Objective: We report a patient who underwent staged angioplasty (SAP) for stenosis of the cervical internal carotid artery (ICA), but developed hyperperfusion syndrome. Case Presentation:The patient was an 84-year-old male. Stenosis of the left cervical ICA (pseudo-occlusion) related to cerebral infarction was observed. Emergency angioplasty was performed. At 9 days after the procedure, carotid artery stenting (CAS) was conducted. Restlessness was noted immediately after CAS. In addition, right hemiparesis and aphasia were exacerbated, and a convulsive seizure occurred 4 days later. MRI did not reveal the new onset of cerebral infraction. Single-photon emission computed tomography (SPECT) showed an increase in cerebral blood flow (CBF) in the left parietal lobe, leading to a diagnosis of hyperperfusion syndrome. An anticonvulsive drug was administered, and strict blood pressure control was performed. There was no hemorrhagic complication. The patient was referred to a rehabilitation hospital. Conclusion:The present case developed hyperperfusion syndrome despite SAP was performed. Currently, there is no consensus for the interval; it is important to carefully determine the interval in each patient by evaluating cerebral perfusion status.Keywords▶ staged angioplasty, stenosis of the cervical internal carotid artery, hyperperfusion syndrome

In coil embolization of ruptured cerebral aneurysms, intraoperative cerebral aneurysm re-rupture and thromboembolism are of concern. A good embolic condition can be expected by adjunctive techniques, but there is an increased risk of complications. We investigated the treatment results by coil embolization procedures for ruptured cerebral aneurysms.Methods: Between January 2016 and December 2019, 75 ruptured saccular cerebral aneurysms were treated by coil embolization at our hospital. The background factors, results of aneurysm embolization, intraoperative re-rupture, symptomatic cerebral embolism, and other factors were investigated retrospectively. We compared and examined these factors based on the procedure. Results:The mean age was 62.8 and there were 57 female patients (76.0%). The single catheter technique (SCT) was used in 44 cases (58.7%) and the adjunctive technique was used in 31 cases (41.3%). Complete obliteration (CO) was achieved in 24 cases (32.0%), there was a neck remnant (NR) in 23 (30.7%), body filling (BF) was observed in 28 (37.3%), intraoperative re-rupture occurred in 7 (9.3%), and symptomatic cerebral embolism developed in 6 (8.0%), but no postoperative re-rupture was observed. Retreatment was required in only three cases of SCT. On comparison by procedure, the incidence of symptomatic cerebral embolism was significantly lower in SCT group than in the adjunctive technique group (2.3% vs 16.1%, p = 0.04). Conclusion:Among the cases of coil embolization for ruptured cerebral aneurysms at our hospital, SCT resulted in a lower incidence of symptomatic cerebral embolism than adjunctive techniques. It is essential to select an appropriate procedure in each case by understanding the characteristics of each procedure.Keywords▶ subarachnoid hemorrhage, ruptured cerebral aneurysm, coil embolization, treatment result by procedure This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

In neuroendovascular therapy, clopidogrel resistance and thrombosis are common problems. In such cases, we use prasugrel as rescue medication, and we clarified its usefulness. Methods: We retrospectively investigated 199 consecutive cases of neuroendovascular therapy performed at our hospital from April 2016 to March 2018, and examined the safety and effectiveness of prasugrel. Results: There were 14 cases of prasugrel administration: six cases of coil embolization for cerebral aneurysm, five cases of carotid artery stenting (CAS), and three other cases. The reasons for prasugrel administration were as follows: emergency stent use in four cases, intraoperative thrombosis in three cases, intra-stent thrombosis after CAS in three cases, and others in four cases. In all cases, it was used in combination with aspirin and the median duration of administration was 212 days. Regarding its safety, there was one hemorrhagic complication at the puncture site for which the involvement of prasugrel was unable to be excluded, but it was improved by conservative treatment and there was no major hemorrhage such as intracranial hemorrhage. Regarding its efficacy, in one case, the thrombus during coil embolization did not completely disappear after prasugrel administration and additional mechanical thrombolysis was required. However, no new thrombosis was observed during prasugrel administration in all 14 cases. Conclusion: Prasugrel may be useful as a rescue medication in neuroendovascular therapy. Keywords▶ neuroendovascular therapy, prasugrel, clopidogrel resistance, thrombosis, antiplatelet drug loading thrombosis. 1,2) To prevent thrombosis, dual antiplatelet drugs are administered before surgery in many cases. However, some stent-inserted patients require the long-term administration of antiplatelet drugs after surgery, and hemorrhagic complications must be considered. 1,2) Therefore, perioperative antiplatelet drug management in neuroendovascular therapy is important. As antiplatelet drugs, aspirin and clopidogrel are routinely used. However, the latter raises the issue of resistance. Several studies demonstrated that the incidence of thromboembolism during coil embolization of cerebral aneurysms increased in the presence of clopidogrel resistance. 3,4) Furthermore, prompt, accurate intraoperative antiplatelet drug loading is required in some emergency cases free from antiplatelet drug administration. Recent studies reported the safety and efficacy of prasugrel for clopidogrel resistance or thrombosis in patients undergoing neuroendovascular therapy. 5-7) Prasugrel resistance is rare, and the interval until its effects are observed is short. However, this drug has not been approved in the cerebrovascular field. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

We investigated the fluoroscopy time (FT) and radiation dose by the number of cerebral angiography (CA) operator experiences to clarify the learning curve of CA. Methods:The subjects were cases for whom CA was performed at our hospital for 5 years between April 2015 and March 2020. Based on the number of CA operator experiences, they were classified into four groups: 1-50 cases (group A), 51-100 cases (group B), 101-200 cases (group C), and 201 cases and later (group D). The FT and radiation dose were retrospectively investigated.Results: Of the 865 consecutive CA cases, 293 cases for follow-up, i.e. after treatment, 54 for arteriovenous shunt diseases, 21 lacking data, and 1 case requiring intervention for thrombosis during CA were excluded. In total, 496 CA cases were investigated. There were 61 cases in group A, 56 cases in group B, 44 cases in group C, and 335 cases in group D, and there was no significant difference in patient background factors among the groups. The median FT and radiation dose (interquartile range) in each group were 20.2 min (14.6) and 374 mGy (185.3) in group A, 14.8 min (12.1) and 366 mGy (167.9) in group B, 10.8 min (6) and 320 mGy (151.7) in group C, and 9.4 min (6.4) and 336 mGy (171) in group D. The FT was significantly shorter in group C than in group A, and significantly shorter in group D than in groups A, B, and C. The radiation dose was significantly lower in groups C and D than in groups A and B. Conclusion:This study suggested that CA can be performed alone after experiencing approximately 100 cases as an operator.

Objective: We report a patient in whom antegrade blood flow blockage with a balloon guiding catheter was effective for external iliac artery (EIA) rupture on 9 Fr sheath insertion.Case Presentation: Thrombectomy was selected for a 76-year-old male in the acute phase of cerebral infarction. The right common femoral artery (CFA) was punctured, and a 4 Fr sheath was exchanged for a 9 Fr sheath. At this point, EIA rupture occurred, causing shock. Hemostasis was not achieved by manual compression. The contralateral CFA was punctured, and a 9 Fr OPTIMO (Tokai Medical Products, Aichi, Japan) was guided to proximal side of the point of rupture.His blood pressure was stabilized by blocking antegrade blood flow via balloon inflation. Artificial blood vessel replacement was performed, leading to a favorable outcome. Conclusion:Antegrade blood flow blockage with a balloon was effective for EIA rupture.Keywords▶ external iliac artery rupture, retroperitoneal hematoma, puncture-associated complications, a balloon guiding catheter