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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

Hyper-responsiveness to clopidogrel abnormally inhibits platelet aggregation and increases hemorrhagic complications. The present study investigated clinical factors related to clopidogrel hyper-responsiveness in neuro-interventional procedures.Two hundred twenty-four patients receiving clopidogrel for coil embolization to treat unruptured cerebral aneurysm or carotid artery stenting to treat carotid artery stenosis at the internal carotid artery origin were retrospectively reviewed for their P2Y12 reactivity unit (PRU) values and clinical characteristics. Hyper-responsiveness to clopidogrel was defined as a PRU of95.The mean PRU was 218.2 ± 77.8. Hyper-responsiveness to clopidogrel was observed in 12 patients (5.4%). Hyper-responsiveness was observed in younger patients, patients with a lower concentration of hemoglobin A1c, and patients with a higher low-density lipoprotein cholesterol (LDL-C) concentration compared with non-hyper-responsive patients (P = 0.01, P 0.01, P 0.01, respectively). On analysis of concomitant drugs, the patients in the hyper-responsive group were less frequently administered calcium channel blockers (CCBs) compared with the non-hyper-responsive group (P = 0.01). No significant differences in the usage of proton pump inhibitors or statins were observed. A LDL-C concentration of120 mg/dL and no usage of CCBs were significant independent predictors of hyper-responsiveness to clopidogrel with a multivariate analysis (OR; 6.16, 95% CI, 1.57-26.64, P = 0.01, OR; 0.09, 95% CI, 0.01-0.82, P = 0.03, respectively).The present study shows that a higher LDL-C concentration and no usage of CCBs are independent predictors of clopidogrel hyper-responsiveness. These results are useful to predict perioperative hemorrhagic complications. Considering dose reduction of clopidogrel or alternative drugs in high risk cases is necessary to prevent perioperative hemorrhagic complications.

Rationale Bridging therapy with endovascular therapy (EVT) and intravenous thrombolysis (IVT) has been reported to improve outcomes for acute stroke patients with large-vessel occlusion in the anterior circulation. While the IVT may increase the reperfusion rate, the risk of hemorrhagic complications increases. Whether EVT without IVT (direct EVT) is equally effective as bridging therapy in acute stroke remains unclear. Aim This randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator for acute stroke with ICA and M1 occlusion aims to clarify the efficacy and safety of direct EVT compared with bridging therapy. Methods and design This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-endpoint clinical trial. The target patient number is 200, comprising 100 patients receiving direct EVT and 100 receiving bridging therapy. Study outcome The primary efficacy endpoint is a modified Rankin Scale score of 0–2 at 90 days. Safety outcome measures are any intracranial hemorrhage at 24 h. Discussion This trial may help determine whether direct EVT should be recommended as a routine clinical strategy for ischemic stroke patients within 4.5 h from onset. Direct EVT would then become the choice of therapy in stroke centers with endovascular facilities. Trial registration UMIN000021488.

Background Transvenous embolization (TVE) via occluded sinus is one option for the treatment of dural arteriovenous fistulas. Understanding of the anatomical characteristics of the occluded sinus is difficult. It is often hard to reach the shunt point because of some risk of vessel perforation. Methods We assessed usefulness of T1 Volumetric Isotropic TSE Acquisition (VISTA) Black Blood (BB) and 3D-T1 Fast Field Echo (FFE) for the evaluation and visualization of an occluded sinus. Evaluation of T1 VISTA BB and 3D-T1 FFE was performed preoperatively. TVE was performed via the occluded sinus while referring to the visualized reconstruction image. Results Fourteen cases of TVE were performed between 2009 and 2015. The entire occluded sinus, including both thrombus and blood flow, was seen as the high-intensity region on 3D FFE T1 gadlinium (Gd). On the other hand, thrombus was seen as the iso- or high-intensity region and blood flow as the low-intensity region on T1 VISTA BB. The maximum intensity projection reconstruction image of 3D FFE T1Gd could visualize the whole occluded sinus and was useful for microcatheter maneuver. Total shunt obliteration was achieved in 13 cases (92.8%) except for one. Conclusions Magnetic resonance imaging evaluation of the occluded sinus using both T1 VISTA BB and 3D FFE T1Gd gives us valuable information of the occluded sinus regarding the development and the course of the occluded sinus, the length of the thrombotic occlusion, and leads to safer catheter maneuvers in TVE.

We report a rare case of a ruptured dissecting internal carotid aneurysm caused epistaxis without a history of trauma or infection. An 89-year-old woman experienced epistaxis and suffered from hemorrhagic shock at her previous hospital. Head computed tomography(CT)images revealed a ruptured internal carotid aneurysm protruding into the Onodi cell, the most posterior ethmoidal sinus, which extends superolaterally to the sphenoid sinus. Cerebral angiography demonstrated a multilobular-shaped dissecting aneurysm with a maximal diameter of 6.7mm at the cavernous portion of the internal carotid artery(ICA). Overlapping stenting was performed to prevent recanalization. However, a fatal subarachnoid hemorrhage occurred 2 days after the procedure due to the progression of the dissection to the intracranial ICA. The anatomical characteristics of the ethmoidal sinus could be associated with the occurrence of epistaxis. A ruptured small ICA aneurysm with an Onodi cell might cause epistaxis without a history of trauma or infection.

Background Inflow into an aneurysm sac immediately following flow diverter (FD) treatment is an assumed cause of delayed aneurysmal rupture. The significance of delayed posttreatment residual flow occurring months after FD treatment is unknown. Case Description A 76-year-old woman with a large intracranial aneurysm measuring 23.0 × 18.1 mm in the cavernous segment of the right internal carotid artery was treated with placement of a single FD (Pipeline Embolization Device, Covidien, Irvine, California, USA). Postprocedure digital subtraction angiography (DSA) demonstrated flow stagnation inside the aneurysm dome. The patient was discharged 9 days post procedure without new neurologic deficits. A 6-month follow-up DSA demonstrated delayed posttreatment residual flow into the aneurysm sac. Although she was scheduled for additional FD placement because of concern for aneurysmal rupture, the operation was not conducted due to an interim motor vehicle accident. Oral treatment with aspirin (100 mg/day) and clopidogrel (75 mg/day) was continued during her recovery. DSA performed 12 months post procedure showed that the aneurysm had completely thrombosed. Conclusions Our findings suggest that delayed post-treatment residual flow into an aneurysm may form part of the normal clinical course post FD placement and may not preclude eventual thrombosis of the aneurysm. Larger studies are needed to determine whether more frequent follow-up DSAs after FD placement are necessary and whether all patients exhibiting delayed post-treatment residual flow into an aneurysm require additional FD placement or if watchful waiting is a more suitable course.

The introduction of the balloon remodeling and stent-assisted technique has revolutionized the approach to coil embolization for wide-neck aneurysms. The purpose of this study was to determine the frequency of thromboembolic events associated with single balloon-assisted, double balloon-assisted, and stent-assisted coil embolization for asymptomatic unruptured aneurysms.A retrospective review was undertaken by 119 patients undergoing coiling with an adjunctive technique for unruptured saccular aneurysms (64 single balloon, 12 double balloon, 43 stent assisted). All underwent diffusion-weighted imaging (DWI) within 24 h after the procedure.DWI showed hyperintense lesions in 48 (40%) patients, and ten (21%) of these patients incurred neurological deterioration (permanent, two; transient, eight). Hyperintense lesions were detected significantly more often in procedures with the double balloon-assisted technique (7/12, 58%) than with the single balloon-assisted technique (16/64, 25%, p = 0.05). Occurrence of new lesions was significantly higher with the use of stent-assisted technique (25/43, 58%) than with the single balloon-assisted technique (p = 0.001). Symptomatic ischemic rates were similar between the three groups. The increased number of microcatheters was significantly related to the DWI abnormalities (two microcatheters, 15/63 (23.8%); three microcatheters, 20/41 (48.8%) (p = 0.008); four microcatheters, 12/15 (80%) (p = 0.001)).Thromboembolic events detected on DWI related to coil embolization for unruptured aneurysms are relatively common, especially in association with the double balloon-assisted and stent-assisted techniques. Furthermore, the number of microcatheters is highly correlated with DWI abnormalities. The high rate of thromboembolic events suggests the need for evaluation of platelet reactivity and the addition or change of antiplatelet agents.

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．

Background.— Based on our encounters with patients who have been treated for unruptured intracranial aneurysms by endovascular coil embolization using bioactive coils, we observed that such patients often present with headaches and fever. Objective.— The purpose of this study was to evaluate the incidence of headache and fever after coil embolization using bioactive coils. Methods.— A database of 92 intracranial unruptured aneurysm patients (88 patients who did not have chronic headaches or migraines before treatment) on whom coil embolization had been performed between July 2007 and October 2010 was retrospectively assessed. Forty-five aneurysms (43 patients) were treated using bioactive coils and the other aneurysms were treated using bare coils. We analyzed the incidence and duration of headache, temperature, C-reactive protein, and white blood cell count before and after coil embolization and compared the 2 groups. Results.— Forty-one patients (46.6%) reported onset of headaches just after treatment. Headache incidences were significantly greater in the patients treated with bioactive coils (bioactive coil group: 62.8% [27/43] vs bare coil group: 31.1% [14/45], P = .003), and the duration of headaches was significantly longer in the bioactive coil group (bioactive coil group: 3.44 ± 1.22 days vs bare coil group: 2.40 ± 1.17 days, P = .027). Seventy-one patients (80.7%) had incidences of fever (over 37°C) after treatment (bioactive coil group: 83.7% [36/43] vs bare coil group: 77.8% [35/45], P = .663). The duration of fever was significantly longer in the bioactive coil group (bioactive coil group: 2.9 ± 1.4 days vs bare coil group: 1.9 ± 1.1 days, P = .0017), and temperatures at 1, 2, or 3 days after treatment were significantly higher in the bioactive coil group (respective temperatures at 1, 2, 3 days after treatment: bioactive coil group: 37.42 ± 0.49, 37.19 ± 0.45, 37.00 ± 0.49 vs bare coil group: 37.14 ± 0.38, 36.96 ± 0.41, 36.63 ± 0.51, P = .009, P = .0246, P = .0032). There were no significant differences in C-reactive protein level and white blood cell count 1 and 3 days after treatment between 2 groups. Conclusions.— Bioactive coils induce headache and fever after coil embolization for intracranial aneurysms due to the inflammatory effects of polyglycolic acid used to accelerate aneurysm fibrosis and neointimal formation.

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.

Study design A case report of aneurysmal bone cyst of the mobile spine. Objective To present a pediatric case of aneurysmal bone cyst (ABC) of the mobile spine treated successfully by selective arterial embolization (SAE) with n-butyl cyanoacrylate (NBCA). Summary of background data The endovascular treatment is an important treatment option for the ABC of the mobile spine. However, there are few reported case treated by SAE with NBCA. Methods A 12-year-old healthy boy was introduced with a complaint of back pain. Computed tomography showed an osteolytic expanding mass in the pedicle, lamina, and spinous process on the level of T10. Magnetic resonance imaging revealed a multicystic mass with fluid-fluid levels that extended into the spinal canal and compressed the spinal cord from the dorsal side. Digital subtraction angiography showed an abnormal blood supply from the posterior spinal branch of the left T9 artery. An abnormal mass was diagnosed as an ABC based on these neuroradiologic examinations. Result The patient underwent SAE with NBCA (Histoacryl, B. Braun, Melsungen, Germany) diluted with Lipiodol (Laboratorie Guerbet, France) in a rate of 1:4. Computed tomography performed 1 month after treatment revealed partial ossification of the bone cortex. MR imaging showed shrinkage of the cyst and decompression of the spinal cord. Back pain of the patient disappeared and the shrunken cyst was stable without recurrence during the 3-year follow-up period. Conclusion SAE in a pediatric case with ABC of the mobile spine was effective in improving of clinical symptom and shrinking of the cyst.

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

Of 175 patients with 181 aneurysms initially treated with Guglielmi Detachable Coils (GDC), 25 were retreated. All retreatments except one were performed on previously ruptured aneurysms. Thirteen aneurysms were retreated because of recurrence, and 12 aneurysms were retreated to complete initial insufficient embolization. Sixteen patients underwent re-embolization and 9 patients were operated upon surgically. No complications related to the retreatment were experienced. We consider that repeat embolization should be attempted before considering surgical treatment in case that additional therapy is required. However, it is difficult to retreat aneurysms having wide necks. In regard to surgical clipping, aneurysms without a coil in the neck are easier to treat with primary clipping, whereas aneurysms with a coil mass in the neck are difficult to surgical clip. We have never used temporary clipping and coil extraction if the distance between the coil and the parent artery was wider than 2 mm. Emerging new embolic agents or devices and technical improvement might decrease the need for retreatment and increase long-term efficacy after endovascular treatment.

A 72-year-old man presented with a very rare case of spinal dural arteriovenous fistula (AVF) with lipomyelodysplasia manifesting as progressive paraparesis and bladder dysfunction. Magnetic resonance imaging revealed a spinal lipoma associated with tethered cord and spinal cord swelling with dilated perimedullary veins. Embolization of the spinal dural AVF was successfully performed, and is an optional treatment for coexisting spinal dural AVF and lipomyelocele in adults.

A 76-year-old female presented with a large upper basilar artery (BA) aneurysm causing obstructive hydrocephalus after coil embolization manifesting as diplopia. Magnetic resonance (MR) imaging and MR angiography showed a large BA top aneurysm. Coil embolization was performed. More than 6 months after the first coil embolization, the aneurysm had re-grown and we performed a second coil embolization. Soon after that, obstructive hydrocephalus at the aqueduct of the midbrain occurred. MR imaging was performed to evaluate whether there was enough space at the prepontine cistern for a third ventriculostomy and also to verify the posterior direction of the aneurysm growth because of the risk of rupturing the aneurysm during the operative procedure. Then, we performed an endoscopic third ventriculostomy (ETV) via a left-sided approach. We could easily identify the infundibular recess, mamillary bodies, and tuber cinereum in the third ventricular floor. We detected a pulsating upper BA aneurysm that appeared to have caused a reddish color change in the right mammillary body and the right side of the thalamus and midbrain. If there is sufficient space in the prepontine cistern for the surgical procedure, ETV is a good choice for the treatment of obstructive hydrocephalus associated with cerebral aneurysms.

Glioblastoma multiforme (GBM) is a very rare type of tumor involving the pineal region. No case of pineal region GBM with tumoral hemorrhage has ever been reported. Here, we present the first such case report.A 65-year-old man presented with sudden-onset disturbance of consciousness. CT revealed intraventricular hemorrhage and acute hydrocephalus. The patient was treated by an emergent operation for ventricular drainage. MRI with contrast media showed a heterogeneous enhanced area in the pineal region. The patient underwent endoscopic biopsy surgery and a third ventriculostomy for non-communicating hydrocephalus. The pathological diagnosis was high-grade glioma, indicating the need for tumor removal via the occipital transtentorial approach. The tumor was removed subtotally and radiation and chemotherapy courses were then started.Pineal GBM with tumoral hemorrhage has never been reported before. Endoscopic operations are useful for rapid decision making prior to radical surgery.

Here we describe the case of a patient with a wide-necked unruptured aneurysm arising at origin of a persistent primitive trigeminal artery (PTA) variant from the right internal carotid artery (ICA), supplying the territory of the right superior cerebellar artery and the anterior inferior cerebellar artery. To preserve the ICA and the PTA variant, coil embolization of the aneurysm was performed using a double-balloon remodeling technique (HyperForm™ and Hyper-Glide™ Occlusion Balloon Systems; ev3 Endovascular Inc., Irvine, CA, USA). The association of a PTA variant with an aneurysm is very rare. To our knowledge, this is the first description of the use of coil embolization using double-balloon remodeling to treat a PTA variant aneurysm. This technique permits complete embolization and reduces the risk of cerebral and cerebellar ischemia.

A 72-year-old man presented with a very rare case of spinal dural arteriovenous fistula (AVF) with lipomyelodysplasia manifesting as progressive paraparesis and bladder dysfunction. Magnetic resonance imaging revealed a spinal lipoma associated with tethered cord and spinal cord swelling with dilated perimedullary veins. Embolization of the spinal dural AVF was successfully performed, and is an optional treatment for coexisting spinal dural AVF and lipomyelocele in adults.

A total of 29 cerebral arteriovenous malformations (AVMs) treated at the University of Tsukuba with multimodality treatment including proton beam (PB) radiotherapy for cerebral AVMs between 2005 and 2011 were retrospectively evaluated. Eleven AVMs were classified as Spetzler-Martin grades I and II, 10 as grade III, and 8 as grades IV and V. For AVMs smaller than 2.5 cm and located on superficial and non-eloquent areas, surgical removal with/without embolization was offered as a first-line treatment. For some small AVMs located in deep or eloquent lesions, gamma knife (GK) radiosurgery was offered. Some AVMs were treated with only embolization. AVMs larger than 2.5 cm were embolized to achieve reduction in size, to enhance the safety of the surgery, and to render the AVM amenable to GK radiosurgery. For larger AVMs located in deep or eloquent areas, PB radiotherapy was offered with/without embolization. Immediately after the treatment, 24 patients exhibited no neurological worsening. Four patients had moderate disability, and 1 patient had severe disability. Three patients suffered brain damage after surgical resection, and 2 patients suffered embolization complications. However, no neurological worsening was observed after either GK radiosurgery or PB radiotherapy, but 3 patients treated by PB radiotherapy suffered delayed hemorrhage. Fractionated PB radiotherapy for cerebral AVMs seems to be useful for the treatment of large AVMs, but careful long-term follow up is required to establish the efficacy and safety.

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 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.

Although several cases of radiation-induced skin injury (RSI) have been reported in association with neurointerventional procedures such as endovascular embolization for cerebral aneurysm, cerebral arteriovenous malformation, and dural arteriovenous fistula, in most cases the absorbed doses are not measured directly; therefore, we built the first direct measurement system that enables the ideal dosimetry for entrance skin dose (ESD) during neurointerventional procedures to be easily determined. This system was then applied to a 55-year-old man who underwent two transvenous embolizations with a 2-month interval, for a right cavernous sinus dural arteriovenous fistula, to establish the efficacy of precise mapping of ESDs. Throughout the procedures, the patient wore a fitted dosimetry cap that contained 60 radiophotoluminescence glass dosimeter (RPLGD) chips. After the first procedure, temporary epilation occurred in the occipital region. Precise mapping of ESDs revealed that this region was exposed to 4.2Gy. In the first procedure, the X-ray tube was generally positioned straight for an optimal posterior-anterior view; however, in the second procedure we intermittently used the second-best position to prevent further RSI. In this position, the maximum ESD was 1.0Gy in the right posterior-temporal region and the epilation site was exposed to

Although several cases of radiation-induced skin injury (RSI) have been reported in association with neurointerventional procedures, in most cases the absorbed doses to these regions are not measured directly; therefore, we built the first direct measurement system that enables the ideal dosimetry for entrance skin dose (ESD) during neurointerventional procedures to be easily determined. This system was then applied to a patient who underwent long and repetitive procedures to establish the efficacy of precise mapping of ESDs using a number of radiophotoluminescent glass dosimeters (RPLDs) with the aim of avoiding RSI. A previously healthy 55-year-old man underwent two transvenous embolizations for dural arteriovenous fistula in the right cavernous sinus, with an interval of 2 months. To measure ESDs throughout the procedures, the patient wore a fitted dosimetry cap made of a thin stretchable material that closely covers the head and neck and contains 60 RPLD chips with sufficient radiolucency for fluoroscopy. After the first procedure, temporal epilation occurred in the occipital region. Precise mapping of ESDs revealed that this region was exposed to 5.4 Gy, the maximum dose for this procedure. In the first procedure, the X-ray tube was generally positioned straight for an optimal posterior- anterior view; however, in the second procedure we intermittently used the second-best position to prevent further RSI. In this position, the maximum ESD was 1.1 Gy in the right posterior- temporal region and the epilation site was exposed to ≤0.8 Gy. Thus, the patient did not develop any further epilation and was completely free from RSI by 3 months after the second procedure. We conclude that direct dosimetry using multiple RPLDs can accurately reveal the maximum ESD and that precise information regarding ESD can prevent further RSIs from subsequent procedures.

To study the efficacy and long-term outcome of percutaneous transluminal angioplasty (PTA) with/without stent placement for intracranial atherosclerotic stenoses, we reviewed our treated cases retrospectively. Between May 1992 and October 2003, PTA with/without stents was performed in 64 intracranial and skull base vessels in 62 patients, including 24 middle cerebral arteries, 16 internal carotid arteries, 13 vertebral arteries, and 11 basilar arteries. PTA was technically successful in 55 vessels (86%). However, four vessels (6%) failed to achieve satisfactory dilatation. We encountered five periprocedural strokes as symptomatic complications, for a mortality rate of 4.7% and a morbidity rate of 3.1%. All the patients with stent placements survived angioplasty without any complication. In the clinical follow-up available for one week to 11.5 years (mean, 4.7 years), there were three strokes related to the treated vessels. The annual stroke rate in the affected territory was estimated at 1.2% per year. According to these results, PTA for intracranial atherosclerotic stenoses seems to be a beneficial therapy for immediate anatomical results and long-term stroke prevention. Stent-assisted PTA could help patients achieve successful dilatation and avoid complications.

Adequate exposure of the distal internal carotid artery (ICA) for carotid endarterectomy may be difficult to achieve because of the position of the mandible and associated soft tissues. A simple yet effective use of a head frame is described to gain several centimeters of exposure of the distal ICA. The patient's head and neck are fixed in an extension position using a radiolucent head frame. Nasotracheal intubation and secure taping of the chin are also employed to keep the mouth closed and to prevent the mandible from spontaneously hanging down. The head frame tightly fixes the patient's neck, so the mandible does not disturb the surgical field throughout the operation. This simple method maximizes exposure of the distal ICA. The radiolucent head frame also enables intraoperative angiography to confirm the patency of the ICA and the absence of flap formation. This simple technique is useful for exposing the distal ICA.

Corrigendum to “Precise mapping system of entrance skin dose during endovascular embolization for cerebral aneurysm” [Radiat. Meas. 46 (2011), 2103e2106.] Takashi Moritake *, Mikito Hayakawa , Yuji Matsumaru , Tomoji Takigawa , Yasuhiro Koguchi , Yuka Miyamoto , Yusuke Mizuno , Koichi Chida , Keiichi Akahane , Koji Tsuboi , Takeji Sakae , Hidehiko Sakurai a a Proton Medical Research Center, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan Department of Endovascular Neurosurgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan Oarai Research Center, Chiyoda Technol Corporation, 3681 Naritacho, Oarai-machi, Higashiibaraki-gun, Ibaraki 311-1313, Japan Department of Anesthesiology, Yokohama City University, Yokohama, Kanagawa 236-0004, Japan Department of Radiological Technology, Tohoku University, Miyagi, Japan Radiological Protection Section, Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan

To report the usefulness of a side-hole on a guiding catheter for transvenous embolization of transverse-sigmoid sinus (TSS) dural arteriovenous fistulae (DAVF) by a contralateral approach with a reversed Y-shaped confluence.A 66-year-old woman presented after an epileptic seizure. Magnetic resonance imaging revealed venous infarctions of the left temporal area. Angiography showed a DAVF in the left TSS with retrograde drainage toward the superior sagittal sinus and remarkable cortical reflux.A transvenous approach through the right jugular vein was attempted after failure of the approach through the angiographically invisible left jugular vein. Catheterization beyond the confluence failed because the shape of the confluence was a reversed Y. A 5-French catheter with a side-hole was then placed in the superior sagittal sinus from the right TSS, and the microcatheter was successfully navigated into the left TSS through the side-hole. Subsequently, the DAVF was completely occluded by transvenous embolization without any adverse events.A side-hole on a guiding catheter was found to be useful for the navigation of a microcatheter to override a reversed Y-shaped confluence in transvenous embolization of TSS DAVF. This technique could be applicable to difficult configurations for transvenous catheterization, although attention should be paid to disruption of the catheter.