We report a rare case of symptomatic vertebral and posterior inferior cerebellar arteries (VA-PICA) aneurysmcaused ipsilateral hemifacial spasm (HFS) for which coil embolization of the aneurysm with the assistance of abnormal muscle response (AMR) monitoring was effective. Case Presentation: A 62-year-old woman presented with left HFS. Magnetic resonance imaging showed a saccular aneurysm of the left VA-PICA which compressed the seventh cranial nerve at its root exit zone (REZ). Stent-assisted coil embolization resulted in intraoperative disappearance of AMR in the intraoperative electrophysiological study and HFS was relieved temporally. One month after endovascular surgery, HFS slightly occurred again with the reappearance of the AMR, although there was no recurrence of aneurysm. Thereafter, the frequency of her HFS markedly decreased to once per several days 1 year after the coiling. Conclusion: Although complete disappearance of symptoms was not obtained, it was suggested that coil embolization is one of the therapeutic options for HFS which is caused by aneurysmal compression of REZ and intraoperative AMR is useful for identification of responsible lesions and determination of therapeutic effects. Keywords▶ hemifacial spasm, aneurysm, coil embolization, abnormal muscle response with assistance of abnormal muscle response (AMR) monitoring and showed the marked improvement in symptoms. Case Presentation A 62-year-old woman presented with HFS in her left eyelid, which appeared 3 years ago and progressively aggravated over the last 6 months to be persistent during the daytime. MRI revealed a left VA-PICA aneurysm, which was in the posterior upper direction, located near REZ of the facial nerve. Then we considered the cause of HFS was the aneurysm. Neurological findings: Her general condition was good and she had no neurological abnormality except for continuous HFS of the left eyelid which did not expand to the orbicularis oris muscle or platysma. Imaging findings: Computed tomography angiography (CTA) revealed that the left vertebral artery (VA) was tortuous and a saccular aneurysm of the left VA-PICA junction, projecting toward the posterior upper direction (Fig. 1A-1C). The aneurysm had a wide neck and its neck slightly rode on the posterior inferior cerebellar artery This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

We report a patient with hyperperfusion-related cerebral hemorrhage after neuroendovascular treatment for symptomatic vertebral artery stenosis. Case Presentation: The patient was a 75-year-old male, who presented with repeated attacks of vertigo. He was diagnosed with vertebral-basilar insufficiency. Subsequently, medical treatment involving the administration of an antiplatelet drug was performed, but brainstem infarction developed. Cerebral angiography showed occlusion of the left vertebral artery and stenosis at the origin and intracranial area of the right vertebral artery. Cerebral blood flow scintigraphy revealed a reduction in cerebellar blood flow as well as the site of infarction. The patient was considered to be resistant to medical treatment, and angioplasty was performed at two stenotic sites of the left vertebral artery. Despite strict blood pressure control, brainstem hemorrhage occurred 4 hours after surgery. The postoperative cerebral blood flow scintigraphy findings suggested hyperperfusion-related hemorrhage. Conclusion: For endovascular treatment of vertebral artery stenosis with cerebral blood flow failure, postoperative hyperperfusion-related cerebral hemorrhage may not be prevented by blood pressure control alone. Therapeutic strategies, such as a staged angioplasty, should be established based on cerebral blood flow examination findings.

Objective: We present a rare case of Takayasu arteritis complicated by eosinophilic granulomatosis with polyangiitis (EGPA), followed by common carotid artery occlusion. Case Presentation: A 49-year-old woman with a history of EGPA rapidly developed left hemiplegia. MRI revealed acute infarction in the right middle cerebral artery territory. The right common carotid artery was not visualized on magnetic resonance angiography. She was transferred to our hospital for a detailed examination. Her erythrocyte sedimentation rate and C-reactive protein level were slightly increased. PET-CT showed high uptake in the aortic arch, right innominate artery, and common carotid artery, which supported the diagnosis of Takayasu arteritis. Rest 123 I-IMP-SPECT demonstrated low uptake in the right middle cerebral artery territory; therefore, subclavian-carotid bypass for revascularization of the right carotid artery was performed. She eventually recovered well from the surgery and was discharged home. Conclusion: Revascularization for common carotid artery occlusion of Takayasu arteritis with EGPA was safe and effective in improving the neurological status, and it should be performed while the disease is inactive.

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Flat detector computed tomography perfusion (FD-CTP) imaging is a new modality that enables quick assessment of the cerebral perfusion in the angiography suite. We present three cases in which FD-CTP served to improve the precision of the therapeutic strategy during endovascular treatment. Case presentation: The first case was a 40-year-old woman with a ruptured blood blister-like aneurysm in the right internal carotid artery (ICA). After the evaluation for tolerance to ICA occlusion using FD-CTP, she was treated successfully with endovascular internal trapping of the ICA. The second case was an 89-year-man with a cerebral infarct in the left cerebrum due to severe stenosis of the left middle cerebral artery. After the angioplasty, we could confirm the therapeutic effect by using FD-CTP, which demonstrated the disappearance of hypoperfusion in the left cerebral hemisphere. The third case was an 88-year-old man with severe stenosis of the left cervical carotid artery. After dilatation of the stenotic lesion by using a small-diameter balloon, a FD-CTP image showed hyperemia in the left cerebral hemisphere, so we decided not to undergo further carotid artery stenting. Conclusion: FD-CTP was useful for determining the therapeutic strategy during endovascular treatment.