case_images: PMC3841922_01
case_images: MR angiogram of the head reveals focal pseudoocclusion of the right M1
case_images: SNI-4-144-g001.jpg
case_images: PMC3841922_01_SNI-4-144-g001.jpg
case_images: F1
case_images: After removal of the patient's orthodontic appliance, magnetic resonance (MR) imaging and MR angiography of the brain confirmed completed infarction of approximately one-half of the right MCA territory due to a focal pseudoocclusion (high-grade stenosis causing near occlusion) in the distal M1 at the MCA bifurcation [Figure 1].
case_images: Diffusion-weighted magnetic resonance image (a) and noncontrast computed tomographic scan of the head (b) show completed infarct
case_images: SNI-4-144-g002.jpg
case_images: PMC3841922_01_SNI-4-144-g002.jpg
case_images: F2
case_images: Endovascular revascularization was felt to be a poor option due to the >24-hour duration of symptoms prior to neurosurgical involvement, completed nature of the infarction, and large volume of MCA territory involved [Figure 2].
case_images: Noncontrast CT scan of head shows hemorrhagic conversion of right MCA territory infarct
case_images: SNI-4-144-g003.jpg
case_images: PMC3841922_01_SNI-4-144-g003.jpg
case_images: F3
case_images: Subsequently, a decompressive craniectomy was performed due to increasing mass effect from the progression of stroke causing increased lethargy and left-sided hemiplegia [Figures 3 and 4].
case_images: Noncontrast CT scan of head after decompressive craniectomy showing improvement of midline shift
case_images: SNI-4-144-g004.jpg
case_images: PMC3841922_01_SNI-4-144-g004.jpg
case_images: F4
case_images: Subsequently, a decompressive craniectomy was performed due to increasing mass effect from the progression of stroke causing increased lethargy and left-sided hemiplegia [Figures 3 and 4].
case_images: Noncontrast CT scan of head shows increased intracerebral hemorrhage with midline shift associated with the ruptured mycotic aneurysm
case_images: SNI-4-144-g005.jpg
case_images: PMC3841922_01_SNI-4-144-g005.jpg
case_images: F5
case_images: CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
case_images: CT angiogram of head, thin-cut axial image, reveals right M1 ruptured mycotic aneurysm
case_images: SNI-4-144-g006.jpg
case_images: PMC3841922_01_SNI-4-144-g006.jpg
case_images: F6
case_images: CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
case_images: CT angiogram of head, coronal reconstruction, reveals right M1 ruptured mycotic aneurysm
case_images: SNI-4-144-g007.jpg
case_images: PMC3841922_01_SNI-4-144-g007.jpg
case_images: F7
case_images: CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
case_images: CT angiogram of head, sagittal reconstruction, reveals right M1 ruptured mycotic aneurysm
case_images: SNI-4-144-g008.jpg
case_images: PMC3841922_01_SNI-4-144-g008.jpg
case_images: F8
case_images: CT angiography of the head revealed a ruptured 19 x 16 mm mycotic aneurysm arising from the M1 occlusion site, associated with a large intracerebral hemorrhage and midline shift [Figures 5-8].
case_images: Cerebral angiogram - early arterial phase, anteroposterior (AP) internal carotid artery injection - reveals right M1 mycotic aneurysm with occlusion of distal branches
case_images: SNI-4-144-g009.jpg
case_images: PMC3841922_01_SNI-4-144-g009.jpg
case_images: F9
case_images: Given completion of the M1 occlusion, extension of the MCA infarction, and rapid growth of the pseudoaneurysm, both parent vessel and pseudoaneurysm were rapidly coiled to complete obliteration [Figures 9-11].
case_images: Cerebral angiogram - mid-arterial phase; AP internal carotid artery injection - reveals right M1 mycotic aneurysm with occlusion of distal branches
case_images: SNI-4-144-g010.jpg
case_images: PMC3841922_01_SNI-4-144-g010.jpg
case_images: F10
case_images: Given completion of the M1 occlusion, extension of the MCA infarction, and rapid growth of the pseudoaneurysm, both parent vessel and pseudoaneurysm were rapidly coiled to complete obliteration [Figures 9-11].
case_images: Cerebral angiogram - early arterial phase, AP internal carotid injection - reveals coiled M1 mycotic aneurysm and parent vessel
case_images: SNI-4-144-g011.jpg
case_images: PMC3841922_01_SNI-4-144-g011.jpg
case_images: F11
case_images: Given completion of the M1 occlusion, extension of the MCA infarction, and rapid growth of the pseudoaneurysm, both parent vessel and pseudoaneurysm were rapidly coiled to complete obliteration [Figures 9-11].
case_images: Noncontrast CT scan of head status post hematoma evacuation showing improvement of mass effect
case_images: SNI-4-144-g012.jpg
case_images: PMC3841922_01_SNI-4-144-g012.jpg
case_images: F12
case_images: From the endovascular suite, the patient was taken directly to the operating room for hematoma evacuation [Figure 12].