Successful Internal Trapping of Vertebral Artery Dissecting Aneurysm Located between Double Origin of the Posterior Inferior Cerebellar Artery, Resulting in Antegrade Blood Flow: A Case Report.

Objective: The double origin of the posterior inferior cerebellar artery (DOPICA) is a rare variant of PICA. Vertebral artery dissecting aneurysm (VADA) with DOPICA is an extremely rare occurrence. Herein, we report a case of VADA located between DOPICA that was successfully treated with endovascular internal trapping. Case Presentation: A 48-year-old male, found collapsed at his workplace, was admitted to our hospital for emergency medical assistance. Head CT revealed a subarachnoid hemorrhage (Fisher group 3), and cerebral angiography revealed right VADA with DOPICA. The VADA was located distal to the proximal component of the posterior inferior cerebellar artery (PCPICA) and just proximal to the hypoplastic distal component of PICA (DCPICA). Emergency endovascular internal trapping was performed using a total of 13 coils from the distal end of the VADA to just the distal of the branching point of PCPICA. VADA was not visualized, and antegrade flow through DOPICA to the basilar artery was confirmed. Head magnetic resonance angiography (MRA) showed antegrade flow via DOPICA, and the patient was discharged home on Day 46 with a modified Rankin Scale 0. Conclusion: Endovascular internal trapping for VADA with DOPICA was considered useful, especially when VADA is distal to PCPICA and proximal to DCPICA.

Vasospasm as a major complication after acute mechanical thrombectomy with stent retrievers.

OBJECTIVE: Mechanical thrombectomy using a stent retriever for acute large vessel occlusion is indispensable in stroke treatment, however, vasospasm may occur. The objective of this retrospective study was to investigate which cases are more likely to experience vasospasm after thrombectomy with stent retrievers. METHODS: We included 29 patients diagnosed with acute cardiogenic cerebral embolism who were treated with stent retrievers at our facility from December 2014 to December 2017. Atherothrombotic brain infarction cases were excluded because it was difficult to evaluate for vasospasms. Vasospasm was defined as reversible arterial narrowing of <80% of the normal vessel diameter after usage of the stent retriever. The age, sex, type of stent retriever, occlusion site, number of procedures, thrombolysis in cerebral infarction (TICI) grade, degree of vasospasm, intracranial hemorrhage by the procedure, and neurological outcomes were analyzed. RESULTS: Among the 29 cases, 12 (41.4%) resulted in vasospasm; nine cases were mild (20-50% stenosis) and 3 cases were severe (≥50% stenosis). Vasospasm frequently occurred in the distal part of the anterior circulation when compared to the proximal part. In addition, the frequency of vasospasm increased as the number of procedures increased. Pooled analysis showed significant difference in the intravenous tissue-type plasminogen activator group (P = 0.029). There was no significant difference in the other groups. CONCLUSION: Stent retrievers appear to cause vasospasm more than expected when including mild cases. Vasospasm tends to occur especially in cases with IV-tPA; prognosis is generally good, and it rarely requires any treatment.

Aberrant left subclavian artery occlusion in right-sided aortic artery associated with left cerebral infarction: A case report.

Purpose Right-sided aortic arch is a rare vessel anomaly with an incidence of 0.1% worldwide. Supra-aortic branches form a mirror image of the left-sided aortic arch or an aberrant left subclavian artery associated with Kommerell diverticulum. Most patients are diagnosed by a difference in blood pressure in each upper extremity or by the presence of left subclavian steal syndrome in their younger age. The diagnosis of onset of ischemic stroke in middle age is rare. Methods We present the case of a female patient who presented with an ischemic stroke in the left posterior circulation area. She had no history of congenital heart malformation. We performed head magnetic resonance imaging, cerebral angiography, and enhanced computed tomography of the aortic arch and major branches. Results The patient had a right-sided aortic arch and an aberrant left subclavian artery. The left subclavian artery was occluded at the proximal portion with a fibrous string. Collateral flow in the anterior cervical subcutaneous area supported left limb perfusion. Conclusion An atheromatous change reduced shunt flow via collateral networks at the anterior cervical region. Congenital subclavian steal supported the ischemic stroke.

Foramen Magnum Dural Arteriovenous Fistula Treated by a Microsurgical Technique Combined with a Feeder Occlusion Using Transarterial Coil Embolization.

The treatment of dural arteriovenous fistulas (DAVFs) at the foramen magnum remains controversial by reason that DAVFs appearing from the foramen magnum represent only a minority of spinal DAVFs. We present our treatment for an asymptomatic patient suffering from a foramen magnum DAVF. A 53-year-old man presented to our hospital with the complaint of a floating sensation. Although there was no subarachnoid hemorrhage or cerebral infarction on magnetic resonance imaging, a magnetic resonance angiography revealed a number of dilated veins and a large varix surrounding the medulla oblongata. Cerebral digital subtraction angiography (DSA) showed a foramen magnum DAVF fed by the neuromeningeal branch of the left ascending pharyngeal artery and occipital artery, draining into the posterior spinal vein. Occlusion of the fistula was achieved by a microsurgical technique combined with a feeder occlusion using transarterial coil embolization, without complications. We verified the complete occlusion on post-operative cerebral DSA. While this combined therapy was already established for the treatment of DAVFs, there were no reports of the combined therapy for foramen magnum DAVFs. This treatment was considered to be useful for foramen magnum DAVFs, especially those DAVFs at the foramen magnum with a number of dilated veins and a large varix.

Effect of pitavastatin on preventing ischemic complications with carotid artery stenting: a multicenter prospective study--EPOCH-CAS study.

PURPOSE: Periprocedural ischemic stroke is one problem associated with carotid artery stenting (CAS). This study was designed to assess whether preoperative statin therapy reduces the risk of periprocedural ischemic complications with CAS. METHODS: In this prospective study at 11 centers, patients with carotid artery stenosis (symptomatic ≥50%, asymptomatic ≥80%) and a high risk of carotid endarterectomy but without previous statin treatments were divided into two groups by low-density lipoprotein cholesterol (LDL-C) levels. With LDL-C ≥120 mg/dl, the pitavastatin-treated (PS) group received pitavastatin at 4 mg/day. With LDL-C <120 mg/dl, the non-PS group received no statin therapy. After 4 weeks, both groups underwent CAS. Frequencies of new ipsilateral ischemic lesions on diffusion-weighted imaging within 72 h after CAS and cerebrovascular events (transient ischemic attack, stroke, or death) within 30 days were assessed. RESULTS: Among the 80 patients enrolled, 61 patients (PS group, n = 31; non-PS group, n = 30) fulfilled the inclusion criteria. New ipsilateral ischemic lesions were identified in 8 of 31 patients (25.8%) in the PS group and 16 of 30 patients (53.3%) in the non-PS group (P = 0.028). Cerebrovascular events occurred in 0 patients in the PS group and in 3 of 30 patients (10.0%) in the non-PS group (P = 0.071). Multivariate analyses demonstrated the pitavastatin treatment (ß = 0.74, 95% confidence interval 0.070-1.48, P = 0.042) to be an independent factor for decreasing post-CAS ischemic lesions. CONCLUSION: Pretreatment with pitavastatin significantly reduced the frequency of periprocedural ischemic complications with CAS.

Endovascular trapping for vertebral artery fusiform aneurysm in a patient with idiopathic thrombocytopenic purpura.

A 56-year-old woman with adult idiopathic thrombocytopenic purpura (ITP) diagnosed 17 years previously presented with a fusiform aneurysm manifesting as chronic headache. She had suffered no major hemorrhagic complications, although her platelet counts were between 3.0 x 10(9)/l and 50.0 x 10(9)/l. Magnetic resonance angiography identified a fusiform aneurysm of the right vertebral artery. Endovascular trapping after high-dose gammaglobulin with steroid therapy was performed. The patient received antiplatelet therapy to prevent thromboembolic events. The parent artery and aneurysm were completely occluded with no hemorrhagic complications. Endovascular treatment is considered safe in patients with ITP, although careful periprocedural management of platelet count is required.

[A de novo distal PICA aneurysm occurring 3 years after clipping of another distal PICA aneurysm: a case report].

Distal posterior inferior cerebellar artery (dPICA) aneurysms are rare with an incidence of approximately 1% of all intracranial aneurysms. The frequent reports of the non-branching aneurysms or tandem aneurysms in an identical artery may be related to the embryology of dPICA and the anterior inferior cerebellar artery which is distinct from other cerebral arteries, as characterized by a thin vessel wall and tortuous course. In this paper, the authors present a case of a 67-year-old man with a ruptured de novo dPICA aneurysm in the tonsillomedullary segment, which occurred 3 years after clipping of a ruptured aneurysm in the identical segment of the dPICA. The patient had a history of smoking and uncontrolled hypertension. He presented with a sudden onset of severe headache and vomiting. On admission computed tomography demonstrated subarachnoid hemorrhage in the left cerebello-medullary cistern with intra-forth ventricular clots. Vertebral angiography demonstrated a saccular dPICA aneurysm just distal from the previous clip. Based on the angiographic characteristics of the aneurysm and the potential difficulty of a second clipping operation, coil embolization of the parent artery was performed. The postoperative course was uneventful except for the presence of hoarseness. The unusual development and location of ruptured de novo dPICA aneurysm may be explainable by uncontrollable risk factors, as well as by the embryological features of dPICA. Careful follow-up neuroimaging studies and management of risk factors should be continued even after complete neck clipping or coil embolization in cases of dPICA aneurysm.

Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients.

OBJECT: Intracranial hemorrhage associated with cerebral hyperperfusion syndrome (CHS) following carotid endarterectomy (CEA) or carotid artery stenting (CAS) is a rare but potentially devastating complication. In the present study the authors evaluated 4494 patients with carotid artery stenosis who had undergone CEA or CAS to clarify the clinicopathological features and outcomes of those with CHS and associated intracranial hemorrhage. METHODS: Patients with postoperative CHS were retrospectively selected, and clinicopathological features and outcomes were studied. RESULTS: Sixty-one patients with CHS (1.4%) were identified, and intracranial hemorrhage developed in 27 of them (0.6%). The onset of CHS peaked on the 6th postoperative day in those who had undergone CEA and within 12 hours in those who had undergone CAS. Results of logistic regression analysis demonstrated that poor postoperative control of blood pressure was significantly associated with the development of intracranial hemorrhage in patients with CHS after CEA (p = 0.0164). Note, however, that none of the tested variables were significantly associated with the development of intracranial hemorrhage in patients with CHS after CAS. Mortality (p = 0.0010) and morbidity (p = 0.0172) rates were significantly higher in patients with intracranial hemorrhage than in those without. CONCLUSIONS: Cerebral hyperperfusion syndrome after CEA and CAS occurs with delayed classic and acute presentations, respectively. Although strict control of postoperative blood pressure prevents intracranial hemorrhage in patients with CHS after CEA, there appears to be no relationship between blood pressure control and intracranial hemorrhage in those with CHS after CAS. Finally, the prognosis of CHS in patients with associated intracerebral hemorrhage is poor.

[Consensus and controversy in the treatment of ischemic cerebrovascular diseases].

Surgical and endovascular revascularization for ischemic cerebrovascular diseases (CVD) should be strictly indicated based on medical treatment. In this report, we describe current consensus and controversy in the treatment of ischemic CVD, and perspectives. 1) Local intra-arterial fibrinolytic therapy for acute cerebral embolism; intra-venous t-PA can be beneficial when given within 3 hours of stroke onset (NINDS), but many patients present later after stroke onset and alternative treatments are needed. Despite an increased frequency intracranial hemorrhage, treatment with intra-arterial proUK within 6 hours for MCA occlusion significantly improved clinical outcome at 90 days (mRS 40% >25%, PROACT-II). MELT-Japan are going now and waiting for results. 2) Carotid stenting; Carotid angioplasty and stenting (CAS) has been proposed as an alternative to carotid endarterectomy (CEA) in those considered at high risk for CEA. SAPPHIRE study confirmed CAS is an excellent option for patients with coexisting coronary artery disease, congestive heart failure, and other comorbid conditions that make them poor candidates for CEA. Now, CREST in USA and CSSA in Europe are going for randomized trial compared with CEA and CAS in any risk for CEA patients. 3) Stenting for intracranial arteries; Stroke rates in patients with symptomatic intracranial stenosis may be high on medical therapy. Although there is no clinical evidence and appropriate devices for intracranial vessels, it seems to be a potentially effective in the future.