PMC9020867_01
Imaging findings on admission.. MR images (DWI: A, MRA: B), left CCA angiography (early phase; C, E, late phase; D, F), and right ICA angiography on admission. Resting single-photon emission tomography (SPECT) of 123I-IMP on the day after admission (H).. Diffusion-weighted MR image showing acute ischemic lesions distributed in the linear border zone (A). The left ICA is not delineated (B). The left ICA is occluded at its origin and collateral blood flow from the ipsilateral external carotid artery through the ophthalmic artery to the ICA was observed (C-F). Right ICA angiography showed no crossflow into the left MCA via the Acom (G). 123I-IMP resting SPECT showed decreased blood flow mainly in the border zone of the left hemisphere (H).. Abbreviations: MR, magnetic resonance; MRA, magnetic resonance angiography; DWI, diffusion-weighted image; CCA, common carotid artery; ICA, internal carotid artery; SPECT, single-photon emission tomography; MCA, middle cerebral artery; Acom, anterior communicating artery.
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Magnetic resonance (MR) imaging showed acute ischemic lesions in the border zone of the middle cerebral artery (MCA) and anterior cerebral artery (ACA) of the left hemisphere (Fig. 1A). MR angiography did not delineate the left internal carotid artery (Fig. 1B). On the day of admission, cerebral angiography revealed that the left ICA was completely occluded from its origin (Fig. 1C, D). Collateral blood flow from the ipsilateral external carotid artery through the ophthalmic artery to the ICA was observed (Fig. 1D, F). Right ICA angiography showed no crossflow into the left MCA via the anterior communicating artery (Fig. 1G). Resting single-photon emission tomography (SPECT) of 123I-IMP on the day after admission showed decreased blood flow mainly in the border zone of the left hemisphere (Fig. 1H).
Imaging when symptoms worsen and endovascular treatment.. MR image on day 4 when symptoms worsened (A). Angiography (B, C, D, F) and gross appearance of a retrieved thrombus (E). New infarcts are observed in the center of the MCA supply region (A, circle). The already existing infarcts in the centrum semiovale enlarge. The occluded ICA is recanalized (early phase; B, late phase; C, arrowheads). There is a thrombus after stenting (D, arrow). Red thrombi are retrieved (E). Finally, complete recanalization is performed (F).. Abbreviations: MR, magnetic resonance; MCA, middle cerebral artery; ICA, internal carotid artery.
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Diffusion-weighted MR image revealed a mildly enlarged infarct zone in the centrum semiovale and new spot infarcts in the left precentral and postcentral gyri (Fig. 2A). A left carotid angiogram revealed recanalization of the left ICA, which had severe stenosis and slow antegrade blood flow (Fig. 2B, C). After retrieval of the SpiderFX, there was a thrombus located in the petrous segment (Fig. 2D). The thrombus was retrieved using React71 (Medtronic, Irvine, CA, USA) (Fig. 2E). Finally, complete revascularization was achieved (Fig. 2F).