PMC3841922_01
MR angiogram of the head reveals focal pseudoocclusion of the right M1
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F1
After removal of the patient's orthodontic appliance, magnetic resonance (MR) imaging and MR angiography of the brain confirmed completed infarction of approximately one-half of the right MCA territory due to a focal pseudoocclusion (high-grade stenosis causing near occlusion) in the distal M1 at the MCA bifurcation [Figure 1].
Diffusion-weighted magnetic resonance image (a) and noncontrast computed tomographic scan of the head (b) show completed infarct
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F2
Endovascular revascularization was felt to be a poor option due to the >24-hour duration of symptoms prior to neurosurgical involvement, completed nature of the infarction, and large volume of MCA territory involved [Figure 2].
Noncontrast CT scan of head shows hemorrhagic conversion of right MCA territory infarct
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F3
Subsequently, a decompressive craniectomy was performed due to increasing mass effect from the progression of stroke causing increased lethargy and left-sided hemiplegia [Figures 3 and 4].
Noncontrast CT scan of head after decompressive craniectomy showing improvement of midline shift
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F4
Subsequently, a decompressive craniectomy was performed due to increasing mass effect from the progression of stroke causing increased lethargy and left-sided hemiplegia [Figures 3 and 4].
Noncontrast CT scan of head shows increased intracerebral hemorrhage with midline shift associated with the ruptured mycotic aneurysm
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F5
CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
CT angiogram of head, thin-cut axial image, reveals right M1 ruptured mycotic aneurysm
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F6
CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
CT angiogram of head, coronal reconstruction, reveals right M1 ruptured mycotic aneurysm
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F7
CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
CT angiogram of head, sagittal reconstruction, reveals right M1 ruptured mycotic aneurysm
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F8
CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
Cerebral angiogram - early arterial phase, anteroposterior (AP) internal carotid artery injection - reveals right M1 mycotic aneurysm with occlusion of distal branches
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F9
Given completion of the M1 occlusion, extension of the MCA infarction, and rapid growth of the pseudoaneurysm, both parent vessel and pseudoaneurysm were rapidly coiled to complete obliteration [Figures 9-11].
Cerebral angiogram - mid-arterial phase; AP internal carotid artery injection - reveals right M1 mycotic aneurysm with occlusion of distal branches
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F10
Given completion of the M1 occlusion, extension of the MCA infarction, and rapid growth of the pseudoaneurysm, both parent vessel and pseudoaneurysm were rapidly coiled to complete obliteration [Figures 9-11].
Cerebral angiogram - early arterial phase, AP internal carotid injection - reveals coiled M1 mycotic aneurysm and parent vessel
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F11
Given completion of the M1 occlusion, extension of the MCA infarction, and rapid growth of the pseudoaneurysm, both parent vessel and pseudoaneurysm were rapidly coiled to complete obliteration [Figures 9-11].
Noncontrast CT scan of head status post hematoma evacuation showing improvement of mass effect
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F12
From the endovascular suite, the patient was taken directly to the operating room for hematoma evacuation [Figure 12].