PMC8769456_01
(A, B) DWI showing high signal intensity areas in the left frontal lobe, insular ribbon cortex, and deep white matter. (C, D) FLAIR images that showed high signal intensity at the DWI no longer showing high signal intensity areas. (E, F) (Stereo vision) MRA showing the left ICA occlusion. DWI: diffusion-weighted imaging, FLAIR: fluid-attenuated inversion recovery, ICA: internal carotid artery, MRA: magnetic resonance angiography.
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F1
Diffusion-weighted imaging (DWI) showed high signal intensity in an area of the left frontal lobe, insular cortex, and deep white matter (Alberta Stroke Program Early CT score [ASPECTS]-DWI, 6/11 points) (Fig. 1A and 1B). These areas did not appear high signal intensity on fluid-attenuated inversion recovery (FLAIR) image (Fig. 1C and 1D). Magnetic resonance angiography (MRA) did not show the left internal carotid artery (ICA), and the left MCA, but showed the left anterior cerebral artery (ACA) because of collateral flow via the anterior communicating artery (Fig. 1E and 1F).
(A) Frontal view, (B) lateral view, and (C) frontal view, enlarged. Left ICA angiogram before thrombectomy showing spontaneous recanalization of the left ICA and MCA, not cerebral flow to the frontal lobe from ACA and a part of the superior trunk of MCA, and filling defect sign at the superior wall of the left MCA near its origin (white arrow). (D) Frontal view, enlarged. Aspiration catheter (AXS Catalyst6, bold white line) was introduced to nearby the filling defect. Thrombectomy using a ADAPT was performed. ACA: anterior cerebral artery, ADAPT: direct aspiration first pass technique, ICA: internal carotid artery, MCA: middle cerebral artery.
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F2
MCA, but no cerebral flow to the frontal lobe from a part of the superior trunk of MCA was noted (Fig. 2A and 2B). Moreover, there was a filling defect sign at the anterior superior wall of the left MCA near its origin (Fig. 2A and 2C). AXS Catalyst6 (Cat6, Stryker), was introduced to the nearby filling defect, using a stent-anchoring technique with Solitaire FR stent 4 x 40 mm (Medtronic, Dublin, Ireland) and expanded it from the left MCA horizontal portion to the distal ICA inside the filling defect (Fig. 2C and 2D).
(A) Frontal view, (B) lateral view, and (C) frontal view, enlarged. Left ICA angiogram after thrombectomy showing complete recanalization. Left ACA (black arrowheads) originating from the filling defect sign (Fig. 2, white arrow). AMCA (black arrow) originating from the proximal ACA. Dotted black arrow showing the main MCA. ACA: anterior cerebral artery, AMCA: accessory middle cerebral artery, ICA: internal carotid artery, MCA: middle cerebral artery.
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F3
The thrombectomy achieved complete recanalization (Fig. 3A and 3B), which was defined as a thrombolysis with a cerebral infraction score of 3 (TICI 3) (door to puncture, 124 minutes; puncture to recanalization, 94 minutes). AMCA, which arose from the proximal A1 segment of the left ACA (Fig. 3C). After the procedure, head CT showed a mild hemorrhagic infarction, which was caused by reperfusion after thrombectomy (Fig. 4A and 4B).
(A, B) CT of the head carried out immediately after thrombectomy showing mild hemorrhagic infarction of the left frontal lobe, insula cortex, and putamen. (C, D) CT of the first day after thrombectomy showing cerebral infarction of left frontal lobe, insula cortex, and putamen. CT: computed tomography.
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F4
AMCA, which arose from the proximal A1 segment of the left ACA (Fig. 3C). After the procedure, head CT showed a mild hemorrhagic infarction, which was caused by reperfusion after thrombectomy (Fig. 4A and 4B).