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Background and Purpose— Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core. Methods— Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days. Result— Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73). Conclusions— Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

Objective: Traumatic arteriovenous fistula (AVF) concomitant with pesudoaneurysm involving the middle meningeal artery is uncommon. Traumatic AVF is also known to occasionally show spontaneous closure. We report a rare case of traumatic pseudoaneurysm of the middle meningeal artery identified after spontaneous closure of a traumatic AVF. Case presentation: A 36-year-old right-handed man suffered a head injury after falling from a step at home, and was brought to our institute. The patient showed no neurological deficits. Computed tomography (CT) showed no intracranial hemorrhage and he was discharged to home. Six days later, he consulted our outpatient clinic because of dizziness and pulsatile tinnitus on the right side. Fracture in the right temporal bone was found on review of the initial CT. Magnetic resonance (MR) imaging showed cerebral contusion in the left temporal lobe and MR angiography demonstrated AVF involving the middle meningeal artery. Angiography revealed direct AVF supplied by the dilated right middle meningeal artery and draining into the cavernous sinus with no cortical venous reflux. Transarterial embolization was attempted 56 days after head injury. Right external carotid artery angiography revealed spontaneous obstruction of the AVF. Selective middle meningeal artery angiography disclosed a small aneurysm, which was embolized completely by coils and glue material. Conclusion: It may be sometimes difficult to detect a traumatic pseudoaneurysm associated with a traumatic arteriovenous fistula of the middle meningeal artery. Close radiographical follow-up is necessary in this lesion.• Key words • traumatic arteriovenous fistula, pseudoaneurysm, spontaneous closure, middle meningeal artery 652-0803 9-2-6

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Objective: Acute mechanical thrombectomy (AMT) in patients with acute ischemic stroke from large vessel occlusion (LVO) is performed without directly identifying the occluded vessels. In this study, we evaluated whether 1.5 T magnetic resonance imaging (MRI) with 3D-fast imaging employing steady-state acquisition (FIESTA) could visualize the occluded intracranial middle cerebral artery (MCA) and internal carotid artery (ICA) before AMT.Methods: This retrospective study included 21 consecutive patients who underwent time-of-flight magnetic resonance angiography (TOF MRA) and 3D-FIESTA MRI immediately before AMT. The patients also underwent TOF MRA after AMT and achieved TICI 2b or 3 by AMT at our hospital between February 2018 and April 2019. When LVO in the anterior circulation was detected by TOF MRA, 3D-FIESTA MRI was additionally performed. Then, the occluded intracranial MCA and ICA, including their branches, were constructed on the workstation with volume rendering. The obtained images were fused with the TOF MRA images to create combined 3D images.Results: The length and top-to-bottom distance of the affected M1 segment (calculated by the ipsilateral-to-contralateral ratio) were 1.29 and 1.17, respectively, on 3D-FIESTA MRI before AMT and 1.34 and 1.24, respectively, on TOF MRA after AMT. We assessed the number of M2 segments branching from the affected M1/M2 junction and visualized the affected anterior temporal artery. The 3D-FIESTA MRI before AMT and TOF MRA after AMT were consistent in all patients, except for two who moved vigorously during imaging.Conclusions: Images acquired by 1.5T 3D-FIESTA MRI can visualize to predict the existing path of the occluded MCA and ICA before AMT in patients with LVO of the anterior circulation.

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Mechanical thrombectomy has become a standard treatment for acute ischemic stroke with large vessel occlusion. In aged patients, it is difficult to guide the catheter via the transfemoral approach due to vessel tortuosity and aortic elongation. We report our preliminary clinical experience using the transbrachial approach. Among the 119 patients who underwent thrombectomy from April 2018 to December 2019, a total of 5 patients were treated via the transbrachial approach. Clinical outcomes were retrospectively analyzed. Successful reperfusion was achieved in 4 out of 5 cases. There was 1 death due to symptomatic intracranial hemorrhage. One patient had a good outcome at discharge. There were no access-site complications associated with any of these cases. Transbrachial access for mechanical thrombectomy is feasible and can provide an alternative to the transfemoral approach.

Objective: Dural arteriovenous fi stulas (dAVFs) draining into the superior petrosal sinus (SPS) are rare. This article describes a case of SPS dAVF treated with transvenous embolization, which resulted in subarachnoid hemorrhage. Case presentation: A 65-year-old female presented with a severe headache and fl oating sensations. CT showed right cerebellar hemorrhage with ventricular perforation. Angiograms revealed innumerable feeders from the tentorial artery of the left internal carotid artery, the left superior cerebellar artery supplying the dAVF at the draining vein and the varix of the SPS and cortical venous refl ux via the petrosal vein. We conducted transvenous coil embolization of the draining vein and the varix, and the dAVF disappeared. CT obtained on the next day of the endovascular procedure demonstrated subarachnoid hemorrhage and acute hydrocephalus. It was postulated that because the embolization was performed at the varix and not at the shunt point, the fragile draining vein may have been ruptured due to excessive pressure or that rapid disproportion of venous pressure occurred at the surrounding draining veins during the procedure, causing subarachnoid hemorrhage. Conclusion: We emphasize that accurate identifi cation of the fi stula sites and careful embolization with suffi cient fl ow control are necessary in the treatment of dAVF with hemorrhages and dangerous drainages.