PMC10370509_01
Pre- and intra-operative images of carotid artery stenting. (A) DWI shows acute cerebral infarction in the watershed area of the right hemisphere. (B and C) MRA shows the right carotid artery stenosis and a decrease in the intensity of the right MCA. (D) Black-blood T1-weighted imaging shows hyperintensity at the right carotid artery stenosis. (E) Resting 99mTc-ECD SPECT shows no significant reduction in cerebral blood flow. (F) Preoperative right common carotid angiography shows carotid artery stenosis (NASCET 85%). (G and H) DA and DSA after stent deployment show no-flow phenomenon caused by plaque protrusion. (I) Balloon angioplasty. (J-L) Postoperative DSA shows good stent dilation and no sign of plaque protrusion in the carotid artery, with no delays in cerebral blood flow and no cerebral vasospasm. DA: digital angiography; DWI: diffusion-weighted imaging; MCA: middle cerebral artery; NASCET: North American Symptomatic Carotid Endarterectomy Trial; SPECT: single-photon emission CT; 99mTc-ECD: technetium-[99m] ethyl cysteine dimer
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F1
MCA watershed region was identified on diffusion-weighted imaging (DWI) (Fig. 1A). MRA showed reduced signal intensity in the right intracranial ICA and cervical MRA showed stenosis in the right ICA (Fig. 1B and 1C). Trial method and appeared as a signal hyperintensity on black-blood T1-weighted MRI (Fig. 1D and 1F). Technetium-[99m] ethyl cysteine dimer (99mTc-ECD) single-photon emission CT (SPECT) did not reveal any reduction in cerebral blood flow (Fig. 1E). After the CCA was unblocked, cerebral angiography revealed a contrast defect in the stent, which was diagnosed as plaque protrusion on intravascular ultrasonography (OtpiCross; Boston Scientific) and gradually progressed to a no-flow phenomenon (Fig. 1H). However, this subsequently improved to 65%/66% right/left after percutaneous balloon angioplasty and careful retrieval of the protection filter (Fig. 1I and 1J). Cervical and intracranial vessels were well delineated on final DSA (Fig. 1K and 1L).
Images on Day X for diagnosis and treatment of cerebral vasospasm. (A) DWI shows a new, small cerebral infarction in the right frontal lobe. (B) MRA shows poor visualization of the distal right MCA. (C) SPECT shows decreased blood flow in the right hemisphere. (D and E) DSA shows diffuse vasospasm and delayed blood flow in the right MCA. (F and G) DSA after selective intra-arterial infusion of fasudil hydrochloride shows immediate improvement of cerebral vasospasm and delayed blood flow. DWI: diffusion-weighted imaging; MCA: middle cerebral artery; SPECT: single-photon emission CT
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F2
Although no decline in rSO2 was evident (61%/59% right/left), 99mTc-ECD SPECT showed reduced blood flow in the right MCA region (Fig. 2A-2C). DSA revealed diffuse cerebral vasospasm in the periphery of the right MCA (Fig. 2D and 2E). Vasospasm improved immediately after selective arterial infusion of fasudil hydrochloride (total dose, 12.5 mg) (Fig. 2F and 2G).
Images after selective intra-arterial infusion of fasudil hydrochloride. (A) MRA on Day X+1 shows no recurrence of vasospasm. (B) SPECT on Day X+2 shows hyperperfusion of the right hemisphere. (C and D) MRA and SPECT on Day X+9 show improvement of cerebral vasospasm and hyperperfusion. SPECT: single-photon emission CT
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F3
The right MCA was well delineated on MRA (Fig. 3A). On Day X+2, SPECT revealed an increase in cerebral blood flow in the right MCA region (Fig. 3B). MRA was performed on Day X+4 and Day X+9, showing no recurrences of vasospasm (Fig. 3C). On Day X+9, 99mTc-ECD SPECT showed that hyperperfusion had improved (Fig. 3D).
Clinical course of rSO2. The vertical line shows rSO2 (%) in the right and left forehead. #1, proximal balloon protection during pre-dilation and stent placement; #2, flow stoppage after stent placement; #3, selective arterial injection of fasudil hydrochloride; and #4, seizure attack. rSO2: tissue oxygen saturation
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F4
Taking these findings together with the previous seizure episode, CHS was diagnosed (Fig. 4).