PMC5013329_01
Magnetic resonance imaging (MRI) and MR angiography (MRA) findings. (A, B) MRI/diffusion-weighted imaging (DWI) at the time of initial presentation shows no acute cerebral infarction, but MRA reveals complete occlusion of the right internal carotid artery (ICA). (C) After intravenous injection of recombinant tissue plasminogen activator (rt-PA), cervical MRA demonstrates that the right ICA is still occluded.
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Diffusion-weighted magnetic resonance imaging (MRI) showed no acute cerebral infarction (Fig. 1A), but magnetic resonance angiography (MRA) revealed occlusion of the right ICA (Fig. 1B). In addition, repeated MRA (Fig. 1C) and cerebral angiography still revealed complete occlusion of the right cervical ICA at its origin (Fig. 2A).
(A) Preoperative right common carotid angiography (CAG) revealing complete occlusion of the right internal carotid artery (ICA) at the origin; (B, C) Right internal carotid angiography (ICAG) from Excelsior SL-10  demonstrating obvious floating clot (white arrow) in the cervical ICA (B: anteroposterior view; C: lateral view).
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ICA segment distal to the occlusion area. Imaging study performed from the Excelsior SL-10  Microcatheter demonstrated obvious floating clot in the cervical right ICA (Fig. 2B and C).
Intraoperative angiography; (A) OPTIMO (black arrow) is placed at the right common carotid artery (CCA). Balloons placed in the CCA are inflated; then a transluminal balloon angioplasty was performed with a 3.0-mm Gateway  PTA balloon catheter (white arrowhead) for the occluded area of the internal carotid artery (ICA). (B) Penumbra aspiration catheter, 5 MAX  ACE (black arrowhead), is passed distal to the position, allowing suctioning of the floating clot (white arrow) using this aspiration system. (C) A carotid wall stent was deployed and revascularization was recognized. (D) Postoperative angiography confirmed successful recanalization of the right ICA (thrombolysis in cerebral infarction (TICI) grade 3).
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Transluminal balloon angioplasty was performed with a 3.0-mm Gateway  Monorail  percutaneous transluminal angioplasty (PTA) Balloon Catheter (Stryker Neurovascular) for the occluded area within the ICA (Fig. 3A) and a Penumbra aspiration catheter 5MAX  ACE (Penumbra, Alameda, CA, USA) was passed distal to the position. Then, we performed a direct aspiration of the floating clot using this Penumbra aspiration catheter (Fig. 3B). Scientific) was deployed (Fig. 3C), and post-dilatation was performed using a 4.5-mm Sterling PTA balloon catheter (Boston Scientific). Subsequent angiography confirmed successful recanalization of the right ICA (thrombolysis in cerebral infarction (TICI) grade 3) at 7 h post-onset (Fig. 3D).
Single photon emission computed tomography (SPECT), three-dimensional computed tomographic angiography (3D-CTA) and carotid ultrasonography. (A) PAO-SPECT (1 day after endovascular surgery) reveals increased cerebral blood flow in the right cerebral hemisphere. (B, C) 3D-CTA (B) and carotid ultrasonography (C) shows sufficient patency 14 days postoperatively.
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The patient was restless with neurological abnormalities, and 123I IMP-single photon emission tomography (SPECT) (Fig. 4A) and INVOS-3100 revealed hyperperfusion in the territory of the right ICA. Carotid ultrasonography and three-dimensional computed tomographic angiography at 14 days (Fig. 4B and C) revealed no further obstruction to flow, and the patient was discharged 3 weeks after surgery with mild left motor weakness.