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Introduction: Embolus due to plaque rupture is a risk of cerebral infarction for carotid artery stenting (CAS). Female have been controversial as a risk factor for cardiovascular interventions in recent years. MMP-9 has been previously reported to be associated with acute ischemic stroke and to be a potential marker for arteriosclerosis.Therefore, this paper aimed to investigate the gender difference of embolic complications for CAS using MMP-9.Material and Methods: We analyzed 46 consecutive cases of CAS performed with distal balloon protection, including 34 males and 12 females. Serum levels of matrix metalloproteinase (MMP) -9 were measured before and after CAS. Embolic events were examined in Diffusion Weighted Imaging (DWI) on MRI the next day after CAS.Results: 13 cases (28.3%) had DWI-positive findings after CAS, and these results showed a significant gender difference (female 58.3% vs. male 17.6%, p < 0.05). Pre-CAS MMP-9 was significantly higher in females than in males (661.7 vs. 428.1 ng/ml, p < 0.05).Pre-CAS MMP-9 tended to be higher in DWI-positive cases than DWI-negative cases with no significant difference (676.9 vs. 415.0 ng/ml, p = 0.051).Conclusion: High serum MMP-9 in female have correlation with DWI positive findings after CAS. We suggest that high serum MMP-9 have a risk of cerebral infarction for CAS. Considering the results, CAS should be carefully performed, especially in female.

Cavernous sinus (CS) dural arteriovenous fistula (dAVF) presents ocular symptoms and visual disorders due to retrograde drainage from the CS into the superior ophthalmic vein (SOV). Some papers reported non-CS dAVFs with those symptoms. We present a unique case of transverse-sigmoid sinus (TSS) dAVF with localizing signs of CS dAVFs resulting from congested cerebral venous outflow into the CSs and SOVs in an 86-year-old female patient. Right pulsatile tinnitus and chemosis appeared a few years ago. After experiencing progressive bilateral blurred vision and decreased visual acuity with papillary edema for a few months, she was admitted to our hospital. Cerebral angiography demonstrated right sigmoid sinus dAVF with retrograde venous reflux into the superior sagittal sinus (SSS) and contralateral TSS without cortical venous reflux. Under the influence of congestion of the SSS, cerebral venous outflow drained into the CSs subsequently into the SOVs. Trans-arterial embolization using ethylene-vinyl alcohol copolymer was conducted via the right middle meningeal artery. After treatment, right chemosis immediately improved. The 2-month follow-up examination revealed resolution of bilateral visual acuity and improvement of papillary edema. Our case demonstrates that retrograde drainage into the SOVs with not only directly arterialized shunted flow but also congested cerebral venous outflow can cause CS dAVFs-like symptoms.

Herein, we describe a case of traumatic direct carotid cavernous fistula (DCCF) treated with target coil embolization using the combined transarterial and transvenous balloon-assisted technique. The patient was a 59-year-old woman who had been involved in a vehicular accident. She was admitted to the hospital due to chemosis and exophthalmos. Cerebral angiography revealed a shunt from the internal carotid artery (ICA) to the cavernous sinus (CS), which indicated DCCF. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique was performed. Angiography was performed 1 week after surgery to confirm the disappearance of DCCF. No recurrence was observed during the 1-year follow-up after treatment. Thus, target coil embolization using the combined transarterial and transvenous balloon-assisted technique is safe and effective for the treatment of traumatic DCCF.

Aim of the study: We retrospectively searched for cases of transvenous embolisation for cavernous sinus dural arteriovenous fistulas. Materials and methods: Twenty-five cases underwent transvenous embolisation via the inferior petrosal sinus (IPS). IPS was probed using a standard 0.035-inch guidewire for microcatheter navigation, which was successful in all cases. Results: IPS was occluded in 17 cases (68%). Only one case experienced a complication, where the approach was changed to the contralateral side because of internal jugular vein injury. The relationship between the external auditory canal and the IPS route was reviewed in 18 cases using digital angiography (lateral view). The guidewire passed across, above, or below the external auditory canal in 10 (56%), six (33%), and two (11%) cases, respectively. Clinical implications: No previous reports have analysed the relationship between the external auditory canal and the IPS route. We present a safe and successful technique for approaching the cavernous sinus via the IPS.

We report a case of a ruptured mycotic cerebral aneurysm caused by Nocardia infection. A 22-year-old immunocompromised woman with adult-onset Still's disease developed a subarachnoid hemorrhage (SAH). Digital subtraction angiography revealed a small aneurysm at the M2-3 bifurcation of the right middle cerebral artery. Cardiac ultrasonography showed vegetation at the posterior cardiac wall, suspecting infective endocarditis (IE). Gram-positive filamentous bacteria were observed in the necrotic tissue surrounding the aneurysm obtained during trapping surgery. Long-term blood culture showed that the cause of her cerebral mycotic aneurysm was nocardiosis. A mycotic ruptured cerebral aneurysm is an important cause of SAH in immunocompromised patients. Early diagnosis of IE, detection of gram-positive rods by Gram staining, and long-term culture to identify the bacteria is crucial in diagnosing nocardiosis.

Background Distal anterior cerebral artery (DACA) aneurysms are rare, and endovascular treatment of these aneurysms is challenging. Thromboembolic events, including silent ischemic events, are one of the most important complications of coil embolization for cerebral aneurysms. The treatment outcomes and predictors of silent ischemic events in coil embolization for unruptured DACA aneurysms were investigated, focusing on the morphological characteristics of aneurysms, especially the inflow angle (IA) and global outflow angle (GOA). Methods A total of 12 patients with 12 unruptured DACA aneurysms, treated with coil embolization at our institute, were retrospectively investigated. Predictors for silent ischemic events were evaluated by comparing diffusion-weighted imaging (DWI)-positive and DWI-negative patients. Results Silent ischemic events detected on DWI were observed in eight aneurysms (66.7%). Comparison of the morphological characteristics of aneurysms between the two groups showed a significantly smaller GOA in the DWI-positive group than in the DWI-negative group (172.6 ± 17.7° vs. 216.8 ± 16.8°, P Conclusion A small GOA was a significant predictor of silent ischemic events after coil embolization for unruptured DACA aneurysms. While some patients can be treated safely with minimally invasive coil embolization, it is necessary to consider surgical clipping in patients at high risk of thromboembolic events with coil embolization.

The efficacy of flow diversion (FD) in the treatment of paraclinoid aneurysms has been established. The pipeline embolization device (PED) is one of the most commonly used FD devices. Coil embolization is also useful for treating paraclinoid aneurysms. This study aimed to compare the efficacy and safety of PED treatment and coil embolization for large unruptured paraclinoid aneurysms. This was a single-center, retrospective study of large unruptured paraclinoid aneurysms treated endovascularly between 2009 and 2019 (coil embolization between 2009 and 2015, and PED between 2015 and 2019). Cases with a follow-up period of less than 1 year and recurrence after coil embolization were excluded. The treatment outcomes between coil embolization and PED were compared. We investigated 45 patients with 45 large unruptured paraclinoid aneurysms treated by endovascular surgery in our institution. Twenty-four patients were treated with coil embolization and 21 with PED. In the PED group, the device cost was significantly lower (2,770.4 ± 699.5 vs. 1941.2 ± 552.8 [1000 yen], P = 0.03), procedure duration was significantly shorter (155.4 ± 66.7 vs. 95.1 ± 35.4 min, P

Thromboembolic complications are a relevant risk in coil embolisation of cerebral aneurysms. This retrospective study aimed to assess the treatment outcomes of unruptured middle cerebral artery (MCA) bifurcation aneurysms and the predictors for thromboembolic complications based on the aneurysm morphological characteristics. We examined the following three features: inflow angle, outflow angle (OA), and bifurcation angle, formed by the aneurysm and neighbouring blood vessels.A total of 32 MCA bifurcation aneurysms were retrospectively investigated in 32 patients treated consecutively at our institute between April 2008 and March 2019. The predictors for thromboembolic complications were analysed in two groups: patients with and without thromboembolic complications.Perioperative thromboembolic complications were detected in six patients (18.8%), including two and six intra- and post-procedural thromboembolic complications, respectively; all cases were resolved. Regarding the aneurysms' morphological characteristics, the group with thromboembolic complications showed a significantly smaller OA (55.58° ± 14.05° vs. 86.04° ± 28.58°, P = 0.01) than the group without complications. Multivariate analysis revealed that smoking habits and OA 70° were significant predictors of thromboembolic complications (smoking habits: P = 0.01, odds ratio [OR]: 6.89, 95% confidence interval [CI]: 3.78-12.62; OA 70°: P = 0.04, OR: 3.19, 95% CI: 1.52-6.56).Our findings indicate significant pre-procedural predictors of thromboembolic complications to consider for safe treatment; clipping should be preferred to coil embolisation in high-risk patients. The method of choice should be considered in each case to allow the safe treatment of unruptured MCA aneurysms.

Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to treat with surgery or endovascular means without parent artery sacrifice. Here, we report on a patient who underwent successful treatment using a flow-diverting stent for an iatrogenic intracranial internal carotid artery pseudoaneurysm following a vessel injury after endoscopic pituitary tumor resection via the transsphenoidal approach. A 62-year-old man with a Rathke’s cleft cyst presenting with bitemporal hemianopia and progressive decline of left visual acuity underwent endoscopic transsphenoidal pituitary tumor resection. During dura incision, brisk arterial bleeding was encountered from the right internal carotid artery. Immediate packing was performed, and hemostasis was achieved. Three days after the vessel injury, an angiography revealed a pseudoaneurysm (2.9 × 2.1 mm) at the cavernous segment of the right internal carotid artery, which showed enlargement on follow-up magnetic resonance imaging at six days postoperatively. Pipeline embolization was performed nine days after the vessel injury. Angiography performed one month after Pipeline embolization revealed significant stagnation but not complete occlusion of blood flow inside the pseudoaneurysm cavity. Dual antiplatelet therapy was replaced with single antiplatelet therapy. Follow-up angiograms three months after Pipeline embolization confirmed complete obliteration of the pseudoaneurysm and successful endoluminal reconstruction of the damaged vessel. Despite the possibility of short-term bleeding and the need for dual antiplatelet therapy administration for a certain period, the use of flow-diverting stents is a feasible vessel-sparing option in the management of intracranial internal carotid artery pseudoaneurysms resulting from transsphenoidal surgery injuries if intraoperative hemodynamic stability can be achieved with effective packing.

We describe a challenging transvenous embolization technique involving a dual-lumen balloon microcatheter (DLBM) and liquid materials for cavernous sinus dural arteriovenous fistula (CSDAVF). DLBM contributed to identifying the shunt point and preventing liquid material leakage to normal venous drainage without treatment-related complications. In a transvenous embolization using liquid materials for CSDAVF complications such as cranial nerve palsy and embolic agent migration into the internal carotid artery due to numerous anastomoses must be considered. The use of angiography during DLBM inflation to characterize the shunt point and DLBM to prevent liquid material leakage to the normal venous drainage might decrease the mass effect due to liquid materials, thereby minimizing the causes of newly occurring cranial nerve palsy. This technique may be helpful for the treatment of CSDAVF in practice, but there is generally a risk in using liquid materials in the cavernous sinus; therefore, further consideration is needed in the future.

Vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysms are rare lesions that are difficult to treat with both endovascular and surgical techniques. Tight angulation of the PICA from VA may make access to the PICA difficult from ipsilateral VA if adjunctive techniques are needed. Recently, the safety and efficacy of retrograde access have been reported. We report a case of endovascular treatment for a VA-PICA aneurysm with a stent-assisted technique using retrograde access via contralateral persistent primitive proatlantal artery (PPA). The patient was a 76-year-old woman with an unruptured VA-PICA aneurysm on the dominant VA side. Coil embolization with a stent-assisted technique using retrograde access seemed appropriate. However, the origin of the left VA was not confirmed. Left common carotid artery angiography demonstrated that the PPA (type 1) branching from external carotid artery joined the VA V4 segment. Retrograde access via the PPA for stenting was performed. A microcatheter for stenting was retrogradely advanced to the right PICA at ease. After deploying the stent, coil insertion was completed from the right VA, and the final angiogram showed adequate occlusion of the aneurysm with preservation of the PICA. Thus, PPA may be an approach route in the treatment of VA-PICA aneurysms with unconfirmed contralateral VA orifice and apparent PPA on angiography, when retrograde access is needed.

Background: Cribriform plate dural arteriovenous fistulas (dAVFs) are rarely encountered. Here, we report a case of cribriform plate dAVF with a rare complication after endovascular therapy. Case Description: A 60-year-old man presented with severe sudden headache. Head computed tomography showed right subdural hematoma, and magnetic resonance angiography showed dilated bilateral frontal cortical vein. Digital subtraction angiography revealed cribriform plate dAVF fed by the anterior and posterior ethmoidal branches of the bilateral ophthalmic arteries. Transarterial embolization with liquid embolic material was performed and the fistula disappeared. Although magnetic resonance imaging showed the disappearance of the cribriform plate dAVF and subdural hematoma, the patient complained of anosmia after the procedure. Conclusion: Endovascular embolization is an effective treatment option for treating cribriform plate dAVFs. However, anosmia is a possible complication, and endovascular surgeons should take care of this complication, especially in cribriform plate dAVFs supplied with blood bilaterally.

Background Parent artery occlusion (PAO) is an effective treatment for hemorrhagic diseases associated with the internal carotid artery. There are several reports of long-term cerebral infarction or the formation of de novo cerebral aneurysms following PAO. Materials and methods We retrospectively reviewed these complications in 38 patients who underwent PAO for therapeutic treatment. We investigated perioperative cerebral infarctions, long-term cerebral infarctions, and de novo aneurysms. Results The mean age of the patients was 64.0 years, and 25 patients (65.8%) were female. The causative diseases were unruptured (n = 19; 50.0%) and ruptured (n = 8; 21.1%) aneurysms. PAO was performed after ischemic tolerance was assessed with balloon test occlusion (BTO), and BTO was performed in 34 patients, of whom 25 (73.5%) had ischemic tolerance. Twenty-six patients (68.4%) were treated with PAO alone, eight (23.5%) with low-flow bypass, and six (17.6%) with high-flow bypass. Perioperative complications occurred in five patients (13.2%): two of the 26 patients (7.7%) who underwent scheduled treatment and three of the 12 patients (25.0%) who underwent emergency treatment. One patient (2.6%) had long-term de novo aneurysm, and none developed cerebral infarction. Conclusions These results showed that the assessment of ischemic tolerance by performing BTO and appropriate revascularization in scheduled treatments are important to reduce perioperative and long-term cerebral infarctions. PAO must be performed with greater caution in emergency treatment.

Background Neuroendovascular therapy is typically performed via the femoral artery, but there are rare cases in which a tortuous upstream angioarchitecture makes it difficult to access the intracranial circulation via this route. Methods In this case series, we describe six cases treated by surgical cut-down in the neck, with puncture of the carotid artery. Antiplatelet and anticoagulation agents were used in all cases. The indications for the technique were postsurgical thoracic aortic aneurysm (two cases), postsurgical abdominal aortic aneurysm (one case), major vessel tortuosity of the common carotid artery (two cases) and aortic arch anomaly (one case). Results The surgical cut-down technique permitted successful neuroendovascular therapy. Although one patient had a small cervical haematoma, he was treated without surgical evacuation. Conclusion Overall, our findings indicate that the surgical cut-down technique is safe and useful for patients in whom the femoral approach is unsuitable.

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are not appropriate treatment procedure for internal carotid artery stenosis (ICAS) in some patients. The importance of plaque vulnerability and the treatment risk evaluation has been reported. We analyzed whether treatment selection contributes to the outcome. We retrospectively examined 121 patients who underwent CEA or CAS. Treatment was selected based on plaque vulnerability and the treatment risk evaluation. We selected CAS for patients with stable plaques and CEA for patients with unstable plaques, and considered the other treatment for high-risk patients. The patients were classified as the stable plaque (Stable: n = 42), the unstable plaque and CEA low risk (Unstable/Low: n = 30), and the CEA high-risk (Unstable/High: n = 49). Frequency of perioperative stroke, myocardial infarction, death, and systemic complications was examined. CEA and CAS were performed in 35 and 86 patients, respectively. One patient (2.9%) had a stroke in CEA and five patients (5.8%) in CAS (P = 0.50). Systemic complications were observed in two patients (5.7%) in CEA and six (7.1%) in CAS (P = 0.80). There were no differences in stroke (Stable; 2.4%, Unstable/Low; 3.2%, and Unstable/High; 8.2%) and systemic complications (Stable; 9.5%, Unstable/Low; 3.3%, and Unstable/High; 6.1%) among three groups (P = 0.44 and P = 0.59, respectively). The treatment selection based on plaque vulnerability and the treatment risk evaluation could provide good treatment outcome for high-risk patients. It is ideal to select an appropriate treatment for ICAS by one neurovascular team.

Background: A flow diverter (FD) has been a promising endovascular therapeutic modality for challenging intracranial aneurysms. However, stent migration has been an unusual complication. Until recently, among some types of FDs, the migration of the flow-redirection endoluminal device (FRED; MicroVention Inc., Aliso Viejo, CA, USA) has almost never been reported. Herein, we report a case of acute distal migration of a single FRED secondary to in-stent thrombi with symptomatic ischemic stroke and review the literature on the distal migration of FDs. Case Description: A 35-year-old woman was diagnosed with a left unruptured internal carotid-ophthalmic artery aneurysm. A 3.5 mm diameter and 17 mm long FRED was adequately deployed. The patient awoke from general anesthesia without neurological deficits. However, shortly after the procedure, the patient presented with conjugate deviation toward the left side, right severe hemiparesis, and total aphasia. Although the symptoms gradually improved, angiography was performed. Angiography revealed some in-stent thrombi and distal migration of the FRED, and initially, one of the left M2 inferior trunk branches was occluded by an embolic thrombus. However, the thrombus spontaneously migrated distally without any specific treatment. Finally, despite leaving the migrated stent in situ, the flow almost completely improved, and the patient’s neurologic deficits disappeared. Magnetic resonance imaging following treatment revealed only a small cerebral infarction in the left temporo-occipital area. Conclusion: Distal migration of an FD in an acute setting, including the FRED, may occur even following appropriate placement. In-stent thrombosis can cause distal stent migration and thromboembolic stroke.

Objective: We report endovascular treatment of a patient with acute basilar artery occlusion considered to be due to an embolus from radiation-induced vertebral artery stenosis. Case Presentation: The patient was a 46-year-old male with a history of neck irradiation. He developed basilar artery occlusion. Temporary recanalization achieved by intravenous alteplase therapy and revascularization was followed by relapse. The origin of the vertebral artery was stenosed, and basilar artery was considered to have been embolized by a thrombus formed on the proximal side of the vertebral artery, where blood flow was stagnated due to reduced antegrade flow from the distal side of the stenotic vertebral artery and the increased collateral flow from the deep cervical artery. Recurrence of cerebellar infarction could be prevented by revascularization and occlusion of the parent artery. Conclusion: Acute basilar artery occlusion considered to be due to an embolus from radiation-induced vertebral artery stenosis is a rare condition, but it must be recognized as a possible cause of posterior circulation infarction.

Background: Optic neuropathy due to an aneurysm is relatively rare, with only a few small case series on this topic, and no randomized trials having been published until now. As such, the functional prognosis and treatment for aneurysm-induced optic neuropathy remain controversial. Objective: We quantified optic nerve injuries using an objective index (the visual impairment score) and evaluated prognostic factors of postoperative visual function. Materials and Methods: Of 960 patients treated for an unruptured intracranial aneurysm, 18 (1.9%) patients had optic neuropathy. Visual acuity and visual field were assessed before surgery and 6 months' postoperatively. Cases were classified on the basis of treatment modality (coil embolization or flow alteration [FA]) and prognostic factors of the two treatment groups. Results: Of the 18 patients with an intracranial aneurysm and optic neuropathy, 12 (67%) were treated using coil embolization and 6 (33%) were FA. Visual function improved after surgery in 8 patients (44%), 5 (42%) in the coil embolization group, and 3 (50%) in the FA group. The visual function remained stable after surgery in 6 (33%) patients and worsened in 4 (22%). Patients with an aneurysms

Importance Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear. Objective To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome. Design, Setting, and Participants Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019. Interventions Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103). Main Outcomes and Measures The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours. Results Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, −11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞];P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, –0.8% [95% CI, –9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43];P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, –16.8% [95% CI, –32.1% to –1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88];P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, –1.8% [95% CI, –9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24];P = .78). Conclusions and Relevance Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority. Trial Registration umin.ac.jp/ctr Identifier:UMIN000021488

An inflammatory reaction in vascular tissue is a potential factor linking restenosis after angioplasty. Although cilostazol, a selective phosphodiesterase type 3 inhibitor that is a unique antiplatelet drug and vasodilator, has been reported to be anti-inflammatory, its effect on the inflammatory action of mononuclear cells homing to endothelial cells is not clearly understood. In this study, whether cilostazol inhibits neointimal formation and improves inflammatory actions by inhibiting sialyl Lewis X (SLX) expression on mononuclear cells and E-selectin expression on endothelial cells was evaluated.The effect of cilostazol (1, 3, 10, 30 μM) on expression of E-selectin in human umbilical vein endothelial cells and SLX in rat mononuclear cells stimulated with lipopolysaccharide by immunofluorescence and real-time polymerase chain reaction (n = 3) was studied. Additionally, a double-balloon injury model was used on rat carotid arteries to evaluate vascular intimal hyperplasia. 0.1% cilostazol was administered 3 days before the first balloon injury, and the second balloon injury was performed 7 days after the first injury. Cilostazol administration was continued until rats were sacrificed 14 days after the second angioplasty. The expression of SLX on mononuclear cells and E-selectin on endothelial cells by immunofluorescence (n = 10) and real-time polymerase chain reaction (n = 5) were studied.Cilostazol effectively inhibited the expression of SLX on mononuclear cells and E-selectin on endothelial cells. Cilostazol inhibited the migration of mononuclear cells in neointimal regions and neointimal hyperplasia after balloon injury. The numbers of macrophages and T-lymphocytes and the hyperplasia area in neointimal regions decreased from 71.06 ± 20.04, 1121 ± 244.4 cells per section, 206,400 ± 96,150 mm(2) to 29.65 ± 16.73, 374.2 ± 124.5 cells per section, and 101,900 ± 16,150 mm(2) due to the administration of cilostazol.These results demonstrate that the protective effect of cilostazol against neointimal hyperplasia may be mediated by its anti-inflammatory actions of mononuclear cells homing to endothelial cells by decreasing SLX and E-selectin expression.It is reported that cilostazol inhibits neointimal hyperplasia by decreasing the expression of some cell-adhesion molecules. We evaluated the effects of cilostazol for the expression of sialyl Lewis X (SLX) on mononuclear cells and E-selectin on endothelial cells, which interaction is the first step of inflammation action. Cilostazol was thought to show the anti-inflammatory actions by decreasing SLX and E-selectin expression in addition to decreasing the expression of some cell-adhesion molecules.

【目的】当院で施行したEnterprise VRDを併用した動脈瘤コイル塞栓術についてその初期成績を検証する．【方法】2010年7月から2011年5月の間に31例のEnterpriseを併用した未破裂脳動脈瘤コイル塞栓術を行っており，その成績を検討した．【結果】平均年齢62.2歳，男女比8：23，動脈瘤部位は前方循環20例（内頚動脈18，前交通動脈2），後方循環11例（後大脳動脈1，脳底動脈6，椎骨動脈4），形状はsaccular 26例，fusiform 5例，瘤径は平均12.5±5.2mmであった．手技はjailing techniqueが8例，balloon assist techniqueの併用が23例であり，治療結果はcomplete occlusionが5（16.2%），neck remnantが25（80.6%），body fillingが1（3.2%），平均体積塞栓率は29.3±9.0%であった．術後に一過性脳虚血が2例（6.5%）で見られたが永続的なものはなかった．【結論】Enterprise VRDの使用により従来の方法では治療困難と思われた症例のいくつかに対しても塞栓術を施行でき，良い結果を得ている．今後はさらに長期成績を検証する必要がある．

Rationale:Endodermal cysts are rare benign lesions in the central nervous system. Their common symptoms include headache and neck pain caused by mass effect or inflammatory reaction. We report the case of an elderly woman with intracranial endodermal cyst who presented with nonobstructive hy

A 58-year-old man presented with a very rare case of pituitary metastasis from hepatocellular carcinoma with active nasal bleeding which was treated by transarterial embolization using ethiodized oil (Lipiodol) and gelatin sponge. After treatment, nasal bleeding ceased and tumor size decreased. The prognosis for patients with pituitary metastases is very poor, so aggressive treatment is recommended to alleviate symptoms. This minimally invasive approach may be a reasonable therapeutic option for pituitary metastases.

A 41-year-old woman presented with progressive hemianopsia caused by compression of the lateral geniculate body by the dilated basal vein draining a contralateral frontal arteriovenous malformation (AVM). Magnetic resonance (MR) imaging revealed left frontal AVM and right lateral geniculate body compression due to the dilated basal vein. Emergent presurgical transarterial embolization and surgical removal were performed. Left hemianopsia completely recovered 3 months after surgery and MR imaging indicated improvement of the compression of the lateral geniculate body. Direct mechanical compression of the enlarged drainage vein is one of the causes of homonymous hemianopsia. Early surgical treatment is recommended to obtain a rapid recovery.

Background Although carotid artery stenting (CAS) has been proposed as an alternative to carotid endarterectomy in cerebral revascularization, restenosis remains an unsolved issue. Cilostazol is a unique antiplatelet drug that has vasodilatory effects and inhibits smooth muscle cell proliferation. We investigated whether cilostazol reduces restenosis after CAS. Methods A database of 113 consecutive CAS procedures between April 2002 and December 2007 was assessed retrospectively. All patients received aspirin (100 mg/d) and another antiplatelet drug such as cilostazol (200 mg/d), ticlopidine (200 mg/d), or clopidogrel (75 mg/d) at least 3 days before CAS. Two antiplatelet drugs were continued for 2 to 3 months after CAS and reduced to one thereafter. Patients were evaluated at 3 and 6 months and at 6-month intervals thereafter with duplex ultrasound (DUS) imaging. Angiography was used for confirmation when stenosis was suspected as >50% with DUS imaging. Results We were able to monitor 97 patients for a 12-month period. The overall combined rate of stroke, myocardial infarction, and death was 3.1% at 30 days and 4.1% at 1 year. In-stent recurrent stenosis was documented in 11 patients (11%); in 10 patients (9.7%), this occurred ≤12 months of CAS. In-stent restenosis was significantly reduced in the cilostazol (+) group (0% vs 15.7% [11 of 70], P = .03). Patient characteristics were similar between the cilostazol (+) and cilostazol (–) groups. Conclusions Although this study was retrospective and nonrandomized, the results suggest that cilostazol administration improves long-term patency after CAS due to its inhibitory effect on smooth muscle cell growth.

A 70-year-old male presented with transient ischemic attacks manifesting as right hemiparesis and motor aphasia due to severe left cervical internal carotid artery stenosis. Carotid artery stenting (CAS) using a flow-reversal system was performed without complications. However, the patient exhibited transient right hemiparesis and motor aphasia 10 days after CAS. Emergent angiography demonstrated in-stent restenosis. In-stent percutaneous transluminal angioplasty and CAS were performed successfully using a distal protection system. However, duplex ultrasound scanning revealed progressive in-stent restenosis, 3 and 6 days after the re-treatment. Emergent angiography again demonstrated in-stent restenosis. Urgent stent removal and carotid endarterectomy were performed. Plaque had prolapsed through the stent. Histological examination revealed that the specimen was mainly plaque consisting of cholesterol crystals and macrophages. The patient was able to return to independent life without neurological deficit. Repeated endovascular surgery with appropriate antiplatelet and anticoagulation therapy should be attempted initially to treat in-stent restenosis. Endarterectomy with stent removal should be considered as a rescue option, especially if plaque protrusion is identified.

BACKGROUND AND PURPOSE: Although radiation skin injuries associated with interventional radiology have been known as a critical issue, there are few reports mentioning direct measurement of the entrance skin dose (ESD). Thus, the purpose of this study was to clarify the regional distributions of ESDs in neurointervention. \nMATERIALS AND METHODS: Using photoluminescence glass dosimeters (PLDs), we measured the ESDs in 32 patients with a median age of 61.5 years. Angiographic parameters, including exposure time, dose-area product (DAP), and the number of digital subtraction angiography (DSA) studies and frames, were recorded. The ESDs of operators were analyzed by the same method. \nRESULTS: The maximum ESD of 28 therapeutic procedures was 1.8 +/- 1.3 Gy. Although the averaged ESD on the right temporo-occipital region was higher than that in other regions, disease-specific patterns were not observed. Statistically positive correlations were found between the maximum ESD and exposure time (r = 0.5283, P = .005), DAP (r = 0.7917, P < .001), the number of DSA studies (r = 0.5636, P = .002), and the number of DSA frames (r = 0.8583, P < .001). As for operators, ESDs to the left upper extremity were significantly higher than those to other regions. However, most of the ESDs were