PMC2718095_01
Case 1. A. Lateral angiogram of right common carotid artery shows occlusion of its proximal internal branch. Focal dimpling (black arrow) of the posterior aspect indicates partial filling of false lumen by thrombus (small arrows). Distal true lumen has collapsed, with linear filling by contrast media.. B. Left internal carotid angiogram shows complete occlusion of proximal segment of right middle cerebral artery, suggesting thromboembolic occlusion.. C. Follow-up angiogram obtained 20 days after initial angiography shows partial recanalization of true lumen. A thick dissecting flap is present (arrows) and the dilated false lumen persists.. D. Angioplasty was performed 35 days after injury, and a self-expandable metallic stent is seen.. E. After angioplasty using a stent, true lumen regained its original diameter. The false lumen, now smaller, may be observed behind the stent. Thirty-five days after stent placement, patency was assessed with CT and the false lumen was no longer visible (not shown).
kjr-2-52-g001.jpg
PMC2718095_01_kjr-2-52-g001.jpg
F1
Angiography performed on admission revealed near-complete occlusion of the suprabulbar portion of the right internal carotid artery and complete occlusion of the ipsilateral proximal middle cerebral artery, suggesting dissection of the vessel and subsequent arterial thromboembolism (Figs. 1A, 1B). Follow-up angiography at day 20 revealed partial restoration of luminal patency; the lumen, however, was largely compromised by the presence of a thick intimal flap (Fig. 1C). Atropine (1mg) was injected intravenously just before stent placement; for primary stenting of the dissected segment, a self-expandable uncovered metallic stent 30 mm in length and 8 mm in diameter (Easy Wallstent; Boston Scientific Corporation, Watertown, Mass., U.S.A.) was used (Fig. 1d), and for postdilatation, a 6-mm diameter angioplasty catheter (Ultra-thin; Boston Scientific Corporation, Watertown, Mass., U.S.A.) at a low inflation pressure was employed. Intermittent neurological examinations were conducted throughout the procedure, and after stenting, focal residual dissected false lumen at the posterior portion of the artery was observed (Fig. 1e).
PMC2718095_02
Case 2. A. Initial angiogram of left internal carotid artery demonstrates a focal stenosis of the subpetrosal portion of the artery, associated with a dissecting aneurysm (arrows). The aneurysmal sac is restricted by the bony canal of that portion.. B. A balloon-expandable stent was inserted, but is barely visible due to the relatively poor radiopacity and surrounding bony structures.. C. Luminal patency of the dissected segment is improved substantially after stent placement, and the aneurysmal sac is much smaller.. D. Follow-up angiography was performed 65 days after stent placement. The arterial lumen is well preserved, though the aneurysmal sac is still partly filled. After stent placement, the patient was asymptomatic.
kjr-2-52-g002.jpg
PMC2718095_02_kjr-2-52-g002.jpg
F2
Angiography was performed the following day, and focal but significant stenosis associated with a dissecting aneurysm was observed at the subpetrosal portion of the left internal carotid artery (Fig. 2A). This was 16 mm in length and was dilated to 4.2 mm with a balloon at a pressure of 10 atm (Fig. 2B). A postangioplastic angiogram showed improved luminal patency, with reduction of the aneurysmal sac (Fig. 2C). Although the filled aneurysmal sac was significantly smaller, focal filling of a part of it was noted (Fig. 2D).