case_images: PMC10629293_01
case_images: (a) Magnetic resonance imaging diffusion weighted imaging at initial onset. Diffuse high-intensity signals are observed in the left corona radiata and middle cerebral artery. (b) Magnetic resonance angiography, left middle cerebral artery occlusion. (c and d) Digital subtraction angiography, left internal carotid angiography, (c) is the early phase, and (d) is the late phase. Occlusion of the left middle cerebral artery and collateral blood flow from the left anterior cerebral artery through the leptomeningeal anastomosis.
case_images: SNI-14-365-g001.jpg
case_images: PMC10629293_01_SNI-14-365-g001.jpg
case_images: F1
case_images: Magnetic resonance angiography (MRA) showed an occlusion of the left middle cerebral artery [Figures 1a and b]. Internal carotid arteriography revealed that the left middle cerebral artery was distally occluded [Figure 1c]. In the delayed phase, an anastomosis of the cerebral pia mater provided the collateral blood flow from the anterior to the middle cerebral arteries [Figure 1d].
case_images: (a and b) Left internal carotid angiography after Trevo deployment. Immediate flow restoration is confirmed. The lesion is at the distal middle cerebral artery. Dilation with Trevo is inadequate distal to the stenosis. (c) Left internal carotid angiography after Trevo retrieval. Recanalization has been achieved; however, severe stenosis remains, and peripheral perfusion is delayed.
case_images: SNI-14-365-g002.jpg
case_images: PMC10629293_01_SNI-14-365-g002.jpg
case_images: F2
case_images: Trevo XP ProVue Retriever 4.0 x 30 mm (Stryker, Kalamazoo, MI, USA) was deployed. The post deployment imaging showed an immediate flow restoration but poor stent dilation in the occluded area, suggestive of arterial stenosis [Figure 2a]. The proximal and distal diameters of the stenosis were 2.6 mm and 2.1 mm, respectively [Figure 2b]. Although reperfusion was achieved, a significant degree of stenosis persisted [Figure 2c].
case_images: (a) Gateway 2.0 x 12 mm monorail (6 atm) is inflated at the center of the lesion. (b) Left internal carotid angiography after percutaneous transluminal angioplasty at the Gateway. Stenosis has improved. (c) Left internal carotid angiography 7 min after B. Restenosis has appeared.
case_images: SNI-14-365-g003.jpg
case_images: PMC10629293_01_SNI-14-365-g003.jpg
case_images: F3
case_images: A gradual dilatation and retraction were performed under nominal pressure [Figure 3a]. Subsequent imaging revealed a temporary recanalization [Figure 3b]; however, restenosis was observed after 7 min [Figure 3c].
case_images: (a) Ryusei 2.5 x 20 mm monorail (2 atm) inflated at the center of the lesion. The white arrow indicates the perfusion marker. (b and c): Left internal carotid angiography during Ryusei inflation. (b) is the early phase, (d) is the late phase. Perfusion lumen enables the blood flow to traverse toward the distal of the balloon. (d) After angioplasty at Ryusei, the stenosis has improved.
case_images: SNI-14-365-g004.jpg
case_images: PMC10629293_01_SNI-14-365-g004.jpg
case_images: F4
case_images: After dilating to 2 atm, the wire was drawn anterior to the proximal perfusion hole, and the perfusion lumen was subsequently unsealed [Figure 4a]. The angiography performed in this state showed that peripheral perfusion was achieved using balloon dilation [Figures 4b and c]. The Ryusei was then deflated and adequate vascular dilation was observed [Figure 4d].
case_images: (a) Magnetic resonance imaging diffusion weighted imaging on day 7. High-intensity signals are indicated in the left corona radiata. There is no enlargement compared to preoperative. (b) Magnetic resonance angiography on day 7. Mild stenosis is observed in the left middle cerebral artery; however, the recanalization findings are maintained. (c) Magnetic resonance angiography 3 months postoperatively. Improvement of the stenotic lesion is observed.
case_images: SNI-14-365-g005.jpg
case_images: PMC10629293_01_SNI-14-365-g005.jpg
case_images: F5
case_images: Postoperative MRI showed a clearly defined high signal DWI without significant enlargement of the infarcted area [Figure 5a] and although a mild stenosis remained, the MRA also showed a satisfactory peripheral perfusion [Figure 5b]. Three months later, the MRA indicated an improvement in the stenosis [Figure 5c], and the patient was prescribed antithrombotic therapy with cilostazol as a single agent.