In mechanical endovascular thrombectomy (MET) for acute basilar artery occlusion (ABAO) in the elderly, navigating a guide catheter via the femoral artery may be difficult due to the approach route’s significant tortuosity. To resolve this problem, we have been performing a technique that uses a direct brachial approach (DiBA) with a large-bore aspiration catheter. We reported our preliminary clinical experience with this technique. MET for ABAO using the DiBA technique was performed on 4 consecutive patients between August 2017 and December 2018. In all patients, thrombolysis in cerebral infarction 2B or 3 recanalization was achieved, but the modified Rankin Scale at 90 days was ≥4. There were no technical difficulties or complications with this technique. The DiBA technique is an effective and feasible approach in MET for ABAO. Although excellent clinical outcomes could not be achieved, the angiographic outcomes were excellent with no technical complications. This approach can be an alternative to the femoral artery approach, particularly for tortuous arteries in the elderly.

Background: Oral infection and dental manipulations can lead to the development of brain abscesses, a rare but potentially life-threatening condition. Herein, we report patients undergoing cancer treatment who developed brain abscesses of odontogenic origin at our hospital. Case Description: Two patients developed brain abscesses during cancer treatment. Both underwent neurosurgical aspiration, and the causative microorganism was identified as Streptococcus intermedius of the Streptococcus anginosus group, which is a part of the normal bacterial flora in the oral cavity. There was clinical and radiographic evidence of dental infection in one of the patients diagnosed with a brain abscess of odontogenic origin. No infectious foci were found in the other patient during hospitalization for the abscess. However, the patient had undergone extraction of an infected tooth approximately 3 months before admission for the abscess, suggesting origination from an oral infection or dental manipulation. The patients’ cancers rapidly worsened because cancer treatment in both patients was interrupted for several months to treat the brain abscess. Conclusion: Oral infections can cause severe infections, such as brain abscesses, particularly during the treatment of malignant tumors. Improving the oral environment or treating oral infections before initiating treatment for malignant tumors is highly recommended. In addition, the possibility of odontogenic origin should always be considered as a potential etiology of brain abscesses.

Occasions to administer endovascular treatment to the elderly have increased, for which rapid and safe guiding catheter (GC) placement even in a lesion with severe arteriosclerosis is required. We investigated an index to easily evaluate the degree of difficulty before treatment. Methods: In all, 83 consecutive patients who received carotid artery stenting (CAS) through the transfemoral approach at our institution between May 2010 and December 2016 were divided into those in whom GC could be placed using the JB2-type inner catheter (IC) (JB2 group) and those who required the Simmons type or Goose neck snare (SM/GS group). Vascular anatomy of the cervicothoracic region was evaluated and an index to select IC was investigated. Results: The JB2 and SM/GS groups consisted of 68 and 15 patients, respectively. The distributions of the following five items were different between the two groups: The level of the origin of the selected artery from the lesser curvature of the aortic arch, aorta type, tortuosity of the common carotid artery, selected artery, and location of the lesion. On decision tree analysis of these factors, a flowchart was prepared in which a lower level of the origin of the selected artery than the level of the lesser curvature of the aortic arch was the first layer. Conclusion: IC selection can be more accurately evaluated based on whether the level of the origin of the selected artery is lower than the level of the lesser curvature of the aortic arch compared with evaluation of the aorta type III.

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Transient bradycardia, hypotension, and asystole arise from activation of the trigemino vagal reflex by direct stimulation of the trigeminal nerve or branches in the dura mater or cerebellar tentorium. We report two cases of transient asystole during surgery by activation of the trigemino vagal reflex. In one case, a 63 year old woman with an unruptured internal carotid artery aneurysm at the origin of the anterior choroidal artery underwent craniotomy. When a clip applied for neck clipping touched the dura mater, transient asystole occurred twice, lasting 4 5 seconds each. After immediate cessation of surgical manipulation, heart contractions recovered spontaneously. The trigemino vagal reflex may occur in any open craniotomy surgery, and is not rare in clipping operations for supratentorial unruptured aneurysm. However, this reflex recovered without any postoperative complications following prompt cessation of surgical manipulations.