Balloon Test Occlusion of the Carotid Artery: Internal Validation of Predictive Results.

AIM: To develop a protocol of balloon test occlusion (BTO) to perform single-photon emission computed tomography (SPECT) only in cases that require it by using mean stump pressure (MSTP). MATERIAL AND METHODS: BTO was performed in 52 consecutive patients (derivation group). Using the derivation group data, a protocol was created and applied to 55 consecutive patients (validation group). RESULTS: In the derivation group, all patients with MSTP ≥65 mmHg had an ischemic tolerance, whereas those with MSTP ?45 mmHg were considered ischemic intolerant. Based on these results, we developed a protocol wherein MSTP between 45 mmHg and 65 mmHg was defined as "ischemic borderzone" and SPECT was performed in these cases. Using this protocol, BTO was performed in the validation group and 19 patients were treated with parent artery occlusion with or without bypass. In two cases that did not follow the protocol, the occurrence of hypoperfusion caused cerebral infarction after treatment. However, if this protocol had been followed for all cases, no false-negative cases of BTO would have occurred. CONCLUSION: By measuring MSTP and identifying the approximate ischemic tolerability, the current protocol can identify cases requiring SPECT, which is particularly reliable but complicated. Moreover, this protocol would be especially useful for reducing false-negative cases of BTO.

Development of Internal Carotid Artery Dissection During Masturbation.

Sexual intercourse is known as one of the daily activities triggering spontaneous cervicocephalic artery dissection (sCAD), however, it has been unclear if masturbation can trigger the development of sCAD. Herein, we report a case of sCAD in association with masturbation. A 51-year-old right-handed man developed subarachnoid hemorrhage during masturbation. The dissection of the left internal carotid artery was evident on the 9th hospital day. Finally, he was treated with stenting and coiling and discharged with a good prognosis.

Cavernous sinus dural arteriovenous fistula accessed through a straightened superficial temporal vein.

Background: Transvenous embolization through the inferior petrosal sinus (IPS) is the most common treatment procedure for cavernous sinus dural arteriovenous fistula (CSDAVF). When the IPS is inaccessible or the CSDAVF cannot be treated with transvenous embolization through the IPS, the superficial temporal vein (STV) is used as an alternative access route. However, the approach through the STV is often challenging because of its tortuous and abruptly angulated course. We report a case of recurrent CSDAVF which was successfully treated using a chronic total occlusion (CTO)-dedicated guidewire and by straightening the STV. Case Description: A 63-year-old woman was diagnosed with CSDAVF on examination for oculomotor and abducens nerve palsy. She was initially treated with transvenous embolization through the IPS. However, CSDAVF recurred, and transvenous embolization was performed through the STV. A microcatheter could not be navigated because of the highly meandering access route through the STV. By inserting a CTO-dedicated guidewire into the microcatheter, the STV was straightened and the microcatheter could be navigated into a shunted pouch of the CS. Finally, complete occlusion of the CSDAVF was achieved. Conclusion: If an access route is highly meandering, the approach can be facilitated by straightening the access route with a CTO-dedicated guidewire.