PMC8593815_01
PMC8593815_02
Case 1. (A) Digital subtraction angiography (DSA) oblique view demonstrating small unruptured aneurysm (red arrow) in the transition between the cavernous and clinoidal segments of the right internal carotid artery (ICA). (B) Intraoperative photograph of direct injection of fibrin glue into the cavernous sinus posterior to the ICA. (C) Indocyanine green (ICG) videoangiography demonstrating patency of the right ICA, darkened by the presence of atheroma in the center of the vessel, and patency of the right posterior communicating artery (PCoA) and (D) companion intraoperative photograph. (E) Postoperative axial computed tomography angiography (CTA) and (F) 3-dimensional CTA, superior skull base view, obtained 2 h after surgery, demonstrating complete occlusion of the right ICA. (G) Postoperative oblique-lateral DSA after several thrombectomies showing patency of the right ICA and contrast stagnation caused by poor collateral flow. Used with permission from Henan Provincial People's Hospital, Juha Hernesniemi International Center for Neurosurgery.
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F1
Digital subtraction angiography (DSA) confirmed a small unruptured aneurysm located in the transition between the ophthalmic and clinoidal segments of the ICA (Figure 1A). The bleeding persisted, requiring the injection of a second dose of fibrin glue at the same point (Figure 1B). Indocyanine green (ICG) videoangiography demonstrated patency of both the ICA and the posterior communicating artery (Figure 1C), with direct visualization noting stoppage of bleeding (Figure 1D). However, ~2 h postoperatively, left-sided hemiplegia and somnolence developed, and emergent computed tomography (CT) (Figure 1E) and CTA (Figure 1F) demonstrated complete occlusion of the ICA. Hence, the presence of contrast stagnation distally on following angiograms (Figure 1G).
PMC8593815_03
Case 2. Intraoperative photographs demonstrating (A) direct injection of fibrin glue into the cavernous sinus; (B) subsequent visualization of the patent internal carotid artery (ICA) during resection; and (C) 90 min later, the thrombosed middle cerebral artery, which has turned blue. (D) Postoperative posteroanterior angiography via the right common carotid artery demonstrating occlusion of the distal ICA. (E) Postoperative axial computed tomography of the head after decompressive hemicraniectomy and resection of ischemic territory. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
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F2
When bleeding from the CS occurred, as might be expected, fibrin glue was injected into the opening of the sinus (Figure 2A). Surgery proceeded in the usual manner (Figure 2B). ICA appeared dusky and darkened (Figure 2C). ICG videoangiography demonstrated a lack of flow in the ICA. The motor-evoked potential loss and arterial change were unexplained, and thus the patient underwent emergent angiography (Figure 2D). She then experienced a devastating ICA territory stroke (Figure 2E).