Hidden Bow Hunter's Syndrome Diagnosed Using Dynamic Cerebral Angiography and Successfully Treated with Spinal Surgery: A Case Report and Review of the Literature.

Hidden bow hunter's syndrome (HBHS) is a rare disease in which the vertebral artery (VA) occludes in a neutral position but recanalizes in a particular neck position. We herein report an HBHS case and assess its characteristics through a literature review. A 69-year-old man had repeated posterior-circulation infarcts with right VA occlusion. Cerebral angiography showed that the right VA was recanalized only with neck tilt. Decompression of the VA successfully prevented stroke recurrence. HBHS should be considered in patients with posterior circulation infarction with an occluded VA at its lower vertebral level. Diagnosing this syndrome correctly is important for preventing stroke recurrence.

Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion.

Hemichorea-hemiballism (HCHB) due to transient ischemic attacks (TIAs) is rare. An 83-year-old woman had repeated episodes of right-sided HCHB for 3 months. Magnetic resonance (MR) angiography demonstrated occlusion of the left carotid and middle cerebral arteries and severe stenosis of the innominate artery, and 24-hour ambulatory blood pressure monitoring showed a blood pressure decrease of >20 mmHg after each meal. We speculated that HCHB developed as TIAs due to hemodynamic failure in the left cerebral hemisphere, caused by a combination of severe stenosis of the innominate artery concomitant with occlusion of the left carotid and middle cerebral arteries as well as postprandial hypotension.

Endovascular Embolization with n-Butyl Cyanoacrylate for Ruptured Distal Posterior Inferior Cerebellar Artery Dissecting Aneurysm.

Parent artery occlusion is a definitive treatment method for preventing rebleeding of dissecting aneurysms. We herein report a case of a ruptured distal posterior inferior cerebellar artery (PICA) dissecting aneurysm treated with internal trapping using n-butyl-2-cyanoacrylate (NBCA). A 65-year-old man visited our hospital with a complaint of headache and neck pain that began 1 week before his arrival. He had a history of spontaneous subarachnoid hemorrhage of unknown cause. Computed tomography of the brain revealed a small amount of subarachnoid hemorrhage, and distal subtraction angiogram showed a distal PICA dissecting aneurysm. We placed a guiding catheter in the left vertebral artery and an intermediate catheter in the PICA. A microcatheter was guided toward the proximal side of the aneurysm and was wedged into the parent artery. The dissecting aneurysm was treated with parent artery occlusion using 50% NBCA. The postoperative course was uneventful, and the patient was discharged 3 weeks after treatment without any neurological deficit. Parent artery occlusion with internal trapping using NBCA could be a safe and definitive treatment method for distal PICA dissecting aneurysms. Angiographical evaluation of the collateral network in the distal branch of PICA before embolization and wedged microcatheter technique in the parent artery are important for successful embolization using NBCA.

Parent Artery Occlusion for Symptomatic Large Internal Carotid Artery Aneurysm with Primitive Trigeminal Artery Variant: A Case Report.

Objective: To report a case of symptomatic large cerebral aneurysm of the internal carotid artery (ICA), associated with a primitive trigeminal artery variant (PTAv), which was treated with a balloon occlusion test (BOT) to evaluate ischemic tolerance. Case Presentation: A 79-year-old woman was diagnosed with a symptomatic large cerebral aneurysm of the ICA bifurcating the PTAv due to diplopia. After confirming the ischemic tolerance of the perfusion area and PTAv by BOT, we performed ICA parent artery occlusion with selective embolization of the PTAv. Postoperative MRI showed no ischemic lesion and the diplopia was resolved. Conclusion: ICA parent artery occlusion with PTAv selective embolization after evaluation by BOT is useful in the treatment of large aneurysms.

Carotid artery stenosis concomitant with severe aortic stenosis treated by combination of staged angioplasty and transcatheter aortic valve implantation: A case report.

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

A Case of Acute Embolic Occlusion of the Common Carotid Artery in Which a Giant Thrombus Was Retrieved Using the Parallel Stent Retriever Technique.

Objective: We report a case of embolic occlusion of the common carotid artery (CCA) in which a giant thrombus was retrieved using the parallel stent retriever technique. Case Presentation: An 84-year-old woman without anticoagulant therapy despite a history of cardioembolic stroke presented to our hospital because of left hemiparesis after developing sudden vision loss in her right eye. Emergency angiography revealed a giant thrombus in the right CCA. After arresting flow in the CCA using a balloon-guided catheter (BGC), we deployed two stent retrievers in parallel from the internal carotid artery to the CCA, and slowly retrieved them simultaneously under manual aspiration through the BGC. As a result, complete recanalization was achieved. Conclusion: Thrombi causing acute embolic occlusion of the CCA are often too large to be completely retrieved using conventional thrombectomy techniques. The parallel stent retriever technique may be effective in such cases.

Vestibular dysfunction as cortical damage with amyotrophic lateral sclerosis.

BACKGROUND: Cortical damage in areas such as the frontal lobe is reported in amyotrophic lateral sclerosis (ALS). However, aside from executive dysfunction, the pathological significance of this cortical damage has yet to be clarified. The present study investigated the effects of cortical damage on vestibular function in ALS. METHODS: Subjects comprised 18 ALS patients and 18 age- and sex-matched healthy controls. Cold air caloric stimulation was performed in all subjects to induce vestibular nystagmus, which was analysed to evaluate vestibular function. Visual suppression testing to investigate the suppressive effects of visual stimuli on vestibular nystagmus was expressed as suppression rate (SR, %). Executive function was tested using the frontal assessment battery (FAB). RESULTS: Suppression rate and FAB score were significantly lower in the ALS group than in the control group (p < 0.01 each). A positive correlation was also observed between SR and FAB score (R = 0.65, p = 0.023). CONCLUSION: Visual suppression testing showed significant damage to the central nervous system vestibular control mechanisms, which utilize visual information in the ALS group and a positive correlation between SR and FAB score suggest a relationship between frontal lobe damage and impaired vestibular control. A simple vestibular function test may be useful as a tool to objectively monitor the progression of cerebral lesions in ALS.

A cerebral phenotype of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids: A case report and review of the literature.

CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an inflammatory central nervous system disorder that gives rise to brainstem symptoms such as diplopia and articulatory disorders. It shows characteristic "salt-and-pepper" enhancing brainstem lesions on magnetic resonance imaging (MRI) scans. We present an unusual case of CLIPPERS, in which a 29-year-old man initially presented with a seizure. Brain MRI revealed faint open-ring enhancements in the right frontal lobe, and a brain biopsy was performed to make a definitive diagnosis. Immunohistological tests showed perivascular infiltration by primarily CD3- and CD20-positive cells, albeit including a few CD68-positive cells, which confirmed a diagnosis of CLIPPERS. Both the symptoms and the MRI findings were markedly improved by 3 courses of steroid (methylprednisolone) pulse therapy, followed by oral steroid (prednisolone) administration. This case shows that CLIPPERS can present as a phenotype of cortical lesions and seizures as the first signs. A brain biopsy should therefore be actively carried out for differential diagnosis, especially when other, cortically based inflammatory disorders are suspected.