With the increasing use of endovascular treatment, training the practitioners has become essential. Skills have traditionally been acquired through surgical participation, but off-the-job training (OFF-JT) offers greater flexibility and practical learning and is more effective. This paper introduces our developed approach for OFF-JT. Using digital subtraction angiography (DSA) images, we create hollow cerebral vasculature models using a 3D printer. Training was then conducted using fluoroscopy or direct visualization. With aneurysm models, procedures including microcatheter navigation and stent or coil deployment can be performed. Thrombectomy training allows practitioners to simulate clot retrieval and practice the use of different devices for improving their understanding of each device's characteristics. These low-cost, realistic 3D models enable diverse training without specialized equipment and allow the replication of real procedures. This shifts surgical education from “watching” to “performing, ” making it suitable for practical training needs. Future efforts should focus on expanding training and integrating objective skill evaluations.

Background and Purpose: In-hospital ischemic strokes (IHIS) following antithrombotic withdrawal account for more than one-fourth of all IHIS cases. Nevertheless, the characteristics of this stroke type remain poorly understood. This study aimed to investigate the clinical features of IHIS associated with discontinuation of anticoagulant (AC) or antiplatelet (AP) therapy.

Methods: We analyzed 100 patients with IHIS who were consecutively admitted to Osaki Citizen Hospital between January 2015 and July 2020. Patients who were taking or had discontinued antithrombotic therapy at the time of stroke onset were categorized into four groups: AC continuation, AP continuation, AC withdrawal, and AP withdrawal. Clinical features were compared between AC continuation and withdrawal groups and between AP continuation and withdrawal groups.

Results: No significant differences were observed between AC continuation (16 patients) and withdrawal (10 patients) groups. Compared with the AP continuation group (24 patients), the AP withdrawal group (9 patients) had a significantly higher proportion of patients with a history of prior stroke or transient ischemic attack (88.9% vs. 41.7%, p=0.021) and higher median (interquartile range) CHA2DS2-VASc scores (6 [5.8-7] vs. 5 [3.5-6], p=0.006).

Conclusions: These findings indicate that patients who have experienced IHIS after AP withdrawal are at elevated risk of thromboembolism, and many will experience recurrent stroke. A thorough risk assessment of these factors is recommended before AP withdrawal.

Carotid artery stenosis caused by atherosclerosis is a major cause of cerebral infarction. When our hospital opened in 2001, carotid endarterectomy (CEA) was the first-line surgical treatment for carotid artery stenosis. However, since 2011, the number of carotid artery stenting (CAS) cases has gradually increased, making CAS an alternative treatment. This study compared the trends in the surgical treatment of carotid artery stenosis and the treatment outcomes of CEA and CAS over the past 20 years.

The mean age was 70.9 years in the CEA group and 75.1 years in the CAS group, with the CAS group being significantly older. There were no significant differences between the two groups in terms of sex, symptomatic rate, or degree of stenosis (NASCET). The rate of general anesthesia was 100% in the CEA group and 3.1% in the CAS group. The mean operative times were 178 min and 43 min, and the mean lengths of hospital stay were 16.9 days and 9.9 days, respectively, with CAS having significantly shorter operative times and hospital stays.

Regarding treatment outcome, the postoperative DWI-positivity rate was 6.5% in the CEA group and 38% in the CAS group, which was significantly higher than that in the CAS group. Conversely, the post-operative stroke rate measured using the modified Rankin scale (mRS) worsened in the CEA (1.6%) and CAS (1.5%) groups, with no significant difference. The restenosis rates requiring re-intervention were 3.1% and 3.7% in the CEA and CAS groups, respectively, again with no significant difference. However, the time to reintervention was significantly longer in the CEA group (43.9 months) than in the CAS group (12.4 months).

The mortality and morbidity rates over the past 20 years were similar for both procedures. Among the 550 CEA cases, 4 mortalities (0.7%) and 5 morbidities (0.9%) the 507 CAS cases, 0 mortalities (0%) and 4 morbidities (0.6%) were reported.

Aneurysms occurring during infundibular dilatation of the posterior communicating artery (PcomA ID) are relatively rare, and their details are unknown. In this study, we report the clinical and neuroradiological findings of five ruptured PcomA ID aneurysms.

Participants: We reviewed five cases of ruptured PcomA ID aneurysms treated in our department over the past 5 years.

Results: During the study period, 75 patients with ruptured aneurysms were treated with craniotomy clipping; the incidence of ruptured PcomA ID aneurysms was 6.7% (5/75 cases). All five cases involved female patients. Their ages ranged from 38–77 years (mean age, 55 years), with two patients in their 70s, one in her 40s, and two in their 30s, indicating a tendency for the disease to be more prevalent among relatively young people. The size of the PcomA ID aneurysms was 1.3–2.3 mm (average, 1.9 mm) in longitudinal diameter and 1.8-3.2 mm (average, 2.4 mm) in transverse diameter. The shape was a bleb-like aneurysm arising from part of the wall of the PcomA ID. All the aneurysms occurred in the distal curvature of the PcomA ID. This was presumably due to the pressure on the wall of the PcomA ID, the impingement force of blood flow, and shear stress.

Discussion: All patients were females, and PcomA ID aneurysms were more common in relatively young patients, as in previous reports. The average aneurysm size was 1.9 × 2.4 mm, indicating that even small bleb-like aneurysms occurring in the PcomA ID may rupture. Caution should be exercised when unruptured cases are encountered in routine clinical practice. Strict follow-up imaging is necessary in young female patients, and active rupture prevention treatments should be considered.

Carotid artery stenting (CAS) was performed on a 72-year-old man with severe symptomatic right cervical internal carotid artery stenosis. Considering the unstable plaque and highly tortuous lesion, an Mo.Ma embolic protection device (EPD) and a CASPER Rx stent were used. There were no obvious complications during the perioperative period. However, angiography performed one year after CAS showed that the stent placement site had straightened, and vascular dilation was observed near the distal edge of the stent. It was diagnosed as a chronic internal carotid artery dissection. As the patient was asymptomatic, a decision was made to observe the patient. Iatrogenic dissection during CAS may be caused by catheter, wire, or EPD manipulation. We report a case of delayed internal carotid artery dissection after CASPER Rx stent placement.

Mycotic aneurysms often cause serious subarachnoid hemorrhages. Appropriate diagnosis and treatment are paramount. This case report described a one-year-old girl with an endocarditis-related mycotic aneurysm of the middle cerebral artery (MCA) that was treated with superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass and trapping surgery.

The infant experienced infective endocarditis after surgery for a ventricular septal defect. She was initially treated with antibiotics. However, cerebral infarction due to occlusion of the right M2 superior trunk of the MCA. Multiple mycotic aneurysms at posterior cerebral artery (PCA) were detected on computed tomographic angiography (CTA). After 1 week, the mycotic aneurysm of PCA disappeared, and the right M2 superior trunk recanalized to form a mycotic aneurysm. This lesion was at high risk of hemorrhage. We performed a direct surgery to prevent rupture of the mycotic aneurysm in the M2 superior trunk. During the surgical procedure, severe stenosis in the parent artery of the aneurysm was detected. Therefore, we performed an STA-MCA bypass just distal to the aneurysm. We could safely trap the aneurysm because of the bypass. The aneurysm was resolved without adverse events. The remaining aneurysms were managed by antibiotic therapy. Mycotic aneurysms have fragile walls, and neck clipping and coil embolization are often difficult. Hence, parent artery occlusion (PAO) is often considered. If the lesion is eloquent, bypass surgery should be performed because of the risk of widespread ischemia.

Ischemic complications often occur perioperatively after carotid artery stenting (CAS). Embolization of plaque or thrombosis is the most common cause, but there are few reports of cerebral vasospasm. Herein, we report a case of symptomatic cerebral vasospasm after CAS.

The patient was a 71-year-old male. He was admitted to the hospital with mild right-sided paralysis. Magnetic resonance imaging (MRI) showed a left cerebral infarction, while magnetic resonance angiography revealed stenosis in the left internal carotid artery. Ultrasonography of the carotid artery revealed a hypoechoic plaque, indicating an unstable plaque. CAS was performed to prevent recurrence. Two hours after surgery, the patient presented with right-sided paralysis and aphasia, and MRI revealed a new cerebral infarction on the operated side. The following day, a cerebral perfusion test showed decreased blood flow in the left cerebral hemisphere, and cerebral angiography revealed cerebral vasospasm on the operated side. Conservative treatment resulted in the resolution of neurological symptoms on the 11th day after surgery, and cerebral angiography one month after surgery showed improvement in cerebral vasospasm.

Although cerebral vasospasm is a rare cause of ischemic complications after CAS, it should also be considered. It is important to promptly distinguish between hyperperfusion syndrome and low blood pressure.

Surgical treatments for intracerebral hematomas include craniotomy, stereotactic hematoma removal, and endoscopic hematoma removal. The 2021 Japanese Stroke Guideline recommends stereotactic hematoma removal for putaminal hemorrhage when certain criteria are met, including specific hematoma volume, evidence of hematoma compression, and relevant neurological findings. Conventionally, a frame is affixed to the patient's head, the hematoma coordinates are measured in the computed tomography (CT) room, and stereotactic hematoma removal is performed in the operating room. In this case report, in addition to coordinate measurement in the CT room, cone-beam computed tomography (cone-beam CT) was used in a hybrid operating room. The patient was a 59-year-old male with a history of hypertension. He was admitted to our hospital with left hemiplegia upon waking and was diagnosed with right putaminal hemorrhage. Stereotactic hematoma removal was subsequently performed. There was no significant difference between hematoma coordinates measured by conventional CT and those obtained by cone-beam CT. The procedure did not require moving the patient between the CT and operating rooms, and intracranial evaluation was possible immediately after surgery on the operating table. These findings suggest that stereotactic hematoma removal based on coordinate measurements using cone-beam CT may be a useful approach.

Mechanical thrombectomy of fenestrated vessels has rarely been reported. Here, we report a case of basilar artery (BA) trunk occlusion where BA fenestration was suspected during the procedure. Recanalization was achieved after mechanical thrombectomy by targeting the right arterial channel of the fenestrated segment. In this case, the stent's behavior played a crucial role in identifying the fenestration. Therefore, it is important to consider the possibility of fenestration in patients with BA trunk occlusion.