PMC8194065_01
Magnetic resonance imaging (MRI) and angiography findings. (A) Magnetic resonance angiography (MRA) showing the left internal carotid artery (ICA) occlusion. (B) T2*-weighted MRI showing the susceptibility vessel sign at the top of the ICA (arrow). (C) Left internal carotid angiography showing the left proximal ICA occlusion (lateral view). (D) Angiography via the aspiration catheter in the cervical ICA showing a continuous filling defect (arrowheads) from the cervical ICA to the intracranial ICA (anteroposterior view). (E) Final angiography showing successful reperfusion (anteroposterior view). (F) Final angiography showing the left ICA stenosis (arrow, lateral view). (G) Neck MRA showing the left ICA stenosis. (H,I) Magnetization-prepared rapid gradient-echo image and maximum intensity projection images from time-of-flight MRA (level of the dotted line) showing high signal intensity in the plaque compared with the sternocleidomastoid muscle (asterisk).
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MR angiography revealed the left ICA occlusion (Figure 1A). T2*-weighted MRI performed as the routine protocol showed a susceptibility vessel sign at the top of the ICA (Figure 1B). The initial left common carotid angiography showed occlusion of the proximal ICA (Figure 1C). Angiography via the aspiration catheter revealed a large filling defect that extended from the cervical ICA to the intracranial ICA (Figure 1D). Thrombolysis in Cerebral Ischemia grade 2b reperfusion and stenosis in the proximal ICA (Figure 1E). The stenosis rate was 65% according to North American Symptomatic Carotid Endarterectomy Trial criteria (Figure 1F). Neck magnetization-prepared rapid gradient-echo image and maximum intensity projection images from time-of-flight MR angiography showed high signal intensity in the plaque compared with the sternocleidomastoid muscle (Figures 1G-I), indicating a vulnerable plaque.
Macroscopic and microscopic findings of the retrieved thrombi. (A) Macroscopic appearance of the retrieved thrombi. (B,C) Histopathological sections showing the erythrocyte-rich thrombus that was immunopositive for anti-glycophorin A (insert) (B) and the platelet-rich thrombus that was immunopositive for anti-glycoprotein IIb/IIIa (insert) (C). Original magnification x40. (D) Many cholesterol clefts are distributed throughout this thrombus specimen. Original magnification x40. (E) Cholesterol clefts (arrow) and foam cells in the erythrocyte-rich thrombus. Original magnification x200. Insert immunohistochemistry with CD68 revealing the presence of macrophages. (F) Necrotic core with aggregation of cholesterol clefts and multinucleated giant cells in the platelet-rich thrombus. Original magnification x400.
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Macroscopically, all retrieved thrombi were dark red in color (Figure 2A). Microscopic observation revealed that most of the thrombi were mainly composed of red blood cells (Figure 2B), although thrombi composed primarily of platelets were also observed (Figure 2C). The thrombus retrieved on the third pass was a red thrombus with diffuse cholesterol clefts (Figure 2D) and with foam cells scattered in the thrombus (Figure 2E). A necrotic core with aggregation of cholesterol clefts and multinucleated giant cells was also found in the platelet-rich thrombus (Figure 2F).