Idiopathic normal-pressure hydrocephalus (iNPH) has become socially significant in Japan. Japanese guidelines for iNPH in 2011 described the diagnostic importance of "disproportionately enlarged subarachnoid space hydrocephalus" (DESH) on magnetic resonance imaging (MRI). However, some patients with iNPH have equivocal or no features of DESH. To clarify the diversity of MRI findings in iNPH, we classified iNPH into three types based on MRI findings. Using this, we investigate predictable MRI findings for shunt effectiveness in iNPH. A total of 83 patients with suspected iNPH who were treated with shunt surgery were reviewed in this study. All patients had a positive cerebrospinal fluid (CSF) tap test. Among the 83 patients, DESH was noted in 64 %, incomplete DESH in 23 %, and no DESH in 13 % (see Fig. 3). Among the three types of incomplete DESH, incomplete DESH-v (ventricle) was 0 %, DESH-c (convexity) in 13 %, and DESH-s (Sylvian fissure) in 10 %. A high improvement rate after the shunt surgery was noted in the DESH and incomplete DESH-s groups, showing 73.5 % and 87.5 %, respectively. The non-DESH group showed a fairly large improvement of 63.6 %. A common MRI finding in DESH and incomplete DESH-s was high convexity tightness with ventriculomegaly. This combination was promising for shunt effectiveness in patients with suspected iNPH. Further study is necessary to elucidate the pathogenesis.

Periprocedural increases in regional cerebral oxygen saturation measured by near- infrared spectroscopy can be an excellent predictor of cerebral hyperperfusion syndrome after carotid artery stenting.

Objectives: This study aimed to evaluate the relationship between the amount of aspirated debris during distal balloon-protected carotid artery stenting (CAS) and the pre-intervention plaque composition, as assessed by Virtual Histology™ (VH) intravascular ultrasound (IVUS). Methods: The study subjects were 25 consecutive patients (mean age, 73.0 ± 5.2 years; 20 males and 5 females) who underwent CAS under distal balloon protection. The average rate of carotid stenosis was 74.6 ± 12.9% by North American Symptomatic Carotid Endarterectomy Trial criteria. We assessed culprit plaque components by VH-IVUS before CAS. Aspirated debris was filtered, stained with HE and mounted onto glass slides. The quantity of debris was evaluated by measuring its surface area. We evaluated the relationship between the quantity of aspirated debris and VH-IVUS measurements before CAS. Results: The amount of debris during CAS was positively correlated with the total plaque volume in grayscale IVUS (Rs = 0.480, p = 0.015) and fibro-fatty volumes over the entire lesion length in VH-IVUS (Rs = 0.561, p = 0.001). Conclusions: Culprit lesions with large plaque volumes, especially larger fibro-fatty volumes, as imaged by VH-IVUS, are associated with large amounts of debris during balloon-protected CAS.

Intraoperative stenting may be an excellent alternative for patients in whom both direct surgical approach and standard percutaneous endovascular approach are not possible.

Purpose: Development of a novel interventional approach for treatment of a fusiform brachiocephalic artery aneurysm in a patient for whom direct surgery could not be performed due to a systemic complication. Methods: As the distal side of the aneurysm involved both the common carotid and subclavian arteries, a combination of parallel stenting and coil embolization was used to avoid disturbing the blood fl ow in each artery. Result: Successful endovascular obliteration of the aneurysm was achieved with preservation of the common carotid and subclavian arteries without any ischemic complications. Conclusion: To our knowledge, this is the fi rst report describing combined use of coil embolization and parallel stenting for treatment of a fusiform brachiocephalic artery aneurysm. This therapeutic approach is an excellent alternative that should be considered as a treatment option for this type of aneurysm.