PMC8769482_01
Preoperative MRI and digital subtraction angiography. (A) High intensity was observed in the left frontal watershed area on initial MRI DWI. (B) MRA showed stenosis of the bilateral ICA terminus. Depiction of the left MCA was reduced compared to the right MCA. (C and D) The right and left ICAG (A-P view) before surgery. ICA stenosis was more severe on the left side than on the right side. (E and F) MRI obtained the day before surgery shows no new cerebral infarction and slightly improved blood flow signal within the ACA; bilateral ICA terminal stenoses remain. A-P: anterior-posterior, ACA: anterior cerebral artery, DWI: diffusion-weighted imaging, ICA: internal carotid artery, ICAG: internal carotid angiography, MCA: middle cerebral artery.
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F1
She was diagnosed with left frontal lobe infarction and bilateral ICA terminal stenosis due to repeated transient right paresis and aphasia (Fig. 1A and 1B). Although stenosis was also found at the terminal of the right ICA, we decided to treat the symptomatic left ICA stenosis (Fig. 1C and 1D). A preoperative MRI showed no new cerebral infarction and slightly improved blood flow signal within ACA; however, bilateral ICA terminal stenoses remained (Fig. 1E and 1F).
MRI, MRA, and digital subtraction angiography just after the appearance of postoperative symptoms. (A) A high-intensity area appeared in the right frontal lobe on MRI DWI. (B) The MCA blood flow signal disappeared in MRA. (C) The right ICAG (A-P view). Blood flow beyond the ICA terminus was delayed. (D) Rebar 18 153 cm (Medtronic, Minneapolis, MI, USA) and Chikai 14 guide wires (Asahi Intech, Aichi, Japan) were guided to the ICA terminus, and only the Micro guide wire was lesion-crossed to MCA. A Penumbra 4MAX catheter (Penumbra, Alameda, CA, USA) was pressed against the obstruction (white arrow). (E) The right ICAG after one pass. The MCA recanalized slightly, and thrombus was revealed just distal of stenosis (white double arrow). (F) Post ICAG showed antegrade blood flow of the MCA. A-P: anterior-posterior, DSA: digital subtraction angiography, DWI: diffusion-weighted imaging, ICA: internal carotid artery, ICAG: internal carotid angiography, MCA: middle cerebral artery.
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F2
Bilateral MCA blood flow signal disappeared in MRA (Fig. 2A and 2B). Blood flow beyond the right ICA terminus was extremely delayed in DSA, and MT was performed using a suction catheter (Fig. 2C-2F).
MRI and MRA after MT. (A) A high-intensity area was observed in part of the frontal lobe and basal ganglia on the follow-up MRI DWI. (B) The right MCA blood flow signal improved in MRA at day 12 after the procedure. The signal of the left MCA remained absent, but no infarction appeared. DWI: diffusion-weighted imaging, MCA: middle cerebral artery, MT: mechanical thrombectomy.
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F3
MT, the disturbance of consciousness improved, and the patient was able to communicate. MRI showed new infarcts in the frontal cortex and basal ganglia instead of extensive infarcts in the right cerebral hemisphere (Fig. 3A). Oral administration of clopidogrel was continued, and MRA on the 12th day after the surgery showed that the blood flow signal of the right MCA was improved (Fig. 3B).