PMC8769422_01
Diffusion-weighted imaging (A) revealed a watershed infarct in the territory of the right anterior circulation. Magnetic resonance angiography (B) image showing a severe stenosis with an irregular plaque (arrowheads) in the right ICA. The plaque (arrowheads) was hyperintense on T1- (C) and T2-weighted (D) MRI. Right CCA angiography (E) and three-dimensional DSA (F) images showing a double-lumen plaque (arrowheads) in the right ICA. Ultrasonography revealed a double lumen distal to the stenosis in the right ICA (surrounded area) (G). CCA: common carotid artery, DSA: digital subtraction angiography, ICA: internal carotid artery, MRI: magnetic resonance imaging.
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F1
Magnetic resonance imaging (MRI) revealed an ischemic lesion in the watershed area of the right hemisphere (Fig. 1A). Magnetic resonance angiography showed severe stenosis and an irregular plaque in the right cervical ICA (Fig. 1B). The plaque was hyperintense on T1- and T2-weighted imaging (Figs. 1C and 1D). Carotid angiography revealed 70% stenosis based on the North American Symptomatic Carotid Endarterectomy Trial criteria and a double lumen distal to the right ICA (Figs. 1E and 1F). Ultrasonography revealed a heterogeneous plaque (mixed hyperechoic, hypoechoic, and isoechoic) with 84% area stenosis and a double lumen distal to the stenosis in the right ICA (Fig. 1G).
Right CCA angiography before PTA image (A) showing severe stenosis in the right ICA and a balloon in the CCA (black arrowhead) and proximal ECA (white arrowhead). PTA was performed using the SIDEN PTA balloon measuring 2.0 x 40 mm through the anterior part of the double lumen (arrow), under total proximal carotid flow arrest with balloon occlusion of the CCA (black arrowhead) and proximal ECA (white arrowhead) (B). Right CCA angiography after PTA (C) showing dilatation of the ICA stenosis (arrow). CCA: common carotid artery, ECA: external carotid artery, ICA: internal carotid artery, PTA: percutaneous transluminal angiography.
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F2
After systemic heparinization, the Mo.Ma Ultra device (Medtronic, Minneapolis, MN, USA) was inserted into the right external carotid artery (ECA) (Fig. 2A). SHIDEN PTA balloon measuring 2.0 x 40 mm (Kaneka Medical Products, Osaka, Japan) was passed through the anterior part of the double lumen and percutaneous transluminal angioplasty (PTA) was performed (Figs. 2B and 2C).
Intraoperative findings during CAS. DSA before CAS (A), pre-dilation (B), stent deployment (C), post-dilation (D), and DSA after CAS (E). Pre-CAS (F) and post-CAS (G) right common carotid angiography image showing a higher cerebral blood flow volume. The Carotid WALLSTENT measuring 10 x 31 mm was deployed against the anterior part of the double lumen (arrow). CAS: carotid artery stenting, DSA: digital subtraction angiography.
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F3
After systemic heparinization, the Mo.Ma Ultra device (Medtronic) was inserted into the right ECA (Fig. 3A). After balloon occlusion of the CCA and proximal ECA, pre-dilation was conducted using the SIDEN PTA balloon measuring 3.0 x 40 mm (Kaneka Medical Products) through the anterior part of the double lumen (Fig. 3B). Medical Products) (Figs. 3C-3E). Subsequently, intracranial digital subtraction angiography (DSA) revealed a higher volume of cerebral blood flow (Figs. 3F and 3G). MRI and IMP SPECT conducted 1 day after CAS revealed no signs of ischemic infarction and hyperperfusion (Figs. 4A and 4B).
MRI (A) and IMP single-photon emission computed tomography (B) conducted 1 day after CAS showing no signs of ischemic infarction and hyperperfusion syndrome. MRI: magnetic resonance imaging.
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F4
Medical Products) (Figs. 3C-3E). Subsequently, intracranial digital subtraction angiography (DSA) revealed a higher volume of cerebral blood flow (Figs. 3F and 3G). MRI and IMP SPECT conducted 1 day after CAS revealed no signs of ischemic infarction and hyperperfusion (Figs. 4A and 4B).