PMC8120027_01
NIHSS scores after different treatments. NIHSS, National Institutes of Health Stroke Scale.
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Health Stroke Scale (NIHSS) score was 16 ( Figure 1 ). Head computed tomography (CT) showed a hyperdense middle cerebral artery (MCA) sign involving the M1 segment and the M2 branch of the left MCA ( Figure 2A ). The patient's symptoms resolved partially with an NIHSS score of 4 at 3 hours after onset ( Figure 1 ). Methylprednisolone (16 mg/day), azathioprine (100 mg/day), aspirin (100 mg/day), and atorvastatin (20 mg/day) were introduced as extended duration treatments ( Figure 1 ).
Head CT showing a hyperdense MCA sign involving the M1 segment and the M2 branch of the left MCA (A). Head CTA showing internal carotid artery asymmetry (left smaller than the right) and abrupt occlusion of the M1 branch of the left MCA (B). CT, computed tomography; CTA, computed tomography angiography; MCA, middle cerebral artery.
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Health Stroke Scale (NIHSS) score was 16 ( Figure 1 ). Head computed tomography (CT) showed a hyperdense middle cerebral artery (MCA) sign involving the M1 segment and the M2 branch of the left MCA ( Figure 2A ). Computed tomography angiography (CTA) of the head showed asymmetry of the internal carotid arteries (left smaller than the right) and an abrupt occlusion of the M1 branch of the left MCA ( Figure 2B ).
CT perfusion showing delayed TTP, increased MTT, reduced CBF, and preserved CBV in the left MCA region, suggesting a large salvageable ischaemic penumbra. CBF, cerebral blood flow; CBV, cerebral blood volume; CT, computed tomography; MCA, middle cerebral artery; MTT, mean transit time; TTP, time to peak.
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On CT perfusion, there was a delayed time to peak (TTP), increased mean transit time (MTT), reduced cerebral blood flow (CBF), and preserved cerebral blood volume (CBV) in the left MCA region, suggesting a large salvageable ischaemic penumbra ( Figure 3 ).
The endovascular therapy procedure. (A) DSA showing multiple stenoses (arrowheads) in the brachiocephalic trunk, the beginning of the right CCA and the bilateral subclavian arteries, with occlusion of the left CCA and its branches (arrow). (B) After mechanical thrombectomy, revascularisation of the left MCA is seen with TIMI flow grade 3 (arrowhead). (C) Percutaneous transluminal balloon angioplasty of the left CCA (arrows). (D) Stent implantation of the proximal left CCA (arrow). Revascularisation of the left CCA is seen (arrowheads). CCA, common carotid artery; DSA, digital subtraction angiography; MCA, middle cerebral artery; TIMI, Thrombolysis in Myocardial Infarction.
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Digital subtraction angiography (DSA) showed multiple stenoses in the brachiocephalic trunk, the beginning of the right common carotid artery (CCA), and the bilateral subclavian arteries, as well as occlusion of the left CCA and its branches ( Figure 4A ). Revascularisation of the left MCA was achieved with TICI flow grade 3 ( Figure 4B ). Percutaneous transluminal balloon angioplasty of the left CCA followed by stent implantation of the proximal left CCA was performed ( Figures 4C, D ).
Head CT showing low-density lesions in the right basal ganglia (A, B) and mild high density inside the lesion (B) at 24 hours after endovascular therapy, suggesting a small core infarct area and contrast medium residue. Head CTA showing revascularisation of the left MCA (C). CT, computed tomography; CTA, computed tomography angiography; MCA, middle cerebral artery.
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Repeated head CT revealed low-density lesions in the right basal ganglia ( Figures 5A, B ) and a mild high density inside the lesion ( Figure 5B ) at 24 h after the endovascular therapy, suggesting a small core infarct area and contrast medium residue. Head CTA showed revascularisation of the left MCA ( Figure 5C ).