PMC10396391_01
CT, MR, and SPECT scans obtained on admission. A: Contrast-enhanced T1-weighted head MRI scan showing an enhanced mass within the sphenoid sinus with infiltration of the bilateral cavernous sinuses (circle). B: Diffusion-weighted images showing scattered high signal intensities in the watershed area of the right cerebral hemisphere. C: MRA scan showing right internal carotid artery occlusion (dotted circle). D: Resting IMP-SPECT scan showing hypoperfusion of the right cerebral hemisphere.
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CT, computed tomography; IMP-SPECT, N-isopropyl-p-123I-iodoamphetamine single-photon emission computed tomography; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging
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This lesion appeared isointense on T1- and T2-weighted images and hyperintense on post-gadolinium T1-weighted images (Fig. 1A). Diffusion-weighted imaging showed scattered high signal intensities in the watershed area of the right cerebral hemisphere (Fig. 1B), and magnetic resonance angiography (MRA) revealed right ICA occlusion (Fig. 1C). N-isopropyl-p-123I-iodoamphetamine single-photon emission computed tomography (IMP-SPECT) performed at rest showed hypoperfusion of the right cerebral hemisphere (Fig. 1D).
Left ICA angiograms obtained before and during the first endovascular treatment. A: Left ICA angiogram (volume-rendered image) obtained on the 14th day of admission showing mild stenosis in the ophthalmic segment of the left ICA (arrow). B: Left ICA angiogram obtained on the 14th day of admission showing perfusion of the right cerebral hemisphere via cross flow from the left ICA. C: Left ICA angiogram (volume-rendered image) obtained on the 28th day showing progressive stenosis of the left ICA (arrow). D-F: Left ICA angiograms obtained on the 31st day before PTA (D), after PTA (E), and after stent placement (F).
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ICA, internal carotid artery; PTA, percutaneous transluminal angioplasty
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Cerebral angiography performed on the 14th day of admission revealed complete occlusion of the right ICA and mild stenosis of the ophthalmic segment of the left ICA (Fig. 2A). Left ICA angiography showed that the right cerebral hemisphere was mainly perfused via cross flow through the anterior communicating artery (Fig. 2B). Follow-up cerebral angiography performed on the 28th day of admission revealed progressive stenosis (Warfarin-Aspirin Symptomatic Intracranial Disease: 69%) in the ophthalmic segment of the left ICA without neurological deterioration (Fig. 2C). On the 31st day of admission, the patient underwent percutaneous transluminal angioplasty (PTA) for left ICA stenosis under general anesthesia using a Gateway 3.0 x 12 mm device (Stryker Neurovascular, Kalamazoo, Michigan, USA), followed by stent placement (Multilink 8: 3.0 x 12 mm [Abbott Laboratories, Chicago, Illinois, USA]) for recurrent stenosis secondary to elastic recoil after PTA (Fig. 2D-F).
Left ICA angiograms obtained before and during the second endovascular treatment. A-C: Left ICA angiograms (volume-rendered images) obtained on the 31st day of admission after stent placement (A), on the 52nd day (B), and on the 66th day (C) showing new progressive stenosis (arrow) adjacent to the proximal end (arrowhead) of the previous stent. D-F: Left ICA angiograms obtained on the 66th day before PTA (D), after PTA (E), and after stent placement (F).
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Follow-up angiographies performed on the 52nd and 66th days revealed new progressive stenosis in the clinoidal segment of the left ICA, immediately proximal to the site of the previous stent (Fig. 3A-C). On day 66, we successfully repeated the PTA procedure (Gateway: 3.0 x 15 mm) with concomitant stenting (Multilink 8: 3.5 x 15 mm) under general anesthesia (Fig. 3D-F).
The patient's clinical course, medications administered, and serum beta-D glucan level. A: T1-weighted head MRI scan showing that mass has disappeared at 2-year follow-up.
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AMPC/CVA, amoxicillin/clavulanate; CTRX, ceftriaxone; MNZ, metronidazole; PTAS, percutaneous transluminal angioplasty and stenting; VCM, vancomycin; VRCZ, voriconazole
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Therefore, the patient was transferred to the rehabilitation hospital on the 88th day of admission and was instructed to continue VRCZ treatment (Fig. 4).