PMC9868288_01
PMC9868288_02
Pre-procedural imaging. (A,B) Axial pre-procedural CT of the head non-contrast shows the blurring of the gray-white border in the middle third and fourth of the left middle cerebral artery (MCA) territory. (C) Pre-procedural CT angiography demonstrating occlusion of the M1 terminus. (D-G) Pre-procedural CT perfusion shows decreased CBF and CBV and increased MTT and TTP in the left MCA territory. CBF suggests a large area of hypoperfusion in the left cerebral hemisphere; CBV suggests an infarct core that is smaller in extent than CBF, suggesting a mismatch in CBF/CBV, which may be good candidates for reperfusion therapy.
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F1
CT Score (ASPECTS) of 8 (Figures 1A, B). CT angiography (CTA) demonstrated occlusion of the left distal MCA (Figure 1C). CT perfusion (CTP) showed massive hypoperfusion with reduced cerebral blood flow (CBF) and cerebral blood volume (CBV), the left cerebral hemisphere had increased mean transit time (MTT) and time to peak (TTP), and a CBF/CBV mismatch that may be a good candidate for reperfusion therapy (Figures 1D-G). CTP data were processed using Siemens syngo via CT Neuroperfusion (version VB20A; Siemens Healthcare, Erlangen,
PMC9868288_03
Angiographic acquisitions, left internal carotid artery injection, and anteroposterior and lateral view obtained during thrombectomy. (A) Demonstration of the left A1 segment of ACA, superior M1 proximal, and inferior Sylvian M2 occlusions (arrow). (B) Lateral view displaying abrupt cutoff of the M1 branch of the left MCA (dashed arrow). (C) Combined balloon guide catheter with stent retriever and distal access catheter technique used in mechanical thrombectomy procedure. The balloon of the BGC is inflated to arrest the antegrade ICA flow (thick arrow). The tip of the DAC indicates placement within the M1 segment (thin arrow). The stent retriever is placed from M1 into the terminal ICA (arrowhead). (D) The same procedure is repeated for the inferior Sylvian M2 occlusion (arrow). (E, F) Full recanalization of the MCA and ACA territory following the second pass.
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F2
Development Co., Hunan, China) was advanced from the 5-French select catheter to the left ICA. Digital subtraction angiography (DSA) showed that the patient had MCA duplication on the left side, with proximal occlusion of the left A1 segment of ACA, superior M1 proximal, and inferior Sylvian M2 (Figures 2A, B), explaining the patient's symptoms and the perfusion deficit seen on CTP. Prior to stent retrieval, the balloon of the BGC was inflated to stop the retrograde flow of the ICA (Figure 2C). The repeated treatment of the thrombus in the inferior Sylvian M2 was performed using a 4 x 20 mm Solitaire AB stent (Figure 2D), which showed complete recanalization with an mTICI score of 2b (Figures 2E, F). There was no evidence of any untoward events in either procedure.
PMC9868288_04
Post-treatment CT angiography (CTA) and perfusion (CTP) at 5 days. (A) CTA demonstrates no occlusion of the ACA and DMCA. (B-E) CTP shows normalization of perfusion in the left cerebral hemisphere.
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F3
Five days later, follow-up of CTA and CTP showed patency of ACA and DMCA complete normalization of perfusion in the left cerebral hemisphere (Figure 3).