PMC10287161_01
Computed tomography (CT). ASPECTS plan basal ganglia with no early ischemic changes (A). Posteroanterior projection of CT angiography showing left ICA occlusion (white arrows) and flow to left MCA through ACOM (B, C).
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F1
Head CT showed microangiopathy without signs of intracranial bleeding (Figure 1A). Furthermore, CT angiography (CTA) of cervical and intracranial vessels evidenced left internal carotid artery (ICA) occlusion at the level of carotid bulb, with compensatory collateral flow from the circle of Willis by anterior communicating artery (ACOM) (Figures 1B, C). TCCS showed a decrease >30% in flow velocity in the A1 segment of the left anterior cerebral artery (Figure 3C). The patient was then carried on with a diagnostic digital subtraction angiography (DSA), which revealed that cerebral left anterior territory was now supplied exclusively by anterior and posterior collateral pial circulation (CPC) (Supplementary Figures 1, 2), with failure in collateral flow from the circle of Willis (Figure 4A). DSA revealed a left carotid bulb subocclusive stenosis, and revascularization was performed (Figures 4B, C). During the procedure, it was observed that the true lumen originated from the petrous segment leading to revascularization performed by two telescopic braided stents plus a carotid stent (Supplementary Figures 1, 2).
Diffusion-weighted magnetic resonance imaging (DW-MRI) and magnetic resonance angiography 3D time-of-flight (MRA 3D-TOF). DW-MRI showing left cortical diffusion restriction in MCA territory (A, B). Posteroanterior projection of MRA 3D-TOF demonstrating left ICA occlusion with apparent patency of the circle of Willis by ACOM (C).
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F2
Diffusion-weighted magnetic resonance imaging (DW-MRI) showed left cortical diffusion restriction in the middle cerebral artery (MCA) territory, and 3D time-of-flight magnetic resonance angiography (3D-TOF-MRA) confirmed left ICA occlusion with apparent patency of the circle of Willis by ACOM (Figure 2). TCCS showed a decrease >30% in flow velocity in the A1 segment of the left anterior cerebral artery (Figure 3C). The patient was then carried on with a diagnostic digital subtraction angiography (DSA), which revealed that cerebral left anterior territory was now supplied exclusively by anterior and posterior collateral pial circulation (CPC) (Supplementary Figures 1, 2), with failure in collateral flow from the circle of Willis (Figure 4A). DSA revealed a left carotid bulb subocclusive stenosis, and revascularization was performed (Figures 4B, C). During the procedure, it was observed that the true lumen originated from the petrous segment leading to revascularization performed by two telescopic braided stents plus a carotid stent (Supplementary Figures 1, 2).
Transcranial color-coded duplex sonography (TCCS). TCCS shows the circle of Willis (A). Initial evaluation shows reversed flow direction: left A1 segment flow from the ACOM (positive wave) (B) and second assessment after clinical worsening demonstrating flow inversion and a significant decrease in velocities (C).
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F3
Furthermore, TCCS was performed and confirmed such findings (Figures 3A, B). TCCS showed a decrease >30% in flow velocity in the A1 segment of the left anterior cerebral artery (Figure 3C). The patient was then carried on with a diagnostic digital subtraction angiography (DSA), which revealed that cerebral left anterior territory was now supplied exclusively by anterior and posterior collateral pial circulation (CPC) (Supplementary Figures 1, 2), with failure in collateral flow from the circle of Willis (Figure 4A).
Digital subtraction angiography (DSA). Posteroanterior projection from right ICA shows pial collateral circulation (blue arrow) from left ACA to left MCA (A). Posteroanterior projection shows left ICA occlusion with subocclusive stenosis (B) and final control from left ICA demonstrating complete reperfusion. There was no embolus in the anterior circulation (C).
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F4
TCCS showed a decrease >30% in flow velocity in the A1 segment of the left anterior cerebral artery (Figure 3C). The patient was then carried on with a diagnostic digital subtraction angiography (DSA), which revealed that cerebral left anterior territory was now supplied exclusively by anterior and posterior collateral pial circulation (CPC) (Supplementary Figures 1, 2), with failure in collateral flow from the circle of Willis (Figure 4A). DSA revealed a left carotid bulb subocclusive stenosis, and revascularization was performed (Figures 4B, C). During the procedure, it was observed that the true lumen originated from the petrous segment leading to revascularization performed by two telescopic braided stents plus a carotid stent (Supplementary Figures 1, 2).