PMC4235116_01
At onset of cerebral infarction, diffusion weighted magnetic resonance imaging (DW-MRI) revealed fresh infarctions in the left cerebral hemisphere (1-A, arrows). MRA revealed a stenotic lesion in the cervical segment of the left ICA (1-B, arrow). DSA (1-C, arrow), and MRA (1-D, arrows) on the second day after the onset revealed no evidence of stenosis
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F1
Emergent diffusion-weighted magnetic resonance imaging (DW-MRI) revealed fresh cerebral infarctions [Figure 1a, arrows]. Magnetic resonance angiography (MRA) revealed a suspicious stenotic lesion in the cervical segment of the left ICA [Figure 1b, arrow]. No evidence of stenosis was found [Figure 1c, arrow]. MRA was performed again, and the result was the same as the DSA [Figure 1d, arrow].
Myocardial scintigraphy identified the area without myocardial viability. Thereafter, an old myocardial infarction of the inferolateral wall was confirmed (Figure 2-a). Normal coronary angiography suggested that vasospasm was also the cause of the myocardial infarction in this case [Figure 2b]
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F2
A Holter electrocardiogram (ECG) detected no arrhythmia; however, her ECG and cardiac echogram suggested an old myocardial infarction of the inferolateral wall, which was confirmed by myocardial scintigraphy [Figure 2a]. Normal coronary angiography suggested that vasospasm was also the cause of the myocardial infarction in this case [Figure 2b].
The first carotid stent was placed covering the bifurcation in the same fashion as for atherosclerotic stenosis from the level of the upper C2 superior endplate to the body of the C5 [Figure 3a, arrowhead]. Without vasospasm, MRA showed no blood flow defects, even after the first stenting [Figure 3b]. While the vasospasm was occurring, MRA revealed moderate [Figure 3c, arrow] or severe [Figure 3d, arrow] stenosis at the prepetrous portion of the internal carotid artery. The second stent was placed covering the stenotic/spasm region [Figure 3e, arrowhead]
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F3
Because the safety of stent deployment near to the first cervical vertebra, where the torsional stress might be larger than lower cervical levels, had not been established, CAS covering only the bifurcation in the same fashion as for atherosclerotic stenosis was performed, using a Carotid Wallstent  [Figure 3a]. However, symptoms suggesting vasospasm continued, and it presented twice radiologically during the 7 months following CAS [Figure 3b-d]. CAS to cover the stenotic/spasm region of the ICA [Figure 3e]. Considering the possible torsional stress and the spasm strength of the carotid artery, we again used a Carotid Wallstent , which is proven to have the highest external pressure among the stents available in Japan.