Tanabe Jun

BACKGROUND: This study evaluated the safety and efficacy of a treatment strategy for Posterior communicating artery (PCOM) aneurysms using first-line Woven EndoBridge (WEB), supplemented by Flow diverter (FD) in selected cases. METHODS: This retrospective study included patients who underwent endovascular treatment for PCOM aneurysms between January 2021 and March 2025. Aneurysms were categorized as fetal or non-fetal. A first-line WEB strategy was adopted when morphology was suitable. Radiological and clinical outcomes were assessed. RESULTS: Forty-six PCOM aneurysms met the criteria: 14 fetal-type and 32 non-fetal-type. All previously untreated fetal-type aneurysms were treated with WEB (n = 9). In the non-fetal group, the initial treatments included WEB (n = 14), FD (n = 10), and coiling (n = 4). All recurrent fetal-type aneurysms were retreated with FD (n = 5), whereas non-fetal recurrences were managed with FD (n = 3) or coiling (n = 1), depending on prior treatment. At a median follow-up of 21 months, complete occlusion was achieved in 66.7% of fetal-type and 59.4% of non-fetal-type aneurysms (P = 0.739), and adequate occlusion was achieved in 75.0% and 90.6%, respectively (P = 0.321). Retreatment was required in two cases (4.3%): one in the fetal group (7.1%) and one in the non-fetal group (3.1%) (p = 0.512). No modified Rankin Scale worsening or major complications occurred. No significant differences in treatment efficacy were observed among modalities selected under the WEB first-line strategy. CONCLUSION: A first-line WEB strategy is safe and effective for PCOM aneurysms, including fetal-type variants, with outcomes for fetal-type aneurysms comparable to non-fetal-type aneurysms.

PURPOSE: The Woven EndoBridge (WEB) was introduced in Japan in January 2021 and approved for all subtypes of wide-neck bifurcation aneurysms (WNBA). This retrospective study evaluated the safety and efficacy of the WEB device for all subtypes of WNBA. MATERIALS AND METHODS: All patients treated with the WEB at our facility between January 2021 and May 2024 was reviewed. We selected the WEB device according to an oversizing policy, based on cumulative clinical evidence from global experience. RESULTS: We analyzed 120 aneurysms in 117 patients (56 males and 61 females with a mean age of 65.5±12.7 years). There were 45 anterior communicating artery aneurysms, 27 middle cerebral artery aneurysms, 17 internal carotid artery-posterior communicating artery aneurysms, 15 basilar artery top aneurysms, and 16 aneurysms in other locations. Aneurysm characteristics included a maximum diameter of 6.5 [5.3, 7.7] mm, height of 4.9 [3.9, 6.0] mm, width of 4.8 [4.0, 6.2] mm, and dome/neck ratio of 1.2 [1.1, 1.4]. All data are expressed in median [interquartile range]. Angiographic follow-up at 12 months in 96 cases showed complete obliteration in 68.8% and adequate obliteration in 90.6% of cases. Intraoperative ischemic events occurred in 5 cases (4.2%). Hemorrhagic events occurred in 2 cases (1.7%), with symptoms resolving by discharge, except for 1 case of mild paralysis. During follow-up, 1 patient developed a major stroke, resulting in morbidity (0.8%). Retreatment was required in 3 cases (2.5%). On multivariate analysis for complete occlusion at 12 months following WEB treatment, age was statistically associated with the outcome (odds ratio, 0.957 per year; 95% confidence interval, 0.919-0.996; P=0.033). CONCLUSION: WEB is safe and effective for all subtypes of WNBA, with a low retreatment rate using an oversizing policy. This is the first report in a Japanese population.

BACKGROUND: This study aimed to determine the efficacy of flow diverters (FDs) for small/medium (≤10 mm) aneurysms and analyzed the factors that prevent aneurysm occlusion. METHODS: This retrospective single-center study evaluated the angiographic and clinical data of consecutive patients between June 2020 and February 2023. RESULTS: Overall, 121 small/medium aneurysms were observed in 106 patients treated with FDs. The median dome diameter was 6.1 (5.1-7.2) mm. Symptomatic thromboembolic complications were observed in four (3.7 %) patients, and none showed a major ischemic stroke. Intracranial hemorrhage was detected using postprocedural computed tomography in one (0.9 %) patient with asymptomatic subarachnoid hemorrhage. The rate of permanent neurological deficits was 1.8 %, and the mortality rate was 0 %. No delayed ischemic or hemorrhagic complications were observed during follow-up. Angiographic follow-up revealed complete and adequate occlusion (O'Kelly-Marotta grades C and D) rates of 77.5 % and 90.8 %, respectively. On multivariate analysis, incomplete occlusion was only associated with the presence of a branch vessel from the aneurysm dome (P < 0.01). In aneurysms with incorporated branch vessels, univariate analysis revealed that coil usage was a predictor of complete occlusion (P = 0.03). Moreover, even without using coils, effective occlusion was achieved when the branch vessel diameter was small (P = 0.03). CONCLUSIONS: FDs are an effective and safe treatment option for small/medium aneurysms. The presence of incorporated branch vessels can predict incomplete occlusion. Even in aneurysms with incorporated branch vessels, FD can obtain therapeutic effects by adding coil embolization or treating with only FD if the branch vessel diameter is small.

We report a case in which a novel distal access catheter proved successful in the placement of a flow diverter for a challenging distal cerebral artery lesion. We discuss the advantages and pitfalls of this technique and considerations for its use. A 74-year-old female presented with intermittent headaches, and was diagnosed with a dissecting aneurysm at the proximal right posterior cerebral artery with a sharp bleb, measuring 9.8 mm in diameter. Given the complex vascular anatomy, stent-assisted coil embolization was initially considered but deemed high risk for dual catheter for jailing technique with 6-Fr size guiding catheter due to the tortuosity and stenosis of the parent vessel. Therefore, we opted for flow diverter treatment, which presented its challenges during delivery. By employing a low-profile distal access catheter, Phenom Plus (outer diameter: 4.2-Fr. inner diameter: 1.13 mm; Medtronic, Minneapolis, Minnesota, United States), with a minimal ledge between it and the delivery catheter, Phenom 27 (outer diameter: 2.8-Fr, 0.91 mm; Medtronic), we successfully crossed the neck of the aneurysm with Phenom Plus and placed the flow diverter. While acknowledging potential risks, this case demonstrates the value of the neck-crossing technique using a low-profile distal access catheter as an alternative option for treating challenging peripheral artery aneurysms with flow diverters. This technique offers promise in specific situations where conventional methods pose challenges.

BACKGROUND: This report presents a rare case of trigeminal neuralgia (TN) caused by a radicular arteriovenous fistula (AVF). CASE DESCRIPTION: A 58-year-old woman presented with severe pain in the right lower jaw, typical of TN. Magnetic resonance imaging showed a vascular signal near the trigeminal nerve. Direct surgery revealed tortuous vessels on the dorsal surface of the nerve, with no offending vessels identified at the root entry zone. Digital subtraction angiography (DSA) confirmed a radicular AVF fed by the trigeminocerebellar artery, with venous drainage into the superior petrosal sinus through the petrosal vein. Endovascular embolization with n-butyl cyanoacrylate resulted in complete obliteration of the fistula and symptom resolution. Although a small pontine infarction occurred, no long-term deficits were observed. Follow-up DSA confirmed no recurrence. CONCLUSION: To the best of our knowledge, this represents the first documented case of a trigeminal radicular AVF, highlighting the importance of recognizing vascular anomalies and efficacy of endovascular treatment in managing TN.

OBJECTIVE: The Woven EndoBridge (WEB; MicroVention TERUMO, Tustin, CA, USA) is an intrasaccular flow disruptor developed for the treatment of wide-neck bifurcation aneurysms (WNBA). While its safety and satisfactory mid- to long-term treatment outcomes have been documented, there have also been reports of complications such as WEB protrusion and migration. We encountered 3 cases in which the WEB protruded or migrated to the parent vessel after deployment, necessitating retrieval. In this report, we address the technical tips for retrieval techniques and factors associated with these complications, including a literature review. CASE PRESENTATION: Of the 120 cases of our experience with WEB treatment for cerebral aneurysms for the period since January 2021, 3 required WEB retrievals. In 2 cases, significant WEB migration toward the parent vessel occurred while maneuvering the delivery microcatheter because of sticky detachment. In the remaining case, after detachment of the WEB, tilting occurred, leading to a strong protrusion into one of the branches, which prevented guiding the microcatheter for bailout stenting. In all cases, the proximal marker of the WEB was captured using an Amplatz Goose Neck Microsnare (Medtronic, Minneapolis, MN, USA) pulled back into the VIA catheter (the delivery catheter for the WEB; MicroVention TERUMO), and further into an intermediate catheter positioned as close to the aneurysm as possible, enabling uneventful retrieval. CONCLUSION: None of the cases damaged the aneurysm or proximal parent vessel wall, and additional aneurysm occlusion treatment was performed. However, WEB protrusions and migration are rare. When retrieval is required, it is crucial to act swiftly owing to the risk of distal thrombosis from the lumen inside of the WEB. Therefore, recognizing Goose Neck Microsnare as a retrieval technique is valuable.

BACKGROUND: Aneurysmal subarachnoid hemorrhage caused by cerebral aneurysm rupture has a poor prognosis, with mortality exceeding 30% despite treatment advancements. Surgical neck clipping remains the standard for preventing rupture, but intraoperative rupture rates vary significantly (3-50%) and are influenced by vascular complexity and technical challenges. Thinning of the vascular wall near the aneurysm neck, particularly with microaneurysm formation, has emerged as a significant risk factor, yet these changes often go undetected in preoperative imaging. OBJECTIVE: This study aimed to evaluate the utility of computational fluid dynamics (CFD) analysis for predicting microaneurysm formation in the parent artery adjacent to unruptured cerebral aneurysms, using the parent artery radiation sign (PARS) as a predictive marker. METHODS: We conducted a single-center, retrospective observational study of 89 patients with unruptured middle cerebral artery (MCA) aneurysms treated with neck clipping from May 2020 to April 2022. Based on preoperative three-dimensional computed tomography angiography (3D-CTA), CFD analysis identified PARS through specific hemodynamic indicators. Intraoperative findings were analyzed and compared between PARS-positive and PARS-negative groups. The sensitivity and specificity of PARS for predicting microaneurysm formation were investigated. RESULTS: Of the 87 aneurysms analyzed, 25 (28.7%) were PARS-positive, and 62 (71.3%) were PARS-negative. Microaneurysms were identified intraoperatively in nine cases, eight of which were in the PARS-positive group. The sensitivity and specificity of PARS for detecting microaneurysms were 89 and 78%, respectively. The positive likelihood ratio was 4.1, while the negative likelihood ratio was 0.142. CONCLUSION: CFD analysis using PARS offers a reliable method for predicting microaneurysm formation in the parent artery, potentially guiding surgical planning and reducing intraoperative rupture risk. While promising, these findings are limited by the retrospective, single-center design, highlighting the need for further research in larger, multicenter cohorts. Incorporating CFD analysis into preoperative assessment could significantly enhance the safety and outcomes of neck clipping procedures for unruptured cerebral aneurysms.

OBJECTIVE: As a solution to the shortage of and overwork among physicians, task shifting and task sharing have been proposed for health-care professionals. This study aimed to investigate the role of nurse practitioners (NPs) in neurovascular interventions and evaluate the validity of task shifting in our institute. METHODS: Medical records from 684 neurovascular intervention cases from 2020 to 2023 were retrospectively reviewed, and the tasks performed by NPs were investigated. Additionally, the procedure times between cases in which NPs acted as the first assistant alongside a physician (NP + physician group) and those in which 2 physicians performed the procedure (physician + physician group) were compared. RESULTS: The main tasks performed by NPs included preoperative checks, assistance during the procedure, postoperative care, the initial handling of complications, and inputting orders. No significant differences in procedure times were found between the NP + physician and physician + physician groups. CONCLUSION: NPs showed potential for task shifting in perioperative neurovascular interventions, particularly in assisting, providing care, inputting orders, and initially handling complications. However, further discussions and improvements are needed regarding task shifting in emergency cases and work arrangements for NPs.

It is impossible to predict underlying anomalies in acute large vessel occlusion and it could be a problem when performing mechanical thrombectomy (MT). We report a case of MT for occlusion of the fenestrated middle cerebral artery (MCA) M1 segment. A 49-year-old woman presented to our hospital with dysarthria and left hemiparesis. Acute ischemic stroke due to right occluded MCA was diagnosed. During performing emergent MT, a part of the M1 segment was revealed to be slit-shaped by digital subtraction angiography, suggesting a fenestrated MCA. The aspiration catheter could not be advanced through the narrow limb of the fenestration, and the distal thrombus was retrieved using a stent retriever, additionally. Postoperatively, the patient's symptoms improved without complications. When occlusion of the fenestrated MCA is suspected, it is necessary to consider converting the strategy from an aspiration catheter alone to the combined use of a stent retriever.

PURPOSE: Prasugrel is not approved for patients treated with flow diverters, which have a high metal coverage ratio. However, robust antiplatelet therapy with prasugrel may prevent thromboembolic complications. We administered prasugrel and aspirin to all patients treated with flow diverters and reported the safety of the antiplatelet therapy regimen. METHODS: This retrospective, single-center study evaluated the angiographic and clinical data of consecutive patients treated with flow diverters for cerebral unruptured aneurysms between June 2020 and May 2022. All patients received dual antiplatelet therapy, including prasugrel and aspirin. The administration of prasugrel ended 3 or 6 months after the procedure, whereas aspirin use continued for at least 12 months. Periprocedural complications (< 30 days post-procedure) and delayed complications (> 30 days post-procedure) were recorded. RESULTS: During the study period, 120 unruptured aneurysms were treated with flow diverters in 110 patients. All patients, except one, survived longer than 12 months after the procedure. The rate of thromboembolic complications was 6.4%, and more than half of the patients had transient symptoms; one (0.9%) had a major ischemic stroke. One patient (0.9%) each had an asymptomatic, small subarachnoid hemorrhage and significant hemorrhagic complications with melena. The rate of permanent neurological deficits was 1.8%, and the mortality rate was 0.9%. CONCLUSIONS: Dual antiplatelet therapy comprising routine use of prasugrel and aspirin for flow diverter-implanted patients possibly contributed to a low rate of thromboembolic complications and low risk of hemorrhagic complications.

OBJECTIVE: LEONIS Mova (SB-KAWASUMI LABORATORIES, Kanagawa, Japan, hereinafter called LEONIS Mova) is a steerable microcatheter (MC) that enables angle adjustment of the catheter tip using a hand-operated dial. LEONIS Mova may be useful for flow diverter placement when access to the distal parent artery with a conventional MC and microguidewire (MGW) is considered difficult or impossible. Here, we report three such cases encountered during flow diverter placement in large and giant internal carotid artery aneurysms. CASE PRESENTATION: In Case 1, a strong S-shaped curve was observed in the proximal parent artery of a giant cerebral aneurysm, and the luminal structure of the parent artery was lost within the aneurysm. It was anticipated that the distal side of the parent artery would be difficult to access with conventional MC and MGW. By adjusting the tip of the LEONIS Mova toward the aneurysm outlet beyond the S-shaped curve, it was possible to induce the MGW to secure the distal parent artery easily. In Case 2, the inflow and outflow axes of the parent artery were completely misaligned at the site of the aneurysm, and stenosis was present in the distal parent artery. Firmly bending the catheter tip increased accommodation for the catheter, enabling the induction of an MGW to access the distal parent artery without kicking back. In Case 3, the lesion extended from the cavernous portion to the petrosal portion; however, by adjusting the tip of the LEONIS Mova toward the aneurysm outlet, it was possible to induce the MGW to secure the distal parent artery easily. In each case, the LEONIS Mova enabled more secure and prompt access to the parent artery than anticipated and facilitated flow diverter placement. CONCLUSION: Encountering difficult-to-access lesions is one reason endovascular treatment may be unsuccessful. The LEONIS Mova is an excellent device that can overcome this obstacle, and its utility in certain applications should be recognized.

PURPOSE: Optimal size selection is important for successful Woven EndoBridge (WEB) treatment. Conventional recommendations for WEB sizing based on aneurysm width and height sometimes require device exchange. We aimed to design a novel volume-based parameter, the ideal WEB-aneurysm volume (iWAVe) ratio, for optimal WEB sizing. METHODS: Consecutive patients who underwent WEB treatment for wide-neck bifurcation aneurysms between January 2021 and May 2022 were retrospectively reviewed. Aneurysm volume was automatically calculated using software. We measured the aneurysm volume based on the expected position of the device within the aneurysm. The WAVe ratio was defined as the ratio of the aneurysm volume to WEB volume. We dichotomized aneurysms treated with a successful sizing or unsuccessful sizing for WEB (successful group and unsuccessful group, respectively). RESULTS: Thirty-five patients were eligible for study enrollment. Ten patients (28.6%) needed to exchange the WEB on the first attempt and required another WEB on the second attempt resulting in deployment success. Hence, 35 aneurysms were in the successful group and 10 were in the unsuccessful group. The median WAVe ratio was 1.0 (range 0.76-1.31) in the successful group and 1.27 (0.58-1.89) in the unsuccessful group. Using logistic regression, iWAVe ratio was from 0.90-1.16 to secure a >80% probability of success by the 95% lower confidence limit. The sensitivity and specificity of the iWAVe ratio for optimal size selection on the first attempt were 0.60 and 1.00, respectively. CONCLUSION: Decision-making based on aneurysm width and the iWAVe ratio could promote optimal WEB sizing.

OBJECTIVE: This retrospective study aimed to investigate factors associated with inhibition of early aneurysm obliteration after flow diverter (FD) treatment. We also created the early obliteration inhibition (EOI) score for pre-operative evaluation. METHODS: We examined 110 cerebral aneurysms in 104 patients who underwent FD treatment. The following parameters were investigated: age, sex, symptoms, aneurysm location and type, maximum aneurysm diameter, parent vessel diameter, neck diameter, and dome-neck ratio. We also noted aneurysm location relative to the curvature of the parent artery and any branches arising from the aneurysm dome. Procedural factors such as FD diameter and length, number of FDs placed, type of FD, and use of adjunctive coiling were also investigated. Aneurysm obliteration was evaluated using digital subtraction angiography 3 months after the procedure. Adequate obliteration was defined as grade C or D on the O'Kelly-Marotta scale. RESULTS: The following factors inhibited early obliteration: 1) extradural location, 2) saccular aneurysm, 3) aneurysm neck located at the outer convexity of the parent artery, and 4) arterial branch arising from the aneurysm dome. Odds ratios were used to create an EOI score. Receiver operating characteristic curve analysis showed that the optimal cut-off EOI score for adequate obliteration was 1.5 (area under the curve, 0.81; 95% confidence interval, 0.73-0.9; sensitivity, 0.9; specificity, 0.57). CONCLUSION: The EOI score, which is based on factors that inhibit early obliteration, may predict early treatment outcomes of FD placement.

<jats:sec xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en">Reperfusion therapy for acute ischemic stroke efficacy is highly time dependent; therefore, stroke centers are required to further reduce the delays from hospital arrival to treatment efficiently. We developed a visual task management application, Task Calculation Stroke (Task Calc. Stroke: TCS), to facilitate hospital acute ischemic stroke treatment by supporting parallel staff task completion. We evaluated TCS for the reduction of reperfusion therapy delays and improvement of clinical outcomes.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods</jats:title> <jats:p xml:lang="en">In this multicenter cohort study, patients were directly admitted to 4 comprehensive stroke centers in Japan and given intravenous tissue plasminogen activator and/or mechanical thrombectomy from June 2018 to December 2020. The research team visited each facility and instructed the staff on TCS use for acute ischemic stroke (training stage), after which the staff used TCS independently (TCS stage). We then compared door‐to‐needle time for intravenous tissue plasminogen activator, door‐to‐puncture time for mechanical thrombectomy, and clinical outcomes at discharge according to the modified Rankin Scale among patients treated before training (original stage), during the training stage, or the TCS stage.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Results</jats:title> <jats:p xml:lang="en"> During the study period, 316 patients with acute ischemic stroke received reperfusion therapy; of these, 246 received intravenous tissue plasminogen activator and 162 mechanical thrombectomy (including 92 receiving both the treatments). The mean door‐to‐needle time was significantly reduced from 58.0 minutes in the original stage to 54.6 minutes in the training stage ( <jats:italic>P</jats:italic> =0.049) and 47.8 minutes in the TCS stage ( <jats:italic>P</jats:italic> &lt;0.001). The door‐to‐puncture time did not change during the training stage; however, in the TCS stage, it significantly reduced from 93.8 minutes in the original stage to 88.5 minutes ( <jats:italic>P</jats:italic> =0.004). The distribution of modified Rankin Scale scores at discharge significantly shifted favorably at the TCS stage ( <jats:italic>P</jats:italic> =0.003). </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusion</jats:title> <jats:p xml:lang="en">In this study, TCS application could reduce workflow time for reperfusion therapy and might have led to improved clinical outcomes.</jats:p> </jats:sec>

The posterior condylar vein is an emissary vein that connects the extracranial and intracranial venous systems through the posterior condylar canal (PCC). Dural arteriovenous fistulas (DAVF) of the PCC are rare, and only seven cases have been reported. Transvenous embolization (TVE) is the first-line treatment for PCC DAVF and is predominantly performed through the internal jugular vein. Herein, we report a case of PCC DAVF treated with TVE through the deep cervical vein. This is the first case report of a PCC DAVF treated with TVE through the deep cervical vein.

OBJECTIVES: This study aimed to determine the impact of the approval of prothrombin complex concentrates on the treatment of vitamin K antagonist-related intracerebral hemorrhage. MATERIALS AND METHODS: We retrospectively studied all patients with vitamin K antagonist-related intracerebral hemorrhage treated with prothrombin complex concentrate at our institutes between January 2010 and June 2021. Before approval, prothrombin complex concentrate was administered as either 500 or 1000 IU at the physician's discretion (previous dose group). After approval, we adopted the manufacturer's recommended regimen (recommended dose group). The primary outcome was post-administration international normalized ratio. Secondary outcomes were the amount of prothrombin complex concentrate administered and proportion of post-administration international normalized ratio <1.5, hematoma expansion, thrombotic events within 30 days, modified Rankin scale 0-3 at discharge, and in-hospital mortality. RESULTS: Thirty-two and 19 patients in the previous and recommended dose groups, respectively, were included. The post-administration international normalized ratio significantly differed between groups. The prothrombin complex concentrate dose and proportion of patients achieving post-administration international normalized ratio <1.5 were significantly higher in the recommended dose group than in the previous dose group (1500 IU vs. 500 IU, p<0.001 and 100% vs. 68%, p = 0.008). The proportions of hematoma expansion, thromboembolic events, modified Rankin scale 0-3, and mortality did not differ between groups. CONCLUSION: After prothrombin complex concentrate approval, prothrombin time-international normalized ratio correction was more effective with a significant increase in the prothrombin complex concentrates dose for vitamin K antagonist-associated intracerebral hemorrhage; however, there was no apparent difference in clinical outcomes.

OBJECTIVES: The benefit of mechanical thrombectomy for acute ischemic stroke is highly time dependent. However, time to treatment is longer for in-hospital stroke patients than community-onset stroke patients. This study aimed to clarify the cause of this difference. METHODS: A retrospective single-center study was performed to analyze patients with large vessel occlusion who underwent mechanical thrombectomy between January 2017 and December 2019. Patients were divided into in-hospital stroke and community-onset stroke groups. Clinical characteristics and treatment time intervals were compared between groups. RESULTS: One hundred four patients were analyzed: 17 with in-hospital stroke and 87 with community-onset stroke. Patient characteristics did not significantly differ between groups. Median door (stroke recognition)-to-computed tomography time (36 min vs. 14 min, P<0.01) and door-to-puncture time (135 min vs. 117 min, P=0.02) were significantly longer in the in-hospital stroke group than the community-onset stroke group. However, median computed tomography-to-puncture time (104 min vs. 104 min, P=0.47) and puncture-to-reperfusion time (53 min vs. 38 min, P=0.17) did not significantly differ. CONCLUSIONS: Longer door-to-puncture time in in-hospital stroke patients was mostly caused by longer door-to-computed tomography time, which is the initial part of the workflow. An in-hospital stroke protocol that places importance on early stroke specialist consultation and prompt transportation to the computed tomography scanner might hasten treatment and improve outcomes in patients with in-hospital stroke.

We report a case of vertebral artery dissecting aneurysm (VADA) that developed with subarachnoid hemorrhage and was found to be occluded based on subsequent digital subtraction angiography. Few reports have been published on ruptured VADA in which ipsilateral vertebral arteries are occluded. The proper management of this type of aneurysm is controversial. A 44-year-old woman developed a sudden onset headache. Computed tomography and three-dimensional computed tomography were immediately performed and showed subarachnoid hemorrhage and VADA distal to the right posterior inferior cerebellar artery bifurcation. We decided to treat the VADA immediately and performed digital subtraction angiography but found the VADA had spontaneously occluded. We performed coil embolization, including the aneurysm and the parent artery, with reference to the findings of three-dimensional computed tomography. On Day 16, recurrence was considered due to the finding of dilation of the distal end where the coil was embolized. An additional embolization was performed via the posterior communicating artery. No cases of endovascular treatment have been reported in VADA cases in which the rupture site is spontaneously occluded. In such cases, the treatment may be incomplete, so strict follow-up is required.

The PulseRider (Cerenovus, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA) is a neck reconstruction device that is used for the treatment of unruptured wide-necked bifurcation aneurysms. Herein, we describe the case of a 51-year-old male patient with a basilar apex aneurysm who was treated with PulseRider but had post-procedural brainstem infarctions caused by one of the proximal markers covering the origin of a perforator. In such cases, repositioning of the PulseRider should be performed to avoid infarctions.

<jats:sec><jats:title>Background</jats:title><jats:p>Recurrent complex middle cerebral artery (MCA) aneurysms after combined clipping and endovascular surgery are challenging, and if conventional techniques are adapted, advanced surgical, endovascular, and a combination of both techniques are often required. For such complex aneurysms, safe and effective straightforward techniques for all neurovascular surgeons are warranted. We describe the details of staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment in a patient with complex MCA aneurysm.</jats:p></jats:sec><jats:sec><jats:title>Illustrative Case</jats:title><jats:p>A 69-year-old woman presented with left recurrent large MCA aneurysm enlargement 25 years after direct surgery and coil embolization for ruptured aneurysm. The recurrent MCA aneurysm had large and complex morphology and was adhering to the brain tissues. Therefore, it was unsuitable to treat such aneurysm with conventional surgical and endovascular techniques with a high risk of morbidity. We performed (1) M2 ligation following superficial temporal artery-M2 bypass and (2) flow diverter deployment assisted with coil packing in two sessions. Three months after the second session, the aneurysm was completely occluded with endothelialization of the neck. Angiographic findings revealed no recurrence 12 months after the treatment.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment may be a safe and effective treatment for complex recurrent MCA aneurysms.</jats:p></jats:sec>

PURPOSE: The Flow Re-direction Endoluminal Device (FRED) has recently become available for flow diversion in Japan. We have encountered cases that failed to deploy the FRED. In this study, we report our initial experience with the FRED for cerebral aneurysms and clarify the causes of failed FRED deployment. METHODS: A retrospective data analysis was performed to identify patients treated with the FRED between June 2020 and March 2021. Follow-up digital subtraction angiography was performed at 3 and 6 months and assessed using the O'Kelly-Marotta (OKM) grading scale. RESULTS: Thirty-nine aneurysms in 36 patients (average age: 54.4 years) were treated with the FRED. The average sizes of the dome and neck were 9.9 mm and 5.2 mm, respectively. In nine patients, additional coiling was performed. In one patient (2.6%), proximal vessel injury caused direct carotid-cavernous fistula during deployment. Ischaemic complications were encountered in one patient (2.6%) with transient symptoms. Angiographic follow-up at 6 months revealed OKM grade C or D in 86.6% of patients. FRED deployment was successful in 35 (92.1%) procedures. In the failure group, the differences between the FRED and the minimum vessel diameter (P = 0.04) and the rate of the parent vessel having an S-shaped curve (P = 0.04) were greater than those in the success group. CONCLUSIONS: Flow diversion using the FRED is effective and safe for treating cerebral aneurysms. The use of the FRED for patients with an S-shaped curve in the parent vessel and oversizing of more than 2 mm should be considered carefully.

PURPOSE: Endovascular treatment of posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome is often challenging because, with conventional techniques, dense packing of aneurysms for posterior communicating artery preservation is difficult; moreover, flow-diversion devices are reportedly less effective. Herein, we describe a novel method called the λ stenting technique that involves deploying stents into the internal carotid artery and posterior communicating artery. METHODS: Between January 2018 and September 2020, the λ stenting technique was performed to treat eight consecutive cases of aneurysms. All target aneurysms had a wide neck (dome/neck ratio < 2), a fetal-type posterior communicating artery with hypoplastic P1, and a posterior communicating artery originating from the aneurysm dome. The origin of the posterior communicating artery from the aneurysm, relative to the internal carotid artery, was steep (< 90°: V shape). RESULTS: The maximum aneurysm size was 8.0 ± 1.9 mm (6-12 mm). The average packing density (excluding one regrowth case) was 32.7 ± 4.2% (26.8-39.1%). Initial occlusion was complete occlusion in 6 (75.0%) patients and neck remnants in 2 (25.0%) patients. Follow-up angiography was performed at 18.4 ± 11.6 months (3-38 months). There were no perioperative complications or reinterventions required during the study period. CONCLUSION: The λ stenting technique enabled dense coil packing and preservation of the posterior communicating artery. This technique enabled safe and stable coil embolization. Thus, it could become an alternative treatment option for this sub-type of intracranial aneurysms.

BACKGROUND: Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel. METHODS: Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint. RESULTS: The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group. CONCLUSION: The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications.

症例1は55歳女性で、頭痛精査で10mm大の右M1-M2動脈瘤を認め、経過観察中に動脈瘤は14mmと増大し、右M1に紡錘状動脈瘤の新生を認めて手術を行った。M1-M2動脈瘤にはwrappingを行い、M1動脈瘤にclippingを行った後に、M1-M2動脈瘤にwrap and clipを行い、Gore-TexをWeck clipで密に被覆した。術後経過は良好で、術後61ヵ月経過で増大や破裂は認めていない。症例2は39歳男性で、左上肢の脱力で発見された未破裂前交通動脈瘤に対しinterhemispheric approachにてneck clippingを行ったが、左A2を動脈瘤から剥離する際に損傷をきたし、圧迫止血後にゼラチンスポンジとfibrin glueで補強したが、術後6日目の血管撮影で左A2にpseudoaneurysmを認め、再手術で左A2とpseudoaneurysmを周囲組織から完全に剥離してGore-Texで被覆し、wrap and clipとした。術後経過は良好で、術後2ヵ月目の脳血管撮影でpseudoaneurysmの消失を確認した。

Carotid plaque constituents such as hemorrhage, lipid core, fibrosis, and calcification are important factors in predicting the clinical outcome of carotid artery stenting (CAS). Magnetic resonance imaging (MRI) can noninvasively assess changes in carotid plaque composition by evaluating the Sp/Sm ratio calculated with the signal intensity of carotid plaque (Sp) compared to that of sternocleidomastoid muscle (Sm) using the black-blood technique. <br> In the current study, we assessed the effects of 5 mg rosuvastatin and 1,800 mg eicosapentaenoic acid (EPA) on carotid plaque composition and volume using MRI and intravascular ultrasound prior to CAS. Thirty consecutive patients with atherosclerotic carotid stenosis were randomly divided into two groups—an EPA/rosuvastatin group (n=15) and a control group (n=15)—and then were treated with CAS. Perioperative complications and postoperative high spotty lesions on diffusion weighted image (DWI) were compared between the two groups. As a result, EPA and rosuvastatin significantly reduced the Sp/Sm ratio in both T1- and T2-weighted images in patients with unstable plaques (T1; p=0.021, T2; p=0.014). Plaque volume was also reduced between baseline and follow-up in 4 of 15 cases treated with EPA/rosuvastatin. The number of postoperative high spotty lesions on DWI significantly decreased in the EPA/rosuvastatin group (13%; 2/15) compared with the control group (40%; 6/15, p<0.05), whereas no significant difference was observed in perioperative complication rate. <br> The combined therapy of EPA and rosuvastatin leads to a benefical effect on plaque composition and volume, which may contribute to reducing the ischemic complications with CAS, particular in patients with vulnerable plaque.<br>