PMC8548632_01
(A) Left hypodense M1 artery (red arrow), (B) histopathology showing bone marrow constituents and adipose tissue consistent with fat embolism, (C) Diffusion weighted imaging (DWI) showing left MCA territory infarction.
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F1
Coma Score (GCS) of 6 (E1V2M3) and had a global aphasia and right hemiparesis with an initial National Institutes of Health Stroke Score (NIHSS) of 24. CT brain (Figure 1A) demonstrated a "hypodense artery sign" with Hounsfield units (HU) of -75 in the left M1 segment of the middle cerebral artery (MCA) suggestive of fat embolism, and tandem occlusions in the left internal carotid artery (ICA) and M1 MCA were seen on CT angiogram (CT-A). Histopathology of the aspirated clot revealed adipose tissue and bone marrow with red blood cells, white cells and platelets, and fibrin fragments containing red blood cells with an admixture of eosinophils and neutrophils (Figure 1B). Magnetic resonance imaging (MRI) of the brain performed at day 3 (Figure 1C) showed extensive left MCA territory infarct with haemorrhagic transformation within the left basal ganglia.
PMC8548632_02
(A) (Red arrow) fat embolism demonstrated in the basilar artery, (B) pre recanalization ECR images confirming occlusive thrombus in basilar artery (red arrow), (C) post recanalization images showing reperfusion of mid and distal basilar artery (red arrow).
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F2
CT-A demonstrated a hypodense basilar artery (HU of-44) extending into the posterior cerebral arteries bilaterally (Figure 2A). He proceeded to ECR with successful recanalisation and stenting of the mid-basilar artery (see Figures 2A-C).
PMC8548632_03
(A) MRI Brain on day 1 post operatively. Diffusion weighted images show left MCA territory infarction with a similar distribution of abnormalities on suspectibility weighted imaging) (B). MCA, middle cerebral artery; DWI, diffusion weight imaging; ECR, endovascular clot retrieval.
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F3
Diffusion weighted MRI the next day revealed a left MCA territory infarction, with cortical, basal ganglia, and thalamic involvement, and associated susceptibility weighted imaging (SWI) changes (Figure 3).