PMC7451183_01
Time-of-flight (TOF) magnetic resonance angiography at onset. (a) A double lumen sign is identified in the C7 segment of the internal carotid artery (ICA). (b) 3D TOF showed narrowing of the C7 portion of the ICA. The line represents the reference line of figure (a). (c) A double lumen sign is identified in the C3 segment of the ICA. (d) The line represents the reference line of figure (c).
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F1
Magnetic resonance imaging (MRI) was immediately performed [Figures 1 and 2].
Diffusion-weighted image (DWI) and digital subtraction angiography. (a) DWI showed infarction of the posterior limb of the internal capsule, basal ganglia, and the insular and frontal cortices. (b and c) Digital subtraction angiography showed C7 narrowing and the superior-most aspect of the ICA occlusion.
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F2
Magnetic resonance imaging (MRI) was immediately performed [Figures 1 and 2]. DSA showed irregular narrowing of the C7 ICA and at the superior-most aspect of the ICA occlusion [Figure 2].
Treatment time course. Surgical embolectomy began 198 min after the patient was admitted to the emergency room. Superficial temporal artery-middle cerebral artery bypass was completed 2 h after skin incision (6.7 h after onset), and complete recanalization was established 8.3 h (498 min) after onset.
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F3
The time course for the procedure is outlined in [Figure 3].
Postoperative imaging. (a) computed tomography angiography showed good patency of the superficial temporal artery-middle cerebral artery bypass and recanalization at the superior-most aspect of the internal carotid artery. (b) Diffusion- weighted image showed no additional infarction. (c) T2 imaging 2 weeks postonset showed hyperintensity on the posterior limb of the internal capsule and basal ganglia.
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F4
Postoperative diffusion-weighted imaging showed no additional infarction [Figure 4] and the patient's hemiparesis dramatically improved.
Pathological findings. Within the red thrombus, the internal elastic lamina is included in the Elastica-HE (a) and Elastica van Gieson stain (b). Calcification was also identified by Elastica van Gieson stain (c). CD34+ cells are identified in the thrombus (d).
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F5
Thrombus characteristics. CD3+ (a), CD20+ (b), and CD 68+ (c) cells are infiltrated in the thrombus.
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F6