PMC9328409_01
(A) This is a non-acute ICAO. The intracranial ICA was occluded, and the ophthalmic artery was the only outflow tract. (B) A Navien 6F catheter was placed as close as possible to the occluded segment. A roadmap was generated by manual injection, whereupon the patient's heart rate and blood pressure suddenly dropped. (C) After a microwire and microcatheter were passed through the occluded site, another manual injection was performed, whereupon another serious drop in heart rate and blood pressure occurred. Finally, the operation was aborted.
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F1
Computed tomography angiography (CTA) showed an intracranial ICAO, which was confirmed by femoral digital subtraction angiography (DSA) with iohexol contrast agent (Figure 1A). A roadmap was generated by manual injection through the Navien, whereupon the patient's heart rate suddenly dropped to 14 BPM (Figure 1B). Another manual injection was then performed, whereupon asystole suddenly occurred and the systolic pressure subsequently dropped to 30 mmHg (Figure 1C).
PMC9328409_02
(A) This is a non-acute ICAO. The intracranial ICA was occluded, and the ophthalmic artery was the only outflow tract. (B) A dual-roadmap was generated manually, whereupon a sudden drop in heart rate occurred, accompanied by a decrease in blood pressure. (C) Postoperative angiography showed severe vasospasm of the proximal ICA.
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F2
DSA with the contrast agent iopromide showed an intracranial ICAO (Figure 2A). A dual vascular roadmap was generated manually by injecting from both the ICA and the vertebral artery, whereupon a sudden drop in heart rate occurred (to 30 BPM), accompanied by a decrease in blood pressure to 65/40 mmHg (Figure 2B). The operation then continued and the occluded ICA was successfully recanalized by the passage of a microwire/microcatheter, balloon dilatation, and stent release (Figure 2C).
PMC9328409_03
(A) This is an acute ICAO. The intracranial ICA was occluded, and the ophthalmic artery was the only outflow tract. (B) A balloon guide catheter was used. After the balloon was dilated, a roadmap was manually generated, whereupon the patient's heart rate suddenly dropped, although the blood pressure did not change substantially. The heart rate returned to normal after atropine administration and the operation was continued. (C) Postoperative angiography showed that the occluded ICA was recanalized successfully.
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F3
Emergent endovascular treatment was performed and a left ICAO was confirmed by diagnostic angiography with iodixanol contrast agent (Figure 3A). A vascular roadmap was then manually generated, whereupon the patient's heart rate suddenly dropped to 40 BPM, although the blood pressure did not change substantially (Figure 3B). Finally, the occluded ICA was successfully recanalized and no negative hemodynamic changes recurred (Figure 3C).
PMC9328409_04
(A) This is a non-acute ICAO. The intracranial ICA was occluded, and the ophthalmic artery was the only outflow tract. (B) A roadmap was generated manually, whereupon a sudden drop in heart rate and blood pressure occurred. After 1 min, the heart rate and blood pressure recovered spontaneously. The operation was then continued. (C) Postoperative angiography showed severe vasospasm of the proximal ICA.
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F4
DSA with the contrast agent iopromide showed an intracranial ICAO (Figure 4A). A vascular roadmap was generated manually, whereupon a sudden decrease in heart rate occurred (to 45 BPM), accompanied by a decrease in blood pressure to 90/40 mmHg (Figure 4B). The operation was then continued, and the occluded ICA was successfully recanalized by the passage of a microwire/microcatheter, balloon dilatation, and stent release (Figure 4C).