PMC10442173_01
Preoperative left cervical angiogram: AP view (A), LAT view (B), and 3D-DSA (C). The lesion was elevated at the level of the second through fourth vertebral bodies, with a lesion length of approximately 4 cm and an NACET 76%. The diameter of the common carotid artery, the narrowest part of the lesion, and the ICA was 6.93 mm, 1.33 mm, and 5.53 mm, respectively. AP: anteroposterior; ICA: internal carotid artery; LAT: lateral; NACET: North American Symptomatic Carotid Endarterectomy Trial
jnet-17-173-g001.jpg
PMC10442173_01_jnet-17-173-g001.jpg
F1
He suddenly developed aphasia and disorientation, which improved spontaneously within 2 hours, but close examination revealed cerebral infarction in the left insular gyrus and left watershed area, and a highly stenotic lesion in the left cervical internal carotid artery (ICA) bifurcation (Fig. 1).
Left cervical MRI plaque axial imaging: T1 (A), T2 (B), and TOF (C). Unstable plaque including intraplaque hemorrhage with T1 high intensity (A), T2 high intensity (B), and TOF high intensity (C), and plaque muscle ratio 3.13 were observed. TOF: time of flight
jnet-17-173-g002.jpg
PMC10442173_01_jnet-17-173-g002.jpg
F2
Cervical MRI plaque imaging showed vulnerable plaques (Fig. 2).
Postoperative imaging: left cervical angiogram AP view (A), LAT view (B), ultrasonogram (C), and head MRI (DWI) (D). Improvement of the stenosis was observed. No obvious PP or in-stent thrombus was observed. No obvious cerebral infarction was observed. AP: anteroposterior; DWI: diffusion-weighted imaging; LAT: lateral; PP: plaque protrusion
jnet-17-173-g003.jpg
PMC10442173_01_jnet-17-173-g003.jpg
F3
Compared with the preoperative period, the intracranial flow delay also appeared to have improved, and the operation was finished (Fig. 3). Postoperative intravascular ultrasound (IVUS) was not performed, but carotid ultrasound was performed on postoperative day 3 and there was no obvious PP or in-stent thrombus (Fig. 3).
Left angiogram 2 weeks after stenting: internal cerebral AP view (A), LAT view (B), cervical AP view (C), and LAT view (D). The patient had a left ICA occlusion from the proximal portion of the stent. However, retrograde blood flow was observed from the ophthalmic artery via a recurrent meningeal artery. AP: anteroposterior; ICA: internal carotid artery; LAT: lateral
jnet-17-173-g004.jpg
PMC10442173_01_jnet-17-173-g004.jpg
F4
However, on postoperative day 14, muscle weakness in the right upper and lower limbs and dysarthria were observed, and imaging showed that the left ICA was poorly visualized from the cervical bifurcation (Fig. 4).
Left internal cerebral angiogram after mechanical thrombectomy: internal cerebral AP view (A), LAT view (B), cervical AP view (C), and LAT view (D). Effective recanalization was obtained. AP: anteroposterior; LAT: lateral
jnet-17-173-g005.jpg
PMC10442173_01_jnet-17-173-g005.jpg
F5
After that, restenosis improved (Fig. 5).
Head MRI (DWI) after mechanical thrombectomy. Scattered cerebral infarctions were observed in the left frontal cortex and deep white matter. DWI: diffusion-weighted imaging
jnet-17-173-g006.jpg
PMC10442173_01_jnet-17-173-g006.jpg
F6
Postoperatively, scattered cerebral infarctions were observed in the left frontal cortex and deep white matter (Fig. 6), and the patient remained symptomatic and was hospitalized with an mRS score 2.