A Pial Arteriovenous Fistula in Infancy as the Presenting Manifestation of Hereditary Hemorrhagic Telangiectasia.

BACKGROUND: Pial arteriovenous fistulas (PAVFs) are rare, accounting for 1.6%-4.7% of all intracranial vascular malformations. Often diagnosed in childhood, about 30% are associated with hereditary hemorrhagic telangiectasia. A case of PAVF diagnosed soon after birth and given cerebrovascular therapy 4 months after birth is reported. CASE DESCRIPTION: The patient presented with heart failure immediately after birth. Ultrasonography of the head showed abnormal blood flow in the brain. On digital subtraction angiography performed 4 months after birth, a PAVF with a dural feeder shunt and a giant varix at the posterior temporal part was confirmed. After transarterial embolization (TAE), shunt blood flow disappeared. New shunt flow from the right posterior cerebral artery into the varix was confirmed by magnetic resonance imaging 3 months after the operation. A second TAE procedure using a liquid embolic material was performed and confirmed the complete disappearance of the shunt. CONCLUSIONS: This report describes a case of infant PAVF with heart failure, a giant varix, hydrocephalus, and intraventricular hemorrhage treated by TAE using platinum coils and liquid embolic material.

[Treatment of a Traumatic Direct Carotid Cavernous Fistula with an Intradural Internal Carotid Artery Pseudoaneurysm Using a Low-profile Visualized Intraluminal Support(LVIS)Stent:A Case Report].

Traumatic carotid cavernous fistula(CCF)is known to present a direct connection between the cavernous segment of the internal carotid artery(ICA)and the cavernous sinus(CS). In rare cases, the fistula is formed between the intradural internal carotid artery(ICA)and the cavernous sinus(CS)via a pseudoaneurysm(pAN), requiring appropriate management and aggressive surgical treatment. We describe a 58-year-old man who sustained a severe head injury diagnosed as traumatic CCF treated with an intradural pAN procedure and transarterial coil embolization combined with a Low-profile Visualized Intraluminal Support(LVIS)stent. While slow arteriovenous shunt flow persisted at the end of the surgery, the fistula was completely occluded on the digital subtraction angiography obtained 2 weeks after the procedure. It was suspected that the flow-diversion effect of the LVIS stent might have caused the curable progression of the fistula occlusion.

Chronic Dilatation of Superficial Temporal Artery and Middle Meningeal Artery Associated with Development of Collateral Circulation After Bypass Surgery for Moyamoya Angiopathy.

OBJECTIVES: Dilatation of the superficial temporal artery (STA) and middle meningeal artery (MMA) were occasionally observed after bypass surgery for moyamoya angiopathy. The purpose of this study was to examine the correlation between angiographic outcomes and magnetic resonance imaging (MRI), specifically focusing on the postoperative dilatation ratio of the STA (rSTA) and MMA (rMMA). METHODS: Fifty-six hemispheres in 36 consecutive patients who underwent revascularization for moyamoya angiopathy were evaluated. All patients underwent angiography and MRI before surgery and during the chronic phase. Angiographic outcomes were classified as good or poor according to the extent of the blood supply through direct or indirect bypass. The rSTA and rMMA was calculated in time-of-flight magnetic resonance angiography (MRA). The signal changes of ivy signs and flow voids in basal ganglia were also evaluated. RESULTS: Postoperative collaterals through direct and indirect bypass was good in 30 (53.6%) and 33 (58.9%) patients, respectively. The mean rSTA and rMMA were 36.04 ± 28.79% and 29.15 ± 22.01%, respectively. Ivy signs and flow voids were decreased in 9 (16.1%) and 26 (46.4%) patients, respectively. Univariate analyses demonstrated no significant correlation between the angiographic outcomes and postoperative signal changes on MRI. However, rSTA was significantly correlated with good collaterals through direct bypass (P = 0.04), whereas rMMA was significantly correlated with good collaterals through indirect bypass (P < 0.001). CONCLUSIONS: MRA may be an alternative to angiography. Both rSTA and rMMA estimated the development of collaterals after bypass surgery for moyamoya angiopathy.

Marked Changes in Blood-Brain Barrier Biomarkers After Direct Bypass Surgery for Moyamoya Angiopathy: Preliminary Study.

OBJECTIVE: The blood-brain barrier (BBB) of patients with moyamoya angiopathy (MMA) is unstable, which may contribute to transient neurologic symptoms (TNS) after direct bypass surgery. However, BBB-related proteins have never been investigated. The purpose of this study was to evaluate the perioperative serum levels of biomarkers representing BBB function in MMA patients based on the hypothesis that postoperative hemodynamic change may disrupt the BBB. METHODS: A total of 12 hemispheres in 11 patients with MMA were prospectively examined. Direct revascularization surgery was performed for all cases. The serum levels of tight junction (occludin and claudin 5), adherens junction (vascular endothelial-cadherin) proteins, and matrix metalloproteinase (MMP)-2 and MMP-9 were measured quantitatively 1 day before surgery and on postoperative days 1, 4, and 7. RESULTS: Successful patency of the direct bypass was achieved in all. The serum level of occludin was significantly increased on postoperative day 1, and the levels in 2 cases with TNS were markedly elevated over 10-fold higher than baseline. Furthermore, the postoperative MMP-9 levels were significantly elevated on each day. On the other hand, there was no significant fluctuation in claudin 5, vascular endothelial-cadherin, and MMP-2 level. CONCLUSIONS: Marked changes in biomarkers representing the tight junction of the BBB were observed. These preliminary results suggest that marked hemodynamic change and TNS in some patients are associated with disruption of the BBB after direct bypass surgery for MMA.

Safety and efficacy of a new outreach distal access catheter, TACTICS, for coil embolization of unruptured intracranial aneurysms.

Background and purpose Current large-bore catheters can be easily and safely placed in the intracranial vessels for the stabilization of microcatheters in several neurointervention scenarios. We considered that a novel 3.4 French catheter (TACTICS, Technorat Corporation, Aichi, Japan) might be useful for intermediate/distal access in a triaxial system. Here, we present our initial experience using the TACTICS catheter for treatment of intracranial aneurysms. Materials and methods A total of 35 endovascular coils were placed to embolize unruptured intracranial aneurysms of the anterior circulation using the TACTICS catheter between December 2016 and November 2017. These procedures were retrospectively reviewed to assess aneurysmal obliteration (Raymond's classification), the volume embolization ratio (VER) and procedural complications in comparison with 96 conventional coil treatments during the 3-year period up to 2016. Data were matched for aneurysmal morphology (location, maximum diameter and aspect ratio) by the propensity method. Results In all procedures, the TACTICS catheter was atraumatically landed beyond the carotid siphon. There were no hemorrhagic or symptomatic ischemic complications. After propensity matching, 68 procedures were assessed (34 in each group). Achievement of Raymond's scale 1 (complete occlusion) showed the same frequency in both groups (50% vs. 50%, p = 0.23). The VER was significantly higher with the TACTICS catheter than with the conventional method (34.0% vs. 28.7%, p = 0.003). Conclusion We reviewed our initial experience of the TACTICS catheter. It can be used as an intermediate catheter for safe and effective endovascular coil embolization of anterior circulation aneurysms.

Simple aspiration with balloon catheter technique (simple ABC technique) against proximal internal carotid artery occlusion in cases of cardiogenic cerebral embolism.

Background In cases of acute ischemic stroke, manual aspiration of the thrombus is commonly performed with a balloon guiding catheter placed in the cervical segment of the internal carotid artery (ICA). However, most manual aspirations using a balloon guiding catheter are combined with inner catheters, as in the direct aspiration first pass technique (ADAPT). We experienced some cases of acute ischemic stroke with proximal ICA occlusion due to cardiogenic thrombus where we obtained sufficient recanalization by simple manual aspiration from inflated Optimo 9F balloon catheters (Tokai Medical Products, Japan) placed in the origin of the cervical segment of the ICA without any inner catheter or stent retriever. We perform by preference this procedure, named the simple Aspiration with Balloon Catheter (simple ABC) technique. Herein, we report two recent cases and discuss this procedure. Case presentation Case 1: An 80-year-old man with paroxysmal atrial fibrillation developed left ICA occlusion. We performed the simple ABC technique and obtained a large amount of dark red and white thrombus. Puncture-to-reperfusion time was 14 minutes with Thrombolysis in Cerebral Infarction (TICI) grade 3. Case 2: A 69-year-old man with chronic atrial fibrillation developed left internal carotid occlusion. We performed the simple ABC technique and obtained a large amount of dark red thrombus. Puncture-to-reperfusion time was 15 minutes with TICI grade 2b. Conclusion The simple ABC technique is useful to deal with a large amount of thrombus, shortens procedure time, enables less invasive thrombectomy, and can shift immediately to subsequent procedures such as delivering a stent retriever or ADAPT.

Predicting ischemic stroke after carotid artery stenting based on proximal calcification and the jellyfish sign.

OBJECTIVE Carotid artery stenting (CAS) has been considered to prevent ischemic strokes caused by stenosis of the cervical carotid artery. The most common complication of CAS is new cerebral infarction. The authors have previously reported that the jellyfish sign-the rise and fall of the mobile component of the carotid plaque surface detected by carotid ultrasonography-suggests thinning and rupture of the fibrous cap over the unstable plaque content, such as the lipid-rich necrotic core or internal plaque hemorrhage. The authors' aim in the present study was to evaluate the risk of a new ischemic lesion after CAS by using many risk factors including calcification (size and location) and the jellyfish sign. METHODS Eighty-six lesions (77 patients) were treated with CAS. The presence of ischemic stroke was determined using diffusion-weighted imaging (DWI). Risk factors included calcification of the plaque (classified into 5 groups for size and 3 groups for location) and the jellyfish sign, among others. Multiple linear regression analysis (stepwise analysis and partial least squares [PLS] analysis) was conducted, followed by a machine learning analysis using an artificial neural network (ANN) based on the log-linearized gaussian mixture network (LLGMN). The additive effects of the jellyfish sign and calcification on ischemic stroke after CAS were examined using the Kruskal-Wallis test, followed by the Steel-Dwass test. RESULTS The stepwise analysis selected the jellyfish sign, proximal calcification (proximal Ca), low-density lipoprotein (LDL) cholesterol, and patient age for the prediction model to predict new DWI lesions. The PLS analysis revealed the same top 3 variables (jellyfish sign, proximal Ca, and LDL cholesterol) according to the variable importance in projection scores. The ANN was then used, showing that these 3 variables remained. The accuracy of the ANN improved; areas under the receiver operating characteristic curves of the stepwise analysis, the PLS analysis, and the ANN were 0.719, 0.727, and 0.768, respectively. The combination of the jellyfish sign and proximal Ca indicates a significantly increased risk for ischemic stroke after CAS. CONCLUSIONS The jellyfish sign, proximal Ca, and LDL cholesterol were considered to be important predictors for new DWI lesions after CAS. These 3 factors can be easily determined during a standard clinical visit. Thus, these 3 variables-especially the jellyfish sign and proximal Ca-may be useful for reducing the ischemic stroke risk in patients with stenosis of the cervical carotid artery.

Overlapped Stenting Is Associated with Postoperative Hypotension after Carotid Artery Stenting.

BACKGROUND: Hypotension (HT) is well recognized to frequently occur during and after carotid artery stenting (CAS), which sometimes causes postoperative complications such as stroke or myocardial infarction. This study aimed to examine the risk factors associated with HT after CAS based on the hypothesis that overlapped stenting may affect postoperative HT. METHODS: A total of 106 lesions in 95 patients with carotid artery stenosis who underwent CAS were reviewed. Bradycardia and HT were defined as a heart rate and a systolic blood pressure less than 60 beats/min and 100 mm Hg, respectively. The patients were categorized by the presence (group H) or the absence (group N) of postoperative HT, respectively, and demographic data, risk factors, conditions of carotid artery stenosis, procedures, and pre- and intraoperative hemodynamics were compared between these 2 groups. Multivariate analysis was performed to evaluate independent factors associated with postoperative HT. RESULTS: In total, postoperative HT was observed in 30 (28.3%) cases. The incidence of overlapped stenting, the use of an open-cell stent, and intraoperative HT were significantly higher in group H (P = .03, .01 and < .01, respectively). The distance from carotid bifurcation and the maximum stenotic lesion tended to be shorter in group H (P = .09). In the multivariate logistic regression analysis, using all these variables, the overlapped stenting and intraoperative HT were found to be independent predictors for postoperative HT. CONCLUSION: The overlapped stenting affected postoperative HT after CAS. Blood pressure should be strictly controlled in cases with overlapped stenting or intraoperative HT after CAS.

Asymptomatic Ischemic Risks in Microsurgical Clipping for Unruptured Intracranial Aneurysms in Anterior Circulation.

BACKGROUND: The ischemic risk in prophylactic treatments of unruptured intracranial aneurysms (UIAs) is a serious health concern. OBJECTIVE: The aim of this study was to elucidate the incidence and characteristics of ischemic events in microsurgical clipping of anterior circulation UIAs. METHODS: Ischemic events were prospectively evaluated before and after surgery between April 2011 and March 2017. The location, volume, minimum value of apparent diffusion coefficient in high-intensity spots (HIS) on 3-T magnetic resonance diffusion-weighted imaging (DWI), and radiographic outcomes were analyzed. The relationships between DWI positivity and patient demographics, surgical procedures, and intraoperative vessel features were assessed. RESULTS: Overall, 78 consecutive patients including 29 men and 49 women (median age, 62 years; range, 24-77 years) with 99 UIAs were analyzed. A total of 10 in 78 craniotomies (13%) detected HIS on DWI, which were all asymptomatic. Seventeen HIS were shown, 5 of which were located in the basal ganglia, 6 in the white matter, and 6 in the cortex. The volume and minimum value of apparent diffusion coefficient were 180.4 ± 31.2 mm3 and 0.56 ± 0.03 × 10-3 mm2/second, respectively. Radiographic outcomes at follow-up showed that 71% of HIS on DWI led to irreversible brain ischemia. The maximum diameter of aneurysms, atherosclerotic features of the aneurysm wall, and procedure-related factors were associated with DWI positivity. CONCLUSIONS: The asymptomatic ischemic risk associated with microsurgical clipping was not low and most lesions were irreversible. Although the mechanism could be various, the use of clips for atherosclerosis of the aneurysm and/or parental vessels requires much attention.

Postoperative Dilatation of Superficial Temporal Artery Associated with Transient Neurologic Symptoms After Direct Bypass Surgery for Moyamoya Angiopathy.

OBJECTIVE: In moyamoya angiopathy, transient neurologic symptoms (TNS) are occasionally observed after superficial temporal artery (STA)-middle cerebral artery direct bypass surgery. The purpose of this study was to investigate the correlation between TNS and postoperative magnetic resonance imaging as well as perform a perfusion study. METHODS: We reviewed 52 hemispheres in 33 consecutive patients with moyamoya angiopathy. TNS were defined as reversible neurologic dysfunction without any apparent intracranial infarction or hemorrhage. All patients underwent magnetic resonance imaging and single-photon emission computed tomography before and within 5 days after surgery. Maximum diameter of STA on time-of-flight magnetic resonance angiography and the dilatation ratio of STA were calculated. The presence of signal changes on fluid-attenuated inversion recovery images and regional cerebral blood flow were also evaluated. RESULTS: TNS were observed in 13 of 52 (25%) cases 1-16 days after surgery. The mean preoperative STA dilatation, postoperative STA dilatation, and dilatation ratio of STA were 1.33 mm ± 0.27, 1.67 mm ± 0.30, and 29.31% ± 28.13%. Postoperative intraparenchymal cortical hyperintensity lesions and high-intensity signals in the cortex sulci (ivy sign) were detected in 24 (46.2%) cases and 29 (55.8%) cases, respectively. Univariate analyses demonstrated no association between TNS and postoperative signal change on fluid-attenuated inversion recovery images as well as cerebral blood flow. Only >1.5-fold dilatation of STA was significantly correlated with TNS (P < 0.0001). CONCLUSIONS: STA dilatation was correlated with TNS after direct bypass surgery for moyamoya angiopathy.

Somatosensory evoked potentials in carotid artery stenting: Effectiveness in ascertaining cerebral ischemic events.

Somatosensory evoked potentials (SSEP) have been used in various endovascular procedures and carotid endarterectomy, but to our knowledge no literature deals exclusively with the utility of SSEP in carotid artery stenting (CAS). The purpose of this study was to evaluate the efficacy of SSEP in detecting cerebral ischemic events during CAS. We conducted a prospective study in 35 CAS procedures in 31 patients during an 18month period. Thirty-three patients without near occlusion underwent stenting using dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration, while two patients with near occlusion underwent stenting without dual protection. All 35 patients underwent SSEP monitoring. SSEP were generated by stimulating median and/or tibial nerves and recorded by scalp electrodes. During the aspiration phase post-dilation, seven patients (20%) exhibited SSEP changes with a mean duration of 11.3±8.5minutes (range: 3-25minutes), three of whom later developed minor stroke/transient ischemic attack. Diffusion-weighted imaging showed new lesions in 10 patients (28.6%). Change in SSEP exhibited mean sensitivity of 100% (95% confidence interval, 0.29-1.0) and specificity of 88% (95% confidence interval, 0.71-0.96) in predicting clinical stroke post-CAS. Intra-procedural SSEP change was predictive of post-procedural complications (p=0.005, Fisher's exact test). Longer span of SSEP change was positively correlated with complications (p=0.032, Mann-Whitney test). Intra-procedural SSEP changes are highly sensitive in predicting neurological outcome following CAS. Chances of complications are increased with prolongation of such changes. SSEP allows for prompt intra-procedural ischemia prevention measures and stratification to pursue an aggressive peri-procedural protocol for high risk patients to mitigate neurological deficits.

Carotid artery stenting for vulnerable plaques on MR angiography and ultrasonography: utility of dual protection and blood aspiration method.

BACKGROUND: Carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis with vulnerable plaques is controversial. We analyzed the effect of a dual protection and blood aspiration method during CAS in patients with vulnerable plaques. METHODS: A total of 111 patients with ICA stenosis underwent CAS using the dual protection (simultaneous flow reversal and distal filter) and blood aspiration method. In 103 of 111 patients, preoperative carotid plaque was estimated by both 3 T MRI and ultrasonography (US). ICA plaques with a high intensity signal on time-of-flight-MR angiography (TOF-MRA) and/or mobile component on US were defined as vulnerable plaques. We assessed major adverse events (MAE) (ie, major stroke, myocardial infarction, and death) and hyperintense spots on diffusion-weighted images (DWI) after CAS. We then evaluated the visible debris captured by dual protection and blood aspiration during CAS. RESULTS: The preoperative ICA plaque on TOF-MRA and US was judged to be vulnerable in 48.5% (50/103 patients). The success rate of the CAS procedure was 100% with no MAE within 30 days. DWI showed small hyperintense spots in 18% (9/50 patients) and 18.9% (10/53 patients) in the vulnerable and non-vulnerable plaque groups, respectively. Visible debris was captured in 68% (34/50 patients) and 45.3% (24/53 patients) in the vulnerable and non-vulnerable plaque groups, respectively (p=0.0286). CONCLUSIONS: The combination of dual protection and blood aspiration could provide effective distal embolic protection although vulnerable plaques on TOF-MRA and US had a high incidence of debris during CAS. Thus, CAS using dual protection and blood aspiration is safe in patients with vulnerable plaques.

The characteristics of human cranial bone marrow mesenchymal stem cells.

Recently, cell-based therapy has attracted attention for treatment of central nervous system (CNS) disorders. Bone marrow-derived mesenchymal stem cells (BMSCs) are considered to have good engraftment potential. Therefore, more efficient and less invasive methods to obtain donor cells are required. Here, we established human BMSCs from cranial bone waste (cBMSCs) obtained following routine neurosurgical procedures. cBMSCs and cells obtained from the iliac crest (iBMSCs, standard BMSCs) showed expression of cell surface markers associated with mesenchymal stem cells and multipotency traits such as differentiation into osteogenic and adipogenic lineages. cBMSCs showed higher expression of the neural crest-associated mRNAs p75, Slug, and Snail than iBMSCs. Neurogenic induced cells from cBMSCs expressed the neural markers nestin, Pax6, neurofilament (NF)-L, and NF-M as seen with RT-PCR, and NF-M protein as seen with western blotting at higher levels than cells from iBMSCs. Immunostaining showed a significantly greater proportion of NF-M-positive cells in the population of induced cBMSCs compared with the population of iBMSCs. Thus, cBMSCs showed a greater tendency to differentiate into neuron-like cells than iBMSCs.

Usefulness of dual protection combined with blood aspiration for distal embolic protection during carotid artery stenting.

BACKGROUND: We describe dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration as a novel technique to provide distal embolic protection during carotid artery stenting (CAS). METHODS: Between July 2011 and August 2014, 190 patients with internal carotid artery (ICA) stenosis underwent 190 CAS procedures as follows. After post-dilation of the stent using dual protection, the aspiration catheter was placed between the distal filter and the proximal end of the stent, and the blood was aspirated several times from the ICA. We assessed hyper-intensity spots in diffusion-weighted images (DWI), and major adverse events (MAE) defined as major stroke, myocardial infarction and death after CAS. We then assessed visible debris captured in aspirated blood, the distal filter and a blood filter during flow reversal. RESULTS: The overall technical success rate was 100 %, and all stenoses were dilated. Hyper-intense spots were found in 33 (17.3 %) of 190 DWI. The rate of MAE within 30 days was 1.05 % (2/190). Visible debris in 175 of 190 CAS procedures was captured in 92 (52.5 %) of these 175. In 25 (27.2 %) of these 92, visible debris was captured in all of aspirated blood, the distal filter and the blood filter during flow reversal, only the blood filter during flow reversal (n = 19; 20.7 %), only the distal filter (n = 14; 15.2 %), only aspirated blood (n = 11; 12 %), aspirated blood and the blood filter during flow reversal (n = 10; 10.8 %), aspirated blood and the distal filter (n = 7; 7.6 %) and the distal filter and blood filter during flow reversal (n = 6; 6.5 %). CONCLUSIONS: Adding a distal filter and blood aspiration to flow reversal during CAS could provide effective distal embolic protection.

Carotid artery stenting using the proximal or dual protection method for near occlusion of the cervical internal carotid artery.

The treatment for patients with near occlusion of the cervical internal carotid artery (ICA) is controversial. The aim of this study was to examine the results of carotid artery stenting (CAS) as a surgical treatment for ICA near occlusion. Between April 2008 and September 2012, 14 patients (all men; mean age, 75.4 years) with ICA near occlusion were treated with CAS. This represents 5.2% of a total of 267 patients treated with CAS during the study period. All patients were treated with CAS using an embolic protection device. The proximal balloon protection method was performed in five patients, and the dual protection method using a proximal balloon and distal filter protection was used in nine patients. We examined the change of stenotic lesion, hyperintensity spot in diffusion-weighted imaging (DWI), and perioperative complications after CAS. All near occlusions were successfully dilated. Among 2 of 14 patients, DWI showed 1 and 4 hyperintensity spots. Transient and persistent complications, including neurological deficits, did not occur in any patients. In this small number of cases, CAS using the proximal or dual embolic protection method seems to be a safe and beneficial treatment for ICA near occlusion.

Multiple antiplatelet therapy contributes to the reversible high signal spots on diffusion-weighted imaging in elective coiling of unruptured cerebral aneurysm.

INTRODUCTION: Our aim was to systematically investigate radiographic characteristics and outcome of diffusion-weighted imaging (DWI) changes in the elective coiling of unruptured cerebral aneurysm with analyzing the correlation of antiplatelet therapy (APT). METHODS: In a total of 34 consecutive patients with unruptured cerebral aneurysms initially treated by coiling without stent assist, 26 (76.5%) had DWI changes with 91 high signal spots within 24-48 h after the procedure. We recorded DWI parameters (location, volume, mean, and minimum values of the apparent diffusion coefficient: expressed as ADCAVE and ADCMIN) for each lesion, and evaluated its radiographic outcome on conventional MRI at follow-up (interval, 58.4 ± 37.2 days) in the modes of APT. RESULTS: All patients with DWI high spots had no clinical symptoms. There was a strong correlation between ADCAVE and ADCMIN (r = 0.82, p < 0.0001). The mean ADCAVE and rADCAVE were 0.74 ± 0.14 × 10(-3) mm(2)/s and 87 ± 10 %. DWI high spots were small with a mean volume of 0.13 ± 0.12 cm(3), ranging from 0.04 to 0.86 cm(3). A negative correlation was observed between the volume and values of ADCAVE (r = -0.48, p < 0.0001). The DWI volume was significantly larger in single APT than in multiple (0.15 ± 0.14 versus 0.10 ± 0.07 cm(3), p = 0.0091). The permanent signal change was more observed in single APT than in multiple (24.5% versus 5.2%, p = 0.02). CONCLUSION: DWI high spots after elective coiling were small without significant decrease of ADC, and do not correspond to brain infarction. Periprocedural use of multiple antiplatelet agents is expected to reduce the volume of thromboembolism and permanent tissue damages.

Arterial spin-labeling imaging at 3-T in dural arteriovenous fistulas of cavernous sinus before and after endovascular treatment.

A 72-year-old man presented with chemosis and ophthalmoplegia due to dural arteriovenous fistulas (DAVF) of the cavernous sinus (CS). Preoperative arterial spin-labeling (ASL) image showed visible vein in the bilateral superior ophthalmic vein (SOV). Endovascular transvenous embolization of the shunting points of the CS-DAVF was performed, and the postoperative angiogram showed complete obliteration of the CS-DAVF. Postoperative ASL showed no visible vein in the bilateral SOV. ASL in CS-DAVF was proved to have shown retrograde venous drainage from the CS-DAVF by comparing ASL before and after treatment.

Endovascular treatment for ruptured distal anterior inferior cerebellar artery aneurysm -case report-.

A 73-year-old woman presented with subarachnoid hemorrhage caused by a ruptured left distal anterior inferior cerebellar artery (AICA) aneurysm. Computed tomography showed a thin subarachnoid hemorrhage in the ambient cistern, and digital subtraction angiography revealed an aneurysm arising from the lateral branch of the left AICA, which was separate from the meatal loop. Endovascular treatment was performed to achieve parent artery occlusion using two Guglielmi detachable coils. Postoperatively, the patient had no complications except for left hearing disturbance, and she was independent in daily life. Endovascular parent artery occlusion for distal AICA aneurysm, especially distal from the meatal loop, can avoid sacrificing the internal auditory artery if the lateral branch of the AICA could be occluded more distally from the meatal loop. Sufficient collateral circulation prevents major infarction, and this strategy may be the first-line treatment choice.

Single-stage operation for a giant haemangiopericytoma following intracranial feeder embolization.

Meningeal haemangiopericytomas (HPC) are malignant intracranial neoplasms that commonly recur and metastasize. Large size at diagnosis, abundant intracranial feeders and the risk of intraoperative bleeding can make them difficult to completely remove in one operation. We report here a rare case of a giant HPC which was treated successfully using a one-stage operation following superselective intracranial feeder occlusion. A 30-year-old man presented with a left middle cranial fossa tumour extending to the left temporal lobe and cerebellar tentorium. Angiography revealed supply from a dilated left posterior temporal artery branching from the posterior cerebral artery. The tumour was totally removed in a single-stage excision after embolization of the intracranial major feeding artery. The present case suggests the usefulness of preoperative embolization for HPC, particularly of intracranial feeders, to achieve total resection safely in a single operation.