PMC4681129_01
(a and b) Initial head diffusion-weighted magnetic resonance image showed cerebral infarction in the left anterior cerebral artery. (c) The magnetic resonance angiogram showed segmental stenosis on the A2 portion of the left anterior cerebral artery (arrow)
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F1
ACA, and MR angiography revealed segmental stenosis at the A2 portion of the left ACA [Figure 1]. A day after the onset, three-dimensional digital subtraction angiogram (3D-DSA) showed segmental dilatation at the left A2 portion and narrowing at the left A3 portion [Figure 2].
(a) The digital subtraction angiogram on day 1 revealed segmental dilatation at the left A2 portion (arrow). (b) Three-dimensional-digital subtraction angiogram showed segmental dilatation and narrowing sign (arrows) in the left A2-A3 portion
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F2
ACA, and MR angiography revealed segmental stenosis at the A2 portion of the left ACA [Figure 1]. A day after the onset, three-dimensional digital subtraction angiogram (3D-DSA) showed segmental dilatation at the left A2 portion and narrowing at the left A3 portion [Figure 2].
(a) The digital subtraction angiogram and (b) three-dimensional digital subtraction angiogram on day 13 revealed that the progress of aneurysmal dilatation causing pearl and string sign on the left A2 portion (a: Arrow), and disappearance of the left pericallosal artery (b: Arrows)
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F3
A pearl string sign caused by the narrowing of the A2 portion was examined [Figure 3].
Three-dimensional digital subtraction angiogram showed enlarged protruding dilatation at the left A2
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F4
Five months after the onset, DSA revealed an enlarged protruding dilatation of the left A2 portion [Figure 4] suggesting increased risk for aneurysmal rupture.
(a) The digital subtraction angiogram in the operative view showed the aneurysm in the left A2 portion. (b) The cone-beam computed tomography revealed the stent covering the aneurysm neck and microcatheter inserted into the aneurysm. (c) The digital subtraction angiogram and (d) three-dimensional digital subtraction angiogram after stent-assisted embolization showed obliteration of the aneurysm and preservation of the left A2. (e) Follow-up three-dimensional digital subtraction angiogram performed 6 months after the operation showed moderate in-stent stenosis
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F5
Working angle for embolization was obtained using 3D rotational angiography [Figure 5a]. Microcatheter (Excelcior SL-10, Stryker, MI, USA) was navigated with a microguidwire (Chikai 14, Asahi Intecc, Aichi, Japan) into the aneurysmal fundus and the stent (Neuroform EZ 2.5 mm x 20 mm, Stryker) was placed at the true lumen of the aneurysmal dilatation to cover its neck [Figure 5b]. Type R, Kaneka Medics, Ohsaka, Japan) were placed. The dilated portion outside the stent was successfully obliterated, and the ACA inside the stent remained patent [Figure 5c and d]. Follow-up 3D-DSA performed 6 months after the operation showed moderate in-stent stenosis, but no neurological symptoms were observed a year after the operation [Figure 5e].