PMC5943549_01
Initial digital subtraction angiography showing right proximal middle cerebral artery occlusion (A) and complete vessel recanalization after successful mechanical thrombectomy (B). DWI-MRI 4 days after stroke depicts small ischemic infarcts in the right posterior basal ganglia and temporal cortex [arrows (C)].
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F1
Solitaire stent retriever (thrombolysis in cerebral infarction scale 3, Figures 1A-B). Symptom-to-recanalization time was 130 min. Brain MRI on day 4 demonstrated small ischemic infarcts in the right posterior basal ganglia region and right temporal cortex (Figure 1C).
Initial MRI scan at second admission showing only a small DWI lesion corresponding to the preceding stroke (A), hypoperfusion of large parts of the middle cerebral artery (MCA) territory [(B), mean transit time], and right proximal MCA occlusion [(C), time-of-flight angiography]. Digital subtraction angiography pre- (D) and post-thrombectomy (E).
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F2
However, a right-sided proximal MCA occlusion was present again and was associated with severe hypoperfusion (Figures 2A-C).
Irregular-shaped plaque formation at the origin of the ipsilateral internal carotid artery (arrows) as seen in contrast-enhanced MRA (A), computed tomography angiography (B), and neurosonography (C).
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F3
The already known ulcerated plaque at the right ICA origin (Figure 3) was, therefore, considered as the most likely cause of the two strokes, and uneventful carotid thrombendarteriectomy was performed.