case_images: PMC11249457_01
case_images: CTA of the chest done over a year prior to his AIS event, demonstrating the extension of a type A AD flap into the right brachiocephalic artery, the left CCA, and the left subclavian artery.
case_images: crn-2024-0016-0001-539441_F01.jpg
case_images: PMC11249457_01_crn-2024-0016-0001-539441_F01.jpg
case_images: F1
case_images: A computed tomography (CT) angiogram (CTA) of the chest revealed a type A AD extending from the aortic root to the aortic arch involving all three great vessels including both common carotid arteries, and further extending into the abdominal aorta (shown in Fig. 1).
case_images: a CT scan of the head without contrast shows hypodensity from an acute infarct in the left lentiform nucleus. b A CTA of the neck shows a dissection flap involving the proximal left cervical ICA at the level of the carotid bulb.
case_images: crn-2024-0016-0001-539441_F02.jpg
case_images: PMC11249457_01_crn-2024-0016-0001-539441_F02.jpg
case_images: F2
case_images: CT of the head without IV contrast revealed a hypodensity in the left lentiform nucleus (shown in Fig. 2a). A known type A AD was seen with extension of the dissection flap into the left common carotid and proximal left cervical internal carotid arteries (shown in Fig. 2b, 3).
case_images: A sagittal reformatted image of a CTA of the chest reveals a type A AD flap extending through the ascending arch with supra-aortic branch extension.
case_images: crn-2024-0016-0001-539441_F03.jpg
case_images: PMC11249457_01_crn-2024-0016-0001-539441_F03.jpg
case_images: F3
case_images: A known type A AD was seen with extension of the dissection flap into the left common carotid and proximal left cervical internal carotid arteries (shown in Fig. 2b, 3). A CTA of the chest demonstrated a dissection involving the ascending aorta, with aneurysmal dilation at the proximal descending aorta of 6.0 cm (previously 4.8 cm), and extension into the left CCA (shown in Fig. 3).
case_images: CT perfusion imaging of the brain demonstrates an area of decreased relative cerebral blood flow (arrow, top right image) and associated matched increased mean transit time/Tmax in the left basal ganglia consistent with an acute core infarct. There is also a larger surrounding area of mismatched increased mean transit time/Tmax (arrows, bottom left and center images) in the left MCA territory consistent with ischemic penumbra.
case_images: crn-2024-0016-0001-539441_F04.jpg
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case_images: F4
case_images: CT perfusion revealed an acute core infarct of approximately 10 cc in volume and an ischemic penumbra of approximately 31 cc in volume (Fig. 4), yielding a mismatch ratio of 3.1.
case_images: a Digital subtraction angiography (DSA) shows an occlusion of the superior M2 branch of the left MCA. b DSA shows complete reperfusion of the previously occluded branch.
case_images: crn-2024-0016-0001-539441_F05.jpg
case_images: PMC11249457_01_crn-2024-0016-0001-539441_F05.jpg
case_images: F5
case_images: Next, a left hemispheric cerebral angiogram was performed, which showed an abrupt occlusion of the superior left MCA M2 division (shown in Fig. 5a). Thrombolysis in Cerebral Infarction (TICI) score of 3 (shown in Fig. 5b). The patient had no procedure-related complications.
case_images: a DWI sequence of the MRI of the brain without contrast revealed restricted diffusion consistent with an acute infarct involving the left lentiform nucleus. b SWI revealed a superimposed susceptibility artifact centrally in this region consistent with hemorrhagic conversion; this also accounts for the hypointense area centrally within the infarct in a. DWI, diffusion-weighted imaging; SWI, susceptibility-weighted imaging.
case_images: crn-2024-0016-0001-539441_F06.jpg
case_images: PMC11249457_01_crn-2024-0016-0001-539441_F06.jpg
case_images: F6
case_images: Punctate ischemic infarcts at the high convexity cortex of the left posterior parietal lobe, left frontal lobe cortex, and left insular cortex were also seen (shown in Fig. 6a). Susceptibility artifact was also seen within the left putamen consistent with hemorrhagic conversion (shown in Fig. 6b).