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Pre-procedural imaging. (A) Magnetic resonance angiography showing occlusion of the right internal carotid artery. The right middle cerebral artery is weakly visible with collateral flow through the anterior communicating artery. (B) Diffusion-weighted imaging showing no apparent acute ischemic changes.
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MRI revealed occlusion of the right ICA without apparent acute ischemic changes (Fig. 1A and B).
Intra-procedural imaging. (A) Initial angiography showing occlusion of the right internal carotid artery. (B and C) In the first pass using a Trevo NXT 6 x 37 mm stent retriever, digital subtraction angiography (DSA) and native angiography in the lateral projection show blood flow restoration with obscure contrast defects in the stent. (D-F) In the second pass using the Trevo stent retriever and a Catalyst 7 aspiration catheter, angiography shows blood flow restoration with changes in the morphology of the contrast defects as well as a parallel linear contrast on the outside of the vessel wall. These angiographic findings, which were identified as mural hematoma and false lumen with dissection flap, indicated the presence of dissection on the paraclinoid segment. (G and H) During antiplatelet loading and preparation of a dedicated intracranial stent, the Trevo stent retriever was left deployed to maintain the blood flow. (I) After the Trevo was resheathed and removed from the microcatheter, the artery became occluded again. (J and K) An Enterprise-2 5 x 39 mm stent was deployed as permanent stenting. (L) Final angiography revealing complete recanalization.
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ICA. Initial angiography revealed occlusion of the right ICA (Fig. 2A). Angiography performed during stent retriever deployment showed obscure contrast defects in the stent strut with immediate flow restoration (Fig. 2B and C). For the second pass, we applied the combined thrombectomy technique using the Trevo stent retriever and a Catalyst 7 aspiration catheter (Stryker) (Fig. 2D-F). During antiplatelet loading (200 mg aspirin and 300 mg clopidogrel) and preparation of a dedicated intracranial stent, the Trevo stent retriever was left deployed to maintain the blood flow (Fig. 2G and H). The lesion became occluded again after the Trevo was resheathed and removed from the microcatheter during the exchange method to keep the microcatheter in the dissected vessel (Fig. 2I). After permanent stenting with an Enterprise-2 stent (Cerenovus, Irvine, CA), angiography revealed thrombolysis in cerebral infarction 3 complete recanalization (Fig. 2J-L).
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Post-procedural imaging. (A) Magnetic resonance angiography performed on the day after the procedure, showing successful revascularization. (B) Diffusion-weighted imaging showing no apparent acute ischemic changes.
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The day after the procedure, MRI revealed successful revascularization without any infarction (Fig. 3A and B).
Follow-up imaging. (A and B) Six months after the procedure, follow-up angiography in the frontal and lateral projections showing resolution of dissection with minimal stenosis. (C) Cone-beam computed tomography imaging showing sufficient stent-wall apposition.
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At 6 months postoperatively, follow-up angiography confirmed the resolution of the dissection with minimal stenosis (Fig. 4A-C).