PMC8492412_01
Diffusion-weighted imaging showing a slightly high-intensity area in the right occipital lobe, right thalamus, and right hippocampus (a and b). MR angiography showing right posterior cerebral artery occlusion at the P1 segment (c).
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F1
Magnetic resonance (MR) diffusion-weighted imaging revealed slightly high-intensity signals in the right occipital lobe, right thalamus, and right hippocampus [Figure 1a and b] while MR-angiography showed the right posterior cerebral artery occlusion at the P1 segment and unclear blood flow in the left VA [Figure 1c].
Angiography before mechanical thrombectomy. The right posterior cerebral artery was occluded at the P1 segment (a). Angiography after thrombectomy. Thrombolysis in cerebral infarction 3 complete reperfusion was achieved (b).
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F2
We immediately started IV rt-PA and performed cerebral angiography, revealing a right P1 occlusion [Figure 2a]. Complete first-pass perfusion was achieved and the thrombolysis in cerebral infarction (TICI) score was Grade 3 [Figure 2b].
Angiography of the left subclavian artery. The left VA was occluded from its origin (a). Anterior-posterior view (b) and lateral view (c) of angiography of the left subclavian artery. The left deep cervical artery was anastomosed to the left VA and its antegrade flow in the VA was stagnant. VA: Vertebral artery.
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F3
Angiography also revealed a left VA occlusion from its origin [Figure 3a], with the left deep cervical artery anastomosed to the left VA and forming an antegrade stagnant flow to the proximal end of the left VA [Figure 3b and c].
Angiography before the second thrombectomy. Basilar artery occlusion was revealed (a). Angiography after thrombectomy. Blood flow to the cerebellum other than the left posterior inferior cerebellar artery was absent (b).
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F4
CT showed a high-density thrombus in the BA while angiography further revealed BA occlusion, necessitating a repeat mechanical thrombectomy with a stent retriever [Figure 4a]. TICI grade 2A partial reperfusion but blood flow to the cerebellum was absent [Figure 4b] and the left VA was still occluded from its origin. The patient died 3 h after the procedure.