PMC8571319_01
Pretreatment imaging (a and b) 9 months before presentation and (c, d) on admission before thrombectomy. (a) DWI revealed subtle right cerebral infarction indicating artery to artery embolism. (b) IA angiogram showed right IA-SA-proximal CCA stenosis. (c) Right ICA was occluded on MRA. (d) DWI showed acute cerebral infarction in the right middle cerebral artery area (DWI-Alberta Stroke Program Early Computed Tomography Score of 9).
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F1
Health Stroke Scale score of 8. He had been diagnosed with subtle right cerebral infarction [Figure 1a] and right IA-subclavian artery (SA)- proximal CCA stenosis 9 months previously [Figure 1b], and he had been treated conservatively with administration of aspirin and clopidogrel in our institute. Diffusion-weighted magnetic resonance imaging (DWI) and magnetic resonance angiography (MRA) showed occlusion of the right ICA with an acute cerebral infarction in the right middle cerebral artery area (DWI-Alberta Stroke Program Early Computed Tomography Score of 9) [Figure 1c and d].
Diagnostic angiogram and mechanical thrombectomy. (a) Frontal view of IA angiogram showed severe stenosis from the IA to proximal CCA and occlusion of the right SA. (b) Frontal view of right CCA angiogram revealed occlusion of the right ICA. (c) Oblique view of right ICA angiogram showed partial recanalization (Thrombolysis in Cerebral Infarction grade 2b) without several branches.
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F2
Angiography showed severe stenosis from the IA to the proximal CCA and occlusion of the right SA [Figure 2a]. As the balloon guiding catheter was carefully passed over the IA lesion, CCA angiography revealed occlusion of the ICA [Figure 2b]. After a second pass using the same system, ICA angiography showed partial recanalization of the inferior trunk of the middle cerebral artery (Thrombolysis in Cerebral Infarction Grade 2B) [Figure 2c].
Post thrombectomy head DWI and neck CTA. (a) DWI showed localized ischemic change in the territory of the right MCA that was almost identical to the preoperative DWI. (b) MRA showed recanalization of the right ICA and MCA without several distal branches. (c) The axial view of neck CTA indicated a massive plaque occupying the IA and right SA (d) CTA showed severe stenosis of the IA and proximal CCA as well as occlusion of the right SA.
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F3
MRA and DWI on postoperative day 1 showed successful recanalization and localized ischemic change [Figure 3a and b]. We also identified severe IAS by postoperative computed tomography angiography [Figure 3c and d].
(a) Microsurgical view and (b-d) postoperative imaging. (a) End-to-side anastomosis between the PTFE vascular graft through the retropharyngeal tunnel and the right CCA was performed. (b) Frontal view of left CCA angiogram revealed patency of the bypass and complete ligation of the right CCA. (c) Frontal view of left CCA angiogram revealed anterograde flow of the bilateral intracranial ICAs. (d) Postoperative computed tomography showed no remarkable change compared with preoperative computed tomography.
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F4
The same procedure was then performed for the right CCA [Figure 4a]. One day after the surgery, the patency of the bypass, ligation of the right CCA, and anterograde flow of the bilateral intracranial ICAs were assessed by angiography [Figure 4b and c]. Postoperative computed tomography showed no remarkable change compared to preoperative computed tomography [Figure 4d].