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A: Magnetic resonance angiography showed the right middle cerebral artery (MCA) occlusion. B: Diffusion-weighted imaging showed acute infarction in the right parietal lobe. C: Angiogram of the right carotid artery. Very mild stenosis was observed at the bifurcation of the internal carotid artery, but the margins were smooth, and there was no floating thrombus or ulcer lesion. D: Right internal carotid angiography confirmed the right proximal MCA occlusion. E: Final angiography showed successful recanalization. F-H: Follow-up magnetic resonance imaging 5 days after thrombectomy showed recanalization of the right middle cerebral artery and newly embolic infarcts in the left frontal lobe (arrowheads) and bilateral cerebellar hemispheres (arrows). I: Macroscopic appearance of the retrieved thrombus.
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MRI showed occlusion of the right middle cerebral artery (MCA) and acute infarction in the territory (Fig. 1A-B). Cerebral angiography revealed a very slight stenosis of the right internal carotid artery bifurcation and occlusion of proximal portion of the right MCA. (Fig. 1C-D). A yellowish thrombus was retrieved in a single procedure by a combined technique using an aspiration catheter and stent retriever (Fig. 1I). The MCA was completely recanalized (TICI 3), and the symptoms tended to improve immediately (Fig. 1E). However, follow-up MRI showed newly embolic infarcts in the left frontal lobe and in the bilateral cerebellar hemispheres, although no re-occlusion of the MCA was observed (Fig. 1F-H).
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Pathological findings for the thrombus. A, B: Hematoxylin and eosin staining shows numerous cholesterol crystal clefts and foam cells in most of the thrombus, with a small platelet aggregate (original magnification x10, x40). C, D: Phosphotungstic acid hematoxylin staining revealed a large amount of fibrin component formed a layer and intermixed between the cholesterol clefts and foam cells (original magnification x10, x100). E, F: The insert immunohistochemistry with CD42b shows the poor platelet content within the thrombus (original magnification x10, x100).
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Pathological examination of the retrieved thrombus revealed atheromatous lesion containing numerous cholesterol crystal clefts and foam cells, with small platelet aggregates and a lack of red blood cells (Fig. 2A, B). Phosphotungstic acid hematoxylin (PTAH) staining identified a large amount of fibrin component that formed a layer and intermixed between the cholesterol clefts and foam cells (Fig. 2C, D). By contrast, the insert immunohistochemistry with CD42b showed that the platelet component was quite minimal (Fig. 2E, F).
A, B, C: Axial view of contrast-enhanced computed tomography scan revealed plaque lesions in the aortic arch and proximal brachiocephalic artery. The inner wall of the aortic arch is irregular, with 7 mm plaques and ulcerations (asterisk), the so-called shaggy aorta. D: The coronal view showed a thick plaque lesion extending continuously along the upper wall of the ascending aorta (arrowheads). E: Sagittal view showed irregularly shaped plaques with calcification from the arch to the descending aorta.
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Based on the pathological results, a whole-body contrast-enhanced CT scan was performed, which revealed a thick plaque lesion extending continuously along the ascending aorta to the descending aorta and maximum 7 mm plaque masses and ulcer lesions on the aortic arch (Fig. 3).
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