of the left convexity cortical vein. Transarterial embolization with Onyx was performed and the shunt was completely obliterated., Conclusion: In this report, we describe a case of de novo dAVF with CVT that was treated with mechanical thrombectomy. Even if CVT improves with mechanical thrombectomy, we must be aware of the occurrence of de novo dAVF., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Surgical Neurology International.)

Objectives: This study aimed to prove the safety and efficacy of the contact aspiration using non-penetrating of thrombus (CANP) technique for the initial procedure for acute ischemic stroke and to increase operator familiarization with the technical aspects of the CANP technique., Materials and Methods: A total of 103 patients with large-vessel stroke who were treated using thrombectomy alone at our institution between April 2019 and March 2021 were included in this study. CANP technique was performed using a large lumen catheter (inner diameter, ≥0.060 in.) without penetrating a thrombus. Results of the CANP technique, including the procedure time; first-pass effect (FPE); angiographical recanalization; functional independence; thrombus migration; and intracerebral hemorrhage (ICH) were compared with combined technique., Results: A total of 77 patients (74.8%) were scheduled to undergo the CANP technique for initial procedure, and 50 (64.9%) attempted the CANP technique. Of 50 patients with CANP technique, 33 (66.0%) achieved angiographically good recanalization using CANP technique alone. FPE was achieved in 31 patients (62.0%) in CANP technique group; the rate of FPE was significantly higher (p = 0.008). Asymptomatic ICH were significantly smaller in the CANP technique group (p = 0.008). The median interval of only the CANP technique was 20 (IQR, 16-29.5) min for groin puncture to final recanalization, and was significantly faster (p < 0.001)., Conclusions: CANP technique was safe with low risk of hemorrhagic complication and effective for the initial procedure of acute ischemic stroke., Competing Interests: Declarations of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Although flexible endoscopy is effective for intraventricular lesions, it is less frequently used for hemorrhagic cases. In some hemorrhagic strokes, blood clots may plunge into the cerebral aqueduct and cause acute obstructive hydrocephalus. A flexible endoscope can aspirate clots and prevent acute hydrocephalus., Methods: Here, we report four cases of hemorrhage: one of intracerebral hemorrhage and three of subarachnoid hemorrhages., Results: In all cases, acute hydrocephalus was not apparent upon admission. Sudden comatose occurred; computed tomography revealed acute obstructive hydrocephalus with a strangulated clot in the cerebral aqueduct. We performed aspiration of the strangulated clot using a flexible endoscope. Consciousness improved in all cases, and acute hydrocephalus was prevented in all cases., Conclusion: The use of simple flexible endoscopic aspiration for clots might be a beneficial and less-invasive procedure for acute obstructive hydrocephalus caused by a small clot with hemorrhagic stroke., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Aneurysmal recanalization is a problem with endovascular coiling and one of its risk factors is the low volume embolization ratio (VER). The first coil VER (1st VER) is believed to be critical for obtaining a high VER. The main objective of this study was to evaluate factors potentially useful for selecting the optimal 1st VER for endovascular coiling., Methods: 609 initial saccular aneurysmal treatments performed between January 2010 and December 2014 at our institution were included in this retrospective study. Attempted procedures, retreatment cases, intraoperative rupture cases, and stent-assisted coiling cases were excluded. Age, sex, aneurysm location, ruptured aneurysm, aneurysm shape, neck size, maximum aneurysm size, dome-to-neck ratio, aneurysm volume, procedure, immediate Raymond scale score, 1st VER, and VER between the recanalization groups and non-recanalization groups were compared., Results: The factors related to recanalization were ruptured aneurysms, neck width, maximum aneurysm size, aneurysm volume, procedure, 1st VER, and VER. The cut-off values for aneurysm recanalization were a 1st VER of 10.0% and a VER of 33.0%. The maximum average VER of normal size aneurysms was found in the groups with a 1st VER of 17.5-20.0%., Conclusions: 1st VER was found to be a helpful index for estimating aneurysmal recanalization after coil embolization. The target 1st VER was 17.5-20.0% for obtaining a higher VER and avoiding recanalization., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Cerebral vasospasm (CVS) is a major determinant of prognosis in patients with subarachnoid hemorrhage (SAH). Alteration in the vascular phenotype contributes to development of CVS. However, little is known about the role of microRNAs (miRNAs) in the phenotypic alteration after SAH. We investigated the expression profile of miRNAs and the chronologic changes in the expression of microRNA-15a (miR-15a) and Kruppel-like factor 4 (KLF4), a potent regulator of vascular phenotype modulation that modulates the expression of miR-15a, in the plasma and cerebrospinal fluid (CSF) of patients with SAH., Methods: Peripheral blood and CSF samples were collected from 8 patients with aneurysmal SAH treated with endovascular obliteration. Samples obtained from 3 patients without SAH were used as controls in the analysis. Exosomal miRNAs were isolated and subjected to microarray analysis with the three-dimensional-gene miRNA microarray kit. The time course of the expression of miR-15a and KLF4 was analyzed using quantitative real-time polymerase chain reaction., Results: Microarray analysis showed that 12 miRNAs including miR-15a were upregulated or downregulated both in the CSF and in plasma after SAH within 3 days. Quantitative real-time polymerase chain reaction showed that miR-15a expression was significantly increased in both the CSF and plasma, with a peak around 3-5 days after SAH, whereas the expression of KLF4 was significantly decreased around 1-3 days after SAH and remained lower than in controls., Conclusions: Our results suggest that an early and persistent decrease in KLF4 followed by an increase in miR-15a may contribute to the altered vascular phenotype, resulting in development of CVS., (Published by Elsevier Inc.)

Persistent trigeminal artery (PTA) and its variant (PTAV) are the most prevalent types of carotid-vertebrobasilar anastomosis, but bilateral anastomoses are exceedingly rare. We report a case of a right PTAV and tiny left lateral-type PTA from which the cerebellar artery (presumed anterior inferior cerebellar artery) arose. And also, bilateral ophthalmic arteries arose from the cavernous segments of the internal carotid arteries and entered the orbits via the superior orbital fissures. Selective cerebral angiography, especially 3-dimensional angiography, is superior to magnetic resonance (MR) angiography to identify rare variations of the cerebral arteries. Careful observation of MR angiographic source images is important for identifying unique arterial coursing.

Objective: Cerebral hyperperfusion syndrome(CHS)and cerebral hyperperfusion phenomenon(CHP)induce intracranial hemorrhage and can become critical complications after carotid artery stenting(CAS). The purpose of the present study was to predict and avoid CHS after CAS using bilateral rSO 2 intraoperative monitoring., Methods: We retrospectively analyzed 100 consecutive patients who underwent CAS between January 2012 and May 2014 in our institution. We performed continuous bilateral rSO 2 monitoring from anesthetic induction to the day following CAS. CHS was defined as the deterioration of neurological conditions post-CAS, no ischemic changes on post-CAS head CT or brain MRI, an increase in cerebral blood flow(CBF)and cerebral blood volume(CBV), and shortening of the mean transit time(MTT)or time to peak(TTP)on CT perfusion. To compare the CHS/CHP group and non-CHS/CHP group, we defined four parameters:rSO 2 difference(rSO 2 at the endpoint of the procedure-baseline rSO 2 ), ΔrSO 2 difference(affected side rSO 2 difference-unaffected side rSO 2 difference), rSO 2 ratio(rSO 2 at the endpoint of the procedure/baseline rSO 2 ), and ΔrSO 2 ratio(affected side rSO 2 ratio/unaffected side rSO 2 ratio)., Results: There were 2 CHS cases(2.2%)and 3 CHP cases(3.3%). In the CHS/CHP group, the ΔrSO 2 difference and ΔrSO 2 ratio were significantly higher than those in the non-CHS/CHP group(p value<0.05);however, no significant differences were found in the affected side rSO 2 difference(p value=0.063)and affected side rSO 2 ratio(p value=0.054)between the groups., Conclusion: We could promptly detect CHS and CHP in all cases by using continuous bilateral rSO 2 monitoring and analysis of the ΔrSO 2 difference and ΔrSO 2 ratio.

Background: Flow-diverter stent (FDS) placement for treatment of intracranial aneurysms can cause flow changes in the covered branches., Objective: To assess the impact of the treatment of carotid siphon aneurysms with FDS on the posterior communicating artery (PComA) flow., Materials and Methods: Between February 2011 and January 2015, 125 carotid siphon aneurysms were treated with FDS. We retrospectively analyzed all cases with PComA ostial coverage. The circle of Willis anatomy was also studied as the flow changes in PComA postoperatively and during angiographic follow-up. Data from neurological examination were also collected., Results: Eighteen aneurysms of the carotid siphon in 17 patients were treated with FDS covering the ostium of the PComA. Based on the initial angiography, patients were divided into two groups: the first with a P1/PComA size ratio >1 (10 cases) and the second with a ratio ≤1 (8 cases). Follow-up angiography (mean time of 10 months) showed 90% of PComA flow changes in group 1 but only 12.5% in group 2. There was a significant difference between the two groups (p=0.002). Nevertheless, no patient had new symptoms related to these flow changes during the follow-up period., Conclusions: In our experience, covering the PComA by FDS when treating carotid siphon aneurysms appeared safe and the P1/PComA ratio is a good predictor of flow changes in PComA., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

We present what we believe is the first report of a patient with an anomalous artery arising from the distal basilar artery and fusing with the mid-portion of an extremely long P1 segment of the left posterior cerebral artery that was diagnosed on magnetic resonance (MR) angiography. Careful review of MR angiographic images is important to detect rare arterial variations, and partial maximum-intensity-projection images aid their identification on MR angiography.

Variations of the anterior cerebral artery-anterior communicating artery (ACoA) complex are common. Most are duplicated or partially duplicated ACoAs that are confused with fenestration of the ACoA. We report here an extremely rare case of true fenestration of the ACoA diagnosed by magnetic resonance angiography. Tiny true fenestrations of the ACoA may be overlooked easily by MR angiography. Partial maximum-intensity-projection image and volume-rendering image are useful in identifying true fenestration of the ACoA.

Background and Purpose: The flow-diverter stent has been proved a feasible, safe, and efficient technique, particularly for the treatment of large and broad-neck carotid siphon aneurysms. Wide-neck bifurcation aneurysms remain, in some cases, a challenge for neurointerventionalists. We report the outcomes of the treatment of saccular middle cerebral artery bifurcation aneurysms with flow diversion in our institution., Materials and Methods: From the institution data base, all saccular, nondissecting MCA bifurcation aneurysms, treated with flow-diverter stents, were retrospectively reviewed. Technical issues, immediate posttreatment and follow-up angiographic findings, and clinical outcomes were assessed., Results: Fourteen patients with 15 aneurysms were included in the study. Ischemic complications, as confirmed by MR imaging, occurred in 6 patients (43%). Procedure-related morbidity and mortality at last follow-up were 21% and 0%, respectively. Angiographic follow-up was available for 13 aneurysms, with a mean follow-up of 16 months. Complete occlusion was obtained for 8 aneurysms (62%)., Conclusions: Compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms., (© 2016 by American Journal of Neuroradiology.)

We herein report three ischemic stroke patients who underwent emergency carotid artery stenting after receiving intravenous tissue plasminogen activator (t-PA) treatment. All patients received antiplatelet medications immediately before stent placement for loading as well as dual antiplatelet therapy after stenting. Under high-dose and dual antiplatelet therapy, none of the three patients showed symptomatic intracranial hemorrhaging. However, one case showed reocclusion of the placed stent after acute thrombosis. As a result, new treatment strategies for the use of antiplatelet agents during emergency stent placement must be developed, particularly for patients who have received intravenous t-PA therapy.

Object: The concept of the flow-diverter stent (FDS) is to induce aneurysmal thrombosis while preserving the patency of the parent vessel and any covered branches. In some circumstances, it is impossible to avoid dangerously covering small branches, such as the anterior choroidal artery (AChA), with the stent. In this paper, the authors describe the clinical and angiographic effects of covering the AChA with an FDS., Methods: Between April 2011 and July 2013, 92 patients with intracranial aneurysms were treated with the use of FDSs in the authors' institution. For 20 consecutive patients (21.7%) retrospectively included in this study, this involved the unavoidable covering of the AChA with a single FDS during endovascular therapy. AChAs feeding the choroid plexus were classified as the long-course group (14 cases), and those not feeding the choroid plexus were classified as the short-course group (6 cases). Clinical symptoms and the angiographic aspect of the AChA were evaluated immediately after stent delivery and during follow-up. Neurological examinations were performed to rule out hemiparesis, hemihypesthesia, hemianopsia, and other cortical signs., Results: FDS placement had no immediate effect on AChA blood flow. Data were obtained from 1-month clinical follow-up in all patients and from midterm angiographic follow-up in 17 patients (85.0%), with a mean length of 9.8 ± 5.4 months. No patient in either group complained of transient or permanent symptoms related to an AChA occlusion. In all cases, the AChA remained patent without any flow changes., Conclusions: The results of this study suggest that when impossible to avoid, the AChA may be safely covered with a single FDS during intracranial aneurysm treatment, irrespective of anatomy and anastomoses.

Objective: Preoperative embolization of meningioma is commonly performed; however, there is no consensus on the best embolic material to reduce intraoperative blood loss and surgery time., Method: We retrospectively assessed the safety and efficacy of 56 cases of preoperative embolization of the middle meningeal artery with N-butyl cyanoacrylate (NBCA) in 105 cases of surgery for meningioma. We also defined a blood loss to tumor volume ratio to compensate for bias caused by tumor volume, and analyzed limited cases (the embolized group n = 52, the non-embolized group n = 21) of the convexity, the parasagittal region, the falx, and the sphenoidal ridge., Result: The blood loss to tumor volume ratio was significantly less in the embolized group (p < 0.007). Preoperative embolization could be useful for cases with the external carotid artery as the dominant feeder vessel (p < 0.02); however, the efficacy decreased for cases with an internal carotid artery feeder. Transient complications occurred in four cases (hemiparesis secondary to edema: two cases; intratumoral bleeding: one case; trigeminal nerve disorder: one case). The cases that showed a postoperative increase in edema or intratumoral bleeding were large tumors with the early filling of veins. For such cases, surgeons should pay close attention to slow injection speed and higher NBCA viscosity, not to cause the occlusion of draining vessels., Conclusion: Tumor embolization with NBCA can be safely performed, and the procedure significantly reduces intraoperative blood loss., (© The Author(s) 2015.)

Objective: Advances in vascular reconstruction devices and coil technologies have made coil embolization a popular and effective strategy for treatment of relatively wide-neck cerebral aneurysms. However, coil protrusion occurs occasionally, and little is known about the frequency, the risk factors and the risk of thrombo-embolic complications., Method: We assessed the frequency and the risk factors for coil protrusion in 330 unruptured aneurysm embolization cases, and examined the occurrence of cerebral infarction by diffusion-weighted magnetic resonance imaging (DW-MRI)., Result: Forty-four instances of coil protrusion were encountered during coil embolization (13.3% of cases), but incidence was reduced to 33 (10% of cases) by balloon press or insertion of the next coil. Coil protrusion occurred more frequently during the last phase of the procedure, and both a wide neck (large fundus to neck ratio) (OR = 1.84, P = 0.03) and an inadequately stable neck frame (OR = 5.49, P = 0.0007) increased protrusion risk. Coil protrusions did not increase the incidence of high-intensity lesions (infarcts) on DW-MRI (33.3% vs 29% of cases with no coil protrusion). However, longer operation time did increase infarct risk (P = 0.0003). Thus, tail or loop type coil protrusion did not increase the risk of thrombo-embolic complications, if adequate blood flow was maintained., Conclusion: Coil protrusion tended to occur more frequently in cases of wide-neck aneurysms with loose neck framing. Moderate and less coil protrusion carries no additional thrombo-embolic risk, if blood flow is maintained, which can be aided by additional post-operative antiplatelet therapy., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Mechanically-induced vasospasm often occurs during guiding catheter insertion, occasionally preventing catheter advancement to the desired location. Delicate manipulation would be impossible without the proper positioning of guiding catheters, and vasospasm-induced cerebral hypoperfusion may cause thrombotic complications. From June 2012 to December 2013, we prospectively analyzed 150 endovascular treatment cases, excluding acute cases, for the frequency of vasospasm, risk factors, and countermeasures. The associated risk factors such as the Japanese-style State-Trait Anxiety Inventory (STAI) score; anatomy and devices; and the efficacies of warm compresses, intra-arterial lidocaine/nicardipine, and tranquilizers were analyzed. Groups 1, 2, and 3 comprised 50 patients each with controls, tranquilizer administration, and prophylactic warm compresses/intra-arterial drug injection, respectively. Moderate or severe vasospasm was seen in approximately 40% patients in each group; however, severe vasospasm was absent in Group 3. Mild vasospasm-induced cerebral infarction occurred in one patient each in Groups 1 and 2. Vasospasm during diagnostic angiography [odds ratio (OR) = 10.63; P = 0.01], many ≥ 30° vessel curves [OR = 4.21; P = 0.01], and the high STAI score [OR = 1.84; P = 0.01] were risk factors for severe vasospasm. Although the relationship between anxiety and sympathetic tone remained unclear, tranquilizer administration relieved vasospasm. Warm compresses and the intra-arterial drug infusion were also useful for relieving vasospasm. Prophylactic measures such as a tranquilizer and warm compresses are expected to alleviate vasospasm; in addition, countermeasures such as the intra-arterial injection of lidocaine/nicardipine are effective.

Introduction: Endovascular treatment of ruptured wide-neck bifurcation aneurysms presents a challenge. While still under evaluation, the Woven Endobridge (WEB) aneurysm embolization system has so far shown promising results in the treatment of complex bifurcation aneurysms. We aimed to evaluate the feasibility and short-term follow-up of endovascular treatment of ruptured wide-neck aneurysm with the WEB device., Methods: Six patients referred to our institution for acute symptomatic subarachnoid hemorrhage (SAH) and treated with the WEB device were enrolled in this study. Clinical presentations, technical details, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 3-month angiographic results were also evaluated., Results: Three middle cerebral artery (MCA) and three anterior communicating artery aneurysms were treated between 1 and 14 days after rupturing. Average dome width was 5.8 mm (range 5-7), average neck size was 4.5 mm (range 4-5), and average dome-to-neck ratio was 1.3 (range 1-1.7). The WEB system was the exclusive treatment and was successfully deployed in all cases. Per procedural thromboembolic events occurred in two cases and were treated with intra-arterial administration of antiplatelet agents without any clinical consequences. The modified Rankin Scale (mRS) score at discharge was 0 for all patients. The 3-month angiographic follow-up showed adequate occlusion in four of our six patients (67 %)., Conclusion: From this preliminary study, the high feasibility rate and lack of need for systematic antiplatelet agents favor the WEB device providing a solution for endovascular treatment of ruptured wide-neck bifurcation aneurysms during the acute phase. However, further studies are needed to evaluate the complication rate and long-term efficiency.

Background and Purpose: The WEB aneurysm embolization system is still under evaluation but seems to be a promising technique to treat wide-neck bifurcation aneurysms. However, this device is barely visible using conventional DSA; thus, high-resolution contrast-enhanced flat panel detector CT (VasoCT) may be useful before detachment to assess the sizing and positioning of the WEB. The purpose of this study was to evaluate the interest of VasoCT during WEB procedures., Materials and Methods: From March 2012 to July 2013, twelve patients (10 women and 2 men; age range, 44-55 years) were treated for 13 intracranial aneurysms with the WEB device. DSA and VasoCT were used and compared to depict any protrusion of the device in parent arteries before detachment. Two neuroradiologists reviewed each VasoCT scan, and the quality was graded on a subjective quality scale., Results: The mesh of the WEB was very well-depicted in all cases, allowing a very good assessment of its deployment. Device protrusion was clearly detected with VasoCT in 5 cases, leading to WEB repositioning or size substitution. During follow-up, VasoCT also allows good assessment of eventual residual blood flow inside the aneurysm or the WEB device., Conclusions: Unlike DSA, VasoCT is an excellent tool to assess WEB deployment and positioning. In our experience, it allowed a precise evaluation of the WEB sizing and its relation to the parent vessel. Such information very likely enhances the ability to safely use this device, avoiding potential thromboembolic events in cases of protrusion in the parent arteries., (© 2014 by American Journal of Neuroradiology.)

Introduction: Cerebral blood volume (CBV) measurement by flat panel detector CT (FPCT) in the angiography suite seems to be a promising tool for patient management during endovascular therapies. A steady state of contrast agent distribution is mandatory during acquisition for accurate FPCT CBV assessment. To the best of our knowledge, this was the first time that steady-state parameters were studied in clinical practice., Methods: Before the CBV study, test injections were performed and analyzed to determine a customized acquisition delay from injection for each patient. Injection protocol consisted in the administration of 72 mL of contrast agent material at the injection rate of 4.0 mL/s followed by a saline flush bolus at the same injection rate. Peripheral or central venous accesses were used depending on their availability. Twenty-four patients were treated for different types of neurovascular diseases. Maximal attenuation, steady-state length, and steady-state delay from injection were derived from the test injections' time attenuation curves., Results: With a 15 % threshold from maximum attenuation values, average steady-state duration was less than 10 s. Maximum average steady-state duration with minimal delay variation was obtained with central injection protocols., Conclusion: With clinically acceptable contrast agent volumes, steady state is a brief condition; thus, fast rotation speed acquisitions are needed. The use of central injections decreases the variability of steady-state's delay from injection. Further studies are needed to optimize and standardize injection protocols to allow a larger diffusion of the FPCT CBV measurement during endovascular treatments.

Purpose: Cognitive dysfunctions with stroke of the brain stem are rare. We focused on and examined cognitive dysfunction after pontine hemorrhages., Object and Method: After July 2008, we treated 23 patients with pontine hemorrhages. Only 10 patients were included, all other patients had old hemorrhages, venous anomalies, and disturbances of consciousness. The patients included six men and four women, aged 51 years to 86 years old. The volume of hematoma was 0.11-5.20mL(average:1.74mL);there were six right side, two left side, two bilateral, three ventral, and seven dorsal hematomas. We performed neuropsychological tests such as mini-mental state examination(MMSE), Raven's coloured progressive matrices(RCPM), and frontal assessment battery(FAB)., Result: Eight cases had an abnormal score on the tests. The volume of hematoma showed a high negative correlation with MMSE scores(p=0.0194)and RCPM(p=0.0338). On the other hand, the volume of hematoma and FAB scores(p=0.0832)were uncorrelated, and the localization of the hematoma did not correlate with tests of cognitive function., Conclusion: Cognitive dysfunction is not rare after pontine hemorrhage. Therefore, for patients with infratentorial lesions, it is necessary to perform detailed cognitive functional tests.

A 44-year-old man presented with traumatic aneurysm of the left ophthalmic artery. The first coil embolization intervention achieved relatively tight packing of the aneurysm and the parent artery. After 5 months, a second embolization procedure was required because of recurrence of the aneurysm with transition of the intraaneurysmal coil formation. No recurrence occurred after the second embolization. We thought that the first embolization might have prevented catastrophic rupture, whereas the second embolization resulted in complete obliteration of the aneurysm. No entity of the aneurysmal wall formation of the current traumatic aneurysm in the acute stage may have resulted in the recanalization of the aneurysm followed by the second intervention. The stability of the wall in the chronic stage may correlate with the complete obliteration.

A 71-year-old male presented with a rare case of dural arteriovenous fistula (AVF) of the anterior cranial fossa associated with carotid artery stenosis manifesting as a transient visual disorder. The therapeutic strategy was complicated because the collateral network to the ischemic brain from the external carotid artery was associated with the dural AVF. Transarterial embolization of the shunt was performed simultaneously with carotid artery stent placement. The patient showed good recovery despite a tiny skin ulcer around his nose.

Background: Symptomatic vasospasm (SVS) is still a major cause of poor outcome in cases undergoing early surgical intervention for ruptured intracranial aneurysm. Among the numbers of therapeutic trials to prevent and ameliorate neurological deterioration due to SVS, removal or quenching of oxy-hemoglobin (OxyHb) from subarachnoid colts and administration of Mg(2+) (Mg) have especially been expected to be effective. In this report the authors investigated the effect of continuous cisternal irrigation (CCI) with mock CSF containing ascorbic acid (ASA) and Mg, performed after early surgery for ruptured aneurysm., Method: Sixty-three cases which had received CCI were retrospectively compared with 40 control cases as to the incidence of SVS and outcome., Findings: Incidence of SVS was significantly less frequent (P < 0.05) in the CCI group (11%) than in the control group (25%). Severe and definitive SVS requiring additional specific treatment occurred only in 3.2% of the CCI group, while 22.5% in the control (P < 0.01). Overall outcome at discharge was significantly better in the CCI group than in the control (P < 0.01)., Conclusions: Postoperative CCI with ASA and Mg was definitively effective in preventing SVS and in lessening severity of SVS if it occurs.

It is well known that significant narrowing of the subclavian or innominate artery may cause cerebrovascular ischemic symptoms. We report a case of a 62-year-old man who was suffering from progressive cognitive impairment and was treated by perctaneous transluminal angioplasty (PTA). The patient had undergone aorto-bifemoral bypass, left femoropopliteal bypass, and right femoral artery endoarterectomy. On admission, he was alert, but had memory impairment, especially delayed recall. He complained of dizziness and dysesthesia on his right upper extremity which got worse on exertion. The right radial pulse was diminished and the right brachial blood pressure was lower about 40 mmHg than the left. Angiography demonstrated severe stenosis of the innominate artery near its origin, hypoplasty of the left horizontal anterior cerebral artery segment (Al), and dilation of the left external carotid artery. Left vertebral arteriography revealed retrograde flow of the right vertebral artery in the late arterial phase. Single photon emission computed tomography (SPECT) revealed marked reduction in cerebral blood flow to the left frontal lobe. The patient underwent PTA of the innominate artery with satisfactory results. Cognitive impairment improved remarkably after the angioplasty. The right radial pulse was quite palpable, and the bilateral brachial blood pressures were the same. The cerebral blood flow was increased in SPECT. Memory disturbance can be generated by stenosis of the innominate artery. PTA is one of the effective methods to reverse such cognitive impairment.

We report the case of conduction aphasia due to injury of the right hemisphere of the brain. The patient was a right-handed male in his fifties with moyamoya disease. T2-weighted MRI showed an extensive high intensity area in the right temporal-parietal-occipital lobes. In the case of language-related symptoms, comprehension was preserved, but phonemic paraphasias were frequent, and kana paragraphias were also observed. Despite the extensive injury of the right hemisphere, these language-related symptoms were consistent with the clinical features of conduction aphasia. Therefore, this patient was diagnosed with atypical crossed aphasia. Improvement in the phonemic paraphasia differed between words and nonsense words, suggesting that the improvement was dependent on the level of meaning of the words.

Unlabelled: We noted, during cerebral angiography, that the contrast medium was contaminated with numerous small black ink clots from gradation marks on syringes. In this report, we show that ink can be removed from syringes in solid form, and that they may result in embolic complications during cerebral angiography., Materials and Methods: To demonstrate that the ink from gradation marks on syringes can come off in a solid form and attach itself to the gloves during cerebral angiography, syringes were gripped many times (just as in an angiographic procedure) after immersion in contrast medium or 0.9% saline for 10 minutes. To see if difference of contrast medium and syringes could affect the removing of ink, five types of nonangiographic syringes and one type of angiographic syringe were rubbed with gauze after certain time periods after immersing them in four kinds of contrast medium or 0.9% saline., Results: Ink attached itself to the gloves in a solid form by repeated gripping due to adherence of contrast medium. Ink was removed from all nonangiographic syringes by rubbing after immersion in any type of contrast medium for two hours. Gradation marks on angiographic syringes were stable with all types of contrast medium., Conclusions: Thus, ink for gradation marks on nonangiographic syringes, which is easily removed in a solid form due to contrast medium, can be the source of embolic complication during cerebral angiography.