case_images: PMC10020348_01
case_images: Day 4 MRI with TOF sequence (A) and 3D SPACE T1 imaging of the vessel wall before (B) and after gadolinium injection (C). The reconstruction of (B) and (C) images follows the dotted line on the TOF sequence (A: dotted line). For easy identification, the internal carotid artery is surrounded by a dotted circle on (B) and (C). On the TOF sequence, the right internal carotid artery is occluded and the right anterior circulation is supplied downstream by the right PComm and AComm. On vessel wall imaging, there is a spontaneous marginalized and asymmetric hyperintense signal (B, arrow) that enhances after injection of gadolinium, without enhancement of the vessel wall itself (C), highly indicative of a wall hematoma due to focal intradural dissection of the right internal carotid artery. MRI, magnetic resonance imaging; PComm, posterior communicating artery; AComm, anterior communicating artery.
case_images: fped-11-1042509-g001.jpg
case_images: PMC10020348_01_fped-11-1042509-g001.jpg
case_images: F1
case_images: The review of the vessel wall imaging concludes with asymmetric vessel wall enhancement of the right supraophthalmic carotid segment evocative of a dissection of the intradural carotid artery associated with multiple focal stenoses of the cerebral arteries, suggestive of RCVS (Figure 1).
case_images: Subtracted DSA on day 12 before any vasodilator infusion (A) and after the first vasodilator infusion (B). The cerebral arteries showed diffuse and severe stenosis (A, arrows), which were improved after the first intra-arterial vasodilator infusion. In particular, blood flow reappeared in a pericallosal branch (B, arrow). On the last follow-up DSA, after the last vasodilator infusion 10 days after the first DSA, the stenosis had almost disappeared with a near-normal appearance of the cerebral arteries (C). DSA, digital angiography.
case_images: fped-11-1042509-g002.jpg
case_images: PMC10020348_01_fped-11-1042509-g002.jpg
case_images: F2
case_images: The last DSA and MRI done on days 22 and 26, respectively, showed recanalization of the right terminal carotid, in line with the hypothesis of RCVS, associated with intracranial carotid occlusive dissection (Figure 2).