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Endovascular revascularization of a stenotic lesion requires appropriate stent positioning. In particular, stenting of the common carotid artery (CCA) ostium makes it difficult to avoid proptosis into the aorta. Furthermore, the guiding catheter may become unstable during the stenting because of its position under the aortic arch. To resolve these problems, we performed antegrade stenting for a patient with a symptomatic stenotic left CCA ostium that was treated by lifting a balloon-guiding catheter with a gooseneck snare. Our patient was a 74-year-old man who presented to the hospital with main complaints of right hemiparesis and motor aphasia. A left cerebral infarction due to severe stenotic left CCA ostium was diagnosed. A CT perfusion study showed decreased cerebral blood flow in the left hemisphere. Stenting of the stenotic left CCA ostium was performed using an antegrade approach. A balloon-guiding catheter positioned under the aortic arch was inflated and lifted from the right brachiocephalic artery using a gooseneck snare. The guiding catheter was stabilized during stenting. This method is highly effective for stenting CCA ostium.

Background: An aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare anomaly, which sometimes causes ischemic infarction. Collateral flow from the ipsilateral anterior cerebral artery (ACA) is important for patients with Ap/T-MCA. If ipsilateral ACA stenosis or occlusion occurs, a large infarction with a wider field than the ACA territory could happen. First, mechanical thrombectomy was performed for the right ACA near occlusion caused by arterial dissection with ipsilateral Ap/T-MCA in this case. Second, Wingspan stenting was performed for the right ACA restenosis. Case Description: A 77-year-old female presented to the hospital with the left hemiparesis. We diagnosed a right ACA infarction caused by right ACA occlusion. Digital subtraction angiography showed right Ap/T-MCA and ipsilateral ACA near occlusion. Thrombectomy was performed, and recanalization was achieved with mild ACA stenosis. The lesion was the dissection due to angiographical finding. Two months after treatment, transient left hemiparesis occurred and right ACA stenosis progressed. Computed tomography perfusion showed hypoperfusion of the right hemisphere. Wingspan stenting was performed from the left internal carotid artery through the anterior communicating artery with an intermediate catheter. The patient was discharged without any neurological deficit. Conclusion: We reported the first case of a patient who underwent Wingspan stenting for the right ACA dissection with Ap/T-MCA. Short-term follow-up and aggressive intervention should be considered for collateral pathway dissection with Ap/T-MCA because the symptoms can become serious. The patients with Ap/T-MCA should be cautious about the collateral pathway arterial changes in particular ipsilateral ACA due to the increasing hemodynamic stress.

Background: Vertebral artery stump syndrome (VASS) develops into recurrent posterior circulation ischemic stroke after ipsilateral vertebral artery (VA) occlusion at its origin. Case Description: The patient was a 46-year-old man with the right posterior cerebral artery occlusion. We used a recombinant tissue plasminogen activator (rt-PA) and then performed mechanical thrombectomy using a stent retriever. Angiography revealed left VA occlusion and stagnant flow to the left VA from the right deep cervical artery; therefore, we diagnosed VASS. Within 24 h of the rt-PA injection, the symptoms had dramatically improved, and so we avoided additional antithrombotic agents. Only 13 h later, the patient developed a basilar artery occlusion and died in spite of a repeated mechanical thrombectomy. Conclusion: Vigilance against early (and sometimes fatal) recurrent stroke induced by VASS is required.

Background Near-infrared spectroscopy (NIRS) is an alternative monitoring method during carotid artery stenting (CAS). NIRS has been reported to be effective in emergency care; however, it is unknown whether it can predict intraoperative ischemic intolerance and cerebral hyperperfusion during CAS. Perioperative ischemic intolerance and cerebral hyperperfusion are potential events during CAS for carotid artery stenosis. We evaluated whether perioperative monitoring of the tissue oxygenation index (TOI) using NIRS with the NIRO system can predict the occurrence of ischemic intolerance and cerebral hyperperfusion. Methods The TOI of 27 patients was measured during CAS. The relationship between the TOI and ischemic intolerance or cerebral hyperperfusion was analyzed, and the cutoff TOI was calculated to predict their occurrence. Results Ischemic intolerance occurred in 5 patients during balloon protection. The TOI in the presence of ischemic intolerance was significantly lower than that without ischemic intolerance. The cutoff TOI to detect ischemic intolerance was 50% and that of the TOI change rate before and after balloon protection was 80%. The ischemic symptoms in all patients had resolved immediately after balloon deflation. The cerebral hyperperfusion phenomenon was detected using single-photon emission computed tomography in 4 patients. These patients showed a transient increase in the TOI immediately after CAS; however, none of these patients showed symptomatic cerebral hyperperfusion phenomenon. The cutoff TOI to detect cerebral hyperperfusion was 109% compared with the TOI before CAS. Conclusion Monitoring of the TOI using the NIRO system could be useful for the detection of ischemic intolerance and cerebral hyperperfusion during CAS and to prevent perioperative adverse events.

Background After subarachnoid hemorrhage (SAH), headache management is often difficult owing to the need to use multiple analgesic drugs. Fentanyl is an opioid we can use after surgery, and it can decrease pain post SAH. The aim of this study was to investigate the effectiveness and safety of fentanyl for management of headache after SAH. Methods Twenty-two patients who underwent surgical clipping for ruptured intracranial aneurysms and complained of severe headache after the surgery were enrolled. Among them, 9 patients were given fentanyl combined with other analgesic drugs. The numeric rating scale score and dietary intake were measured in the acute phase after the SAH. Results The numeric rating scale scores were significantly lower in the fentanyl (+) group. The maximum numeric rating scale decreased to 7.7 ± 3.8 days in the fentanyl (+) group. At day 14, the fentanyl (+) group showed significantly better dietary intake than that of the fentanyl (−) group. Conclusions Using fentanyl after surgical clipping for ruptured intracranial aneurysms might decrease headache and produce few adverse effects. Adequate headache control showed improved dietary intake after SAH.