case_images: PMC10858435_01
case_images: CT head showed normal brain parenchyma attenuation and no territorial hypodensity. CT perfusion showed symmetrical bilateral perfusion abnormality involving the anterior circulation with increased time to drain (TTD), likely secondary to severe stenosis of the distal cervical segments of the ICAs bilaterally. CT angiogram showed bilateral severe stenosis noted at the distal cervical segment of the bilateral ICAs and moderate stenosis at the V2 segment of the right vertebral artery.
case_images: qmj-2024-01-006-g001.jpg
case_images: PMC10858435_01_qmj-2024-01-006-g001.jpg
case_images: fig1
case_images: An urgent Computed Tomography (CT) scan of the head, CT perfusion, and CT angiogram were performed that showed bilateral severe stenosis of the long segment (2 cm) of the distal cervical segment of Internal Carotid Arteries (ICAs), moderate right vertebral artery stenosis of a long segment (2.5 cm) at the V2 segment, and bilateral symmetrical increase time to drain (TTD) and maintained cerebral blood volume (CBV) in the perfusion study as shown in Figure 1.
case_images: Cerebral angiogram selective catheterization showed bilateral flame-shaped signs of occlusion, implicating both cervical ICAs typical for dissection. Right ICA is revascularized via ECA/ophthalmic artery anastomosis. The left ICA has good revascularization through the left PCOM and the ophthalmic /ECA anastomosis. There is a mild focal narrowing of the cervical RT vertebral artery, likely dissection.
case_images: qmj-2024-01-006-g002.jpg
case_images: PMC10858435_01_qmj-2024-01-006-g002.jpg
case_images: fig2
case_images: There is a mild focal narrowing of the cervical right vertebral artery at the V2 segment, likely dissection, as shown in Figure 2.
case_images: MRI, MRA head, and neck vessels showed multiple, variable-sized areas of acute ischemic strokes seen in the right frontal lobe, basal ganglia, corona radiata, and centrum semiovale along the MCA territory, and the similar regions are seen in the left frontoparietal lobes. MRA showed bilateral severe stenosis of the upper cervical ICA and cranial right ICA. The visualized parts of the right MCA and ACA are markedly attenuated. There is stenosis of the middle 1/3 of the cervical right vertebral artery.
case_images: qmj-2024-01-006-g003.jpg
case_images: PMC10858435_01_qmj-2024-01-006-g003.jpg
case_images: fig3
case_images: There was severe stenosis of the middle 1/3 segment of the right cervical (V2) vertebral artery, as depicted in Figure 3.
case_images: CT cerebral angiogram showed good filling of the bilateral common carotid arteries to the carotid bifurcation and the proximal cervical course of the internal carotid artery. The reduced caliber of the bilateral distal cervical course of the internal carotid arteries is seen with residual dissection, and focal outpouching of the right ICA is noted opposite C1 right lateral mass representing ICA pseudoaneurysm. The vertebral arteries bilaterally appear to be patent, with dominant left-sided noted.
case_images: qmj-2024-01-006-g004.jpg
case_images: PMC10858435_01_qmj-2024-01-006-g004.jpg
case_images: fig4
case_images: After the 6th-month follow-up, intracranial CT angiogram showed focal outpouching of the right ICA opposite to the C1 level, representing ICA pseudoaneurysm as shown in Figure 4.