PMC7771481_01
Lateral view of conventional angiography showing (a) the bifurcation of the right common carotid artery and (b) the right internal carotid artery terminal occlusion. The black arrow indicates the occluded site.
SNI-11-446-g001.jpg
PMC7771481_01_SNI-11-446-g001.jpg
F1
Conventional angiography revealed terminal occlusion of the ICA [Figure 1].
(a) Contrast injection through microcatheter-guided distal to the occlusion site depicted a middle cerebral artery (MCA) bifurcation aneurysm. The black arrow indicates the aneurysm. (b) The stent retriever is deployed from the MCA M2 segment proximal to the internal carotid artery terminal (ICA-T), and the reperfusion catheter is placed at the ICA-T. The arrowheads show the stent retriever. (c) Angiography performed after the first attempt showing persistence of the MCA M1 proximal occlusion.
SNI-11-446-g002.jpg
PMC7771481_01_SNI-11-446-g002.jpg
F2
The microcatheter passed through the occlusion site, and contrast injection showed that it was guided distal to the occlusion site; an MCA aneurysm was also revealed [Figure 2a]. The stent retriever (Trevo 4 x 30 mm; Stryker Neurovascular, Fremont, CA, USA) was deployed from the MCA M2 segment proximally to cover the thrombus [Figure 2b], and the reperfusion catheter (Catalyst 6; Stryker Neurovascular, Fremont, CA, USA) was placed at the ICA terminal. Recanalization of the anterior cerebral artery was achieved on the first attempt, but the MCA M1 proximal occlusion remained [Figure 2c].
(a) Angiography performed immediately before the second mechanical thrombectomy (MT) showing subarachnoid hemorrhage around the middle cerebral artery aneurysm. (b) Angiography performed after the second MT showing recanalization of the thrombolysis in the cerebral infarction 2b and hemostasis achievement. (c) Subarachnoid hemorrhage and extravasated contrast medium as seen on flat-panel detector computed tomography.
SNI-11-446-g003.jpg
PMC7771481_01_SNI-11-446-g003.jpg
F3
Angiography performed after the stent retriever deployment showed subarachnoid hemorrhage (SAH) [Figure 3a], possibly caused by the rupture of the aneurysm during withdrawal of the first stent or during microguidewire manipulation, until the second stent was deployed. In the angiography after the second MT, we confirmed that the bleeding due to the ruptured MCA aneurysm had stopped and recanalization of thrombolysis in cerebral infarction (TICI) 2b was achieved [Figure 3b]. SAH and extravasated contrast medium [Figure 3c]. Shortly thereafter, coil embolization of the ruptured aneurysm was performed under general anesthesia [Figure 4].
(a) Pre- and (b) postcoil embolization of the ruptured middle cerebral artery aneurysm.
SNI-11-446-g004.jpg
PMC7771481_01_SNI-11-446-g004.jpg
F4
SAH and extravasated contrast medium [Figure 3c]. Shortly thereafter, coil embolization of the ruptured aneurysm was performed under general anesthesia [Figure 4].