case_images: PMC11787995_01
case_images: (A) DWIs show high-intensity areas of the left basal ganglia and corona radiata. (B) MRA shows occlusion of the left ICA and the M2 segment of the left MCA. (C) DSA of the right ICA shows the occlusion of the M2 segment of the left MCA (arrow). (D) DSA of the right ICA shows improved flow of the M2 (arrowhead) by intravenous tPA therapy. (E) Lateral angiographic view of the left CCA shows left ICA occlusion. CCA, common carotid artery; DWI, diffusion-weighted imaging; ICA, internal carotid artery; MCA, middle cerebral artery; tPA, tissue plasminogen activator
case_images: jnet-19-01-2024-0087-g001.jpg
case_images: PMC11787995_01_jnet-19-01-2024-0087-g001.jpg
case_images: F1
case_images: Diffusion-weighted imaging (DWI) on head MRI revealed a hyperintense area from the left basal ganglia to the corona radiata, with a DWI-Alberta Stroke Programme Early CT Score (ASPECTS) of 9 points (Fig. 1A). MRA demonstrated poor visualization of the left internal carotid artery from its origin, with the left MCA being poorly visualized beyond the M2 segment (Fig. 1B). Because the tPA therapy gradually recanalized the left M2 superior trunk, further treatment was discontinued (Fig. 1C-1E).
case_images: (A) DWIs show the enlargement of the high-intensity area. (B) MRA shows occlusion of the M1 segment of the left MCA. (C) Preoperative DSA of the left ICA. AP view shows the top of the left ICA occlusion (T occlusion). (D) Postoperative DSA of the left ICA. AP view shows complete recanalization of the left MCA and ACA. ACA, anterior carotid artery; AP, anteroposterior; DWI, diffusion-weighted imaging; ICA, internal carotid artery; MCA, middle cerebral artery
case_images: jnet-19-01-2024-0087-g002.jpg
case_images: PMC11787995_01_jnet-19-01-2024-0087-g002.jpg
case_images: F2
case_images: On the second day, aphasia and right upper and lower limb paralysis worsened, and DWI showed a high-intensity area in the left basal ganglia and the cortex of the left MCA territory (Fig. 2A and 2B). After 2000 U of intravenous heparin was administered, left internal carotid angiography revealed an occlusion at the top of the left internal carotid artery (T occlusion) (Fig. 2C), and an aspiration catheter (Catalyst7; Stryker) and stent retriever (Trevo NXT 4 mm/41 mm; Stryker) were inserted into the left internal carotid artery. Good recanalization (thrombolysis in cerebral infarction [TICI] 3) had been achieved in 1 pass (Fig. 2D) and the procedure was terminated 3 hours and 50 minutes after the second symptom developed.
case_images: (A) A skin incision was made and a 6 Fr sheath was inserted into the ICA. (B) The enlarged view of the surgical field. (C) The intraoperative schema shows the calcified area of the bifurcation (arrow) so that we punctured distal ICA with no calcification (asterisk). CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery
case_images: jnet-19-01-2024-0087-g003.jpg
case_images: PMC11787995_01_jnet-19-01-2024-0087-g003.jpg
case_images: F3
case_images: The distal side was elastic, so a 6 Fr sheath was inserted by puncturing the same site, a Y connector (OKAY; Goodman, Aichi, Japan) was attached to the sheath, and it was fixed to the skin with silk thread (Fig. 3).
case_images: 3D-CTA shows slight recanalization and severe calcification of the internal carotid artery.
case_images: jnet-19-01-2024-0087-g004.jpg
case_images: PMC11787995_01_jnet-19-01-2024-0087-g004.jpg
case_images: F4
case_images: Postoperative DWI showed a high-intensity area in the left basal ganglia and insular gyrus, and MRA showed the left MCA recanalization. 3D-CTA performed on the seventh day showed recanalization of the internal carotid artery (Fig. 4).