PMC3008916_01
Right lateral common carotid digital subtraction angiography cervical view showing an intimal flap and smooth tapered cervical carotid dissection extending up to the cervical/petrous junction.
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F1
Initial cervical carotid catheter angiography revealed a right posterior cervical carotid intimal flap indicating an intimal-media arterial dissection (Figure 1).
Right lateral common carotid digital subtraction angiography cerebral view showing markedly delayed anterograde flow in the internal carotid artery with a supraclinoid occlusion and flow defects in petrous and cavernous section of carotid artery.
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F2
Cerebral views showed delayed anterograde filling in the internal carotid artery associated with a carotid terminus occlusion (Figure 2).
Right lateral common carotid digital subtraction angiography cervical view showing microguidewire in the dissected segment of cervical carotid artery, worsening the underlying pathology.
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F3
Attempts at advancing a Penumbra 41 reperfusion catheter (Penumbra Inc, Alameda, CA, USA) intracranially were unsuccessful because the edge of the reperfusion catheter could not be advanced past the dissection flap at the distal cervical carotid artery (Figure 3).
Right lateral common carotid digital subtraction angiography cerebral view showing a near occlusive intimal flap at the cervical petrous section.
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F4
Subsequent angiography showed a more proximal occlusive lesion, suggesting that the intimal flap had extended into the petrous carotid with further compromise of the luminal diameter (Figure 4).
After proximal flow arrest and aggressive proximal guiding catheter aspiration, TIMI 3 flow in the internal carotid is restored. The dissection is now seen to extend into the petrous section, but is not flow limiting.
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F5
Subsequent angiographic runs, however, demonstrated TIMI 3 recanalization of the internal carotid artery with a persisting but non-occlusive intimal flap along the petrous/cervical section (Figure 5).
Diffusion weighted MRI showing increased signal in a superior division middle cerebral artery branch territory.
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F6
MRI and MRA of the head and neck was done the following day, showing a stable appearance to the dissection and a right superior division MCA territory stroke (Figure 6).