PMC3290017_01
Patient 1. A CT perfusion maps showing a large hypoperfusion area in the left hemisphere with prolonged mean transit time (MTT) and decreased cerebral blood flow (CBF). A reduction of cerebral blood volume (CBV) suggestive of core infarction is visible in the temporal lobe. A large mismatch between the MTT and CBF maps in relation to the CBV maps suggests a large penumbra. B CTA demonstrating flame-shaped occlusion of the left ICA (asterisk). C CTA of intracranial arteries showing intracranial occlusion of the M2 segment (asterisk). D X-ray image showing the two overlapping stents implanted into the left ICA. E Digital subtraction angiogram (DSA) after ICA stent implantation demonstrating complete recanalization. F Diffusion-weighted MRI at 24 h showing temporoparietal cortical infarction. Patient 2. A CT perfusion maps showing a large area of hypoperfusion in the left hemisphere with prolonged MTT and decreased CBF. A reduction of CBV suggestive of core infarction is visible in the striatocapsular region. B Two CTA images (separated by dashed line) demonstrating narrowing of the cervical ICA (asterisk) with no contrast filling above the skull base (arrow). The findings are suggestive of dissection and were confirmed by subsequent DSA. C CTA of intracranial arteries showing intracranial ICA and M1 occlusion (asterisks). D DSA showing proximal flame-shaped occlusion of the ICA (asterisk). E DSA after ICA stent implantation with persistent distal ICA occlusion (asterisk). F DSA after mechanical thrombectomy demonstrating complete recanalization. G CT at 24 h showing striatocapsular infarction.
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PMC3290017_02_crn-0004-0013-g01.jpg
F1
CTP showed an ischemic lesion covering the whole left MCA territory (fig. 1A). CTA revealed an intramural hematoma and narrowing of the left ICA with flame-shaped tapering at the skull base consistent with ICAD and tandem M1 occlusion (fig. 1B, C). ICA distal to the skull base which is, however, not specific for complete occlusion in the presence of a major intracranial occlusion and slow flow (fig. 1B). IV thrombolysis per standard protocol was initiated at 94 min after symptom onset. The first angiogram showed a proximal flame-shaped ICA occlusion at the C2 level and no intracranial flow (fig. 1D). It was apparent that the ICAD had progressed during the time between the two examinations (fig. 1B, D). After application of 5,000 units of heparin and stenting of the ICAD (Protege  7 x 40 mm, ev3) angiography showed distal ICA occlusion (fig. 1E). Complete recanalization of the ICA and MCA was achieved by 2 passes with the TrevoTM device (Concentric Medical) at 5:15 h after symptom onset (fig. 1F). At 24 h the patient's NIHSS score was 4, CT showed striatocapsular infarction (fig. 1G) and clopidogrel medication was started.
PMC3290017_02
Patient 1. A CT perfusion maps showing a large hypoperfusion area in the left hemisphere with prolonged mean transit time (MTT) and decreased cerebral blood flow (CBF). A reduction of cerebral blood volume (CBV) suggestive of core infarction is visible in the temporal lobe. A large mismatch between the MTT and CBF maps in relation to the CBV maps suggests a large penumbra. B CTA demonstrating flame-shaped occlusion of the left ICA (asterisk). C CTA of intracranial arteries showing intracranial occlusion of the M2 segment (asterisk). D X-ray image showing the two overlapping stents implanted into the left ICA. E Digital subtraction angiogram (DSA) after ICA stent implantation demonstrating complete recanalization. F Diffusion-weighted MRI at 24 h showing temporoparietal cortical infarction. Patient 2. A CT perfusion maps showing a large area of hypoperfusion in the left hemisphere with prolonged MTT and decreased CBF. A reduction of CBV suggestive of core infarction is visible in the striatocapsular region. B Two CTA images (separated by dashed line) demonstrating narrowing of the cervical ICA (asterisk) with no contrast filling above the skull base (arrow). The findings are suggestive of dissection and were confirmed by subsequent DSA. C CTA of intracranial arteries showing intracranial ICA and M1 occlusion (asterisks). D DSA showing proximal flame-shaped occlusion of the ICA (asterisk). E DSA after ICA stent implantation with persistent distal ICA occlusion (asterisk). F DSA after mechanical thrombectomy demonstrating complete recanalization. G CT at 24 h showing striatocapsular infarction.
crn-0004-0013-g01.jpg
PMC3290017_02_crn-0004-0013-g01.jpg
F1
CTP showed an ischemic lesion covering the whole left MCA territory (fig. 1A). CTA revealed an intramural hematoma and narrowing of the left ICA with flame-shaped tapering at the skull base consistent with ICAD and tandem M1 occlusion (fig. 1B, C). ICA distal to the skull base which is, however, not specific for complete occlusion in the presence of a major intracranial occlusion and slow flow (fig. 1B). IV thrombolysis per standard protocol was initiated at 94 min after symptom onset. The first angiogram showed a proximal flame-shaped ICA occlusion at the C2 level and no intracranial flow (fig. 1D). It was apparent that the ICAD had progressed during the time between the two examinations (fig. 1B, D). After application of 5,000 units of heparin and stenting of the ICAD (Protege  7 x 40 mm, ev3) angiography showed distal ICA occlusion (fig. 1E). Complete recanalization of the ICA and MCA was achieved by 2 passes with the TrevoTM device (Concentric Medical) at 5:15 h after symptom onset (fig. 1F). At 24 h the patient's NIHSS score was 4, CT showed striatocapsular infarction (fig. 1G) and clopidogrel medication was started.