PMC9078832_01
(a) Noncontrast CT: small border zone infarcts (white arrows) ASPECTS 10. (b) CT angiography: occlusion of the left ICA caused by a preexisting atherosclerotic stenosis (white arrow). (c) Time-to-peak map of CT perfusion: delay in maximum attenuation of 5.7 seconds.
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fig1
On in-house admission, the patient presented with only a mild neurological deficit (NIHSS 3 points given for Broca's aphasia and mild right arm paresis). cCT with CTA and CT perfusion (CTP) showed a persistent occlusion of the left ICA, with beginning border zone infarct demarcation between the anterior and middle cerebral artery territories and an extensive perfusion deficit within the territory of the middle and anterior cerebral arteries with a delay in a time-to-peak of 5.7 s in comparison to the nonaffected hemisphere (Figure 1).
(a) Lateral angiogram of the common carotid artery (CCA) showing occlusion of the ICA. (b) Lateral CCA angiogram: exclusive filling of the intracranial vessels through multiple collaterals (*), retrogradely filled ophthalmic artery (OA); arrows depict a connection between the middle meningeal artery (MMA) and OA. Dural anastomoses from MMA to ICA at the level of the skull base (**); arrow heads depict a branch of the sphenopalatine artery feeding the cavernous ICA (superimposed by the superficial temporal artery). (c) Lateral angiogram after intervention: (TICI3). Vessel wall irregularities are rated as atherosclerotic.
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fig2
Angiograms of the left common carotid artery showed the occluded ICA with distal filling at the level of the skull base through multiple collaterals from the external carotid artery indicating insufficient intracranial crossflow (Figures 2(a) and 2(b)). Despite concerns about thromboembolism from the long-term persisting long-distance occlusion, the final angiograms showed no intracranial vessel occlusions (modified treatment in cerebral infarction (mTICI) score 3) (Figure 2(c)).