case_images: PMC9063025_01
case_images: Radiological images at initial symptom onset are presented. DWI showed multiple hyperintense lesions at the left hemisphere (a) and intracranial blood flow was impaired at the lesion side on magnetic resonance angiography (b: Red arrow). The blood flow signal was absent at the high cervical portion of the ICA (c: Red arrow). 3D-CTA revealed an enlarged styloid process, whose length was 32.3 mm (d), and a cerebral blood flow study by arterial spin labeling showed a remarkable CBF decrease at the affected side (e).
case_images: SNI-13-183-g001.jpg
case_images: PMC9063025_01_SNI-13-183-g001.jpg
case_images: F1
case_images: Diffusion-weighted image (DWI) revealed several small infarctions [Figure 1a] and magnetic resonance angiography showed a decrease of flow signal of the right intracranial arteries [Figure 1b], which was due to partial disappearance of the high cervical portion of the left internal carotid artery (ICA) [Figure 1c]. Furthermore, a three-dimensional computed tomography angiogram (3D-CTA) revealed an elongated styloid process stenosing the nearby ICA [Figure 1d]. The arterial spin labeling study revealed a remarkable decrease in cerebral blood flow (CBF) [Figure 1e], with mural hematoma around the stenotic ICA on thin slice T1-weighted images.
case_images: DSA at initial symptom onset (a) and 5 days later (b) are shown. The red arrows indicate the location of stenosis. Carotid artery stenting (CAS) was performed and a reasonable vascular reconstruction was achieved (c). The red arrowheads indicate the whole length of the placed stent. Magnetic resonance angiography after CAS showed recovered cerebral blood flow (d: red arrow).
case_images: SNI-13-183-g002.jpg
case_images: PMC9063025_01_SNI-13-183-g002.jpg
case_images: F2
case_images: Angiogram examination again revealed severe stenosis of the left ICA [Figures 2a and b] at around the elongated styloid process. After percutaneous transluminal angioplasty (PTA) for stenosis, A 6 to 8 mm tapered Carotid WALLSTENT (Boston Scientific, Boston, USA) was placed at the stenotic lesion after PTA [Figure 2c]. MRA 3d-tof improved the signal intensity compared to before CAS [Figure 2d].
case_images: Iodoamphetamine single-photon emission computed tomography before (a) and after (b) carotid artery stenting (CAS) is shown. Cerebral blood flow of the anterior circulation decreased by 75-80% compared with that at the right side before the treatment. The decrease recovered after CAS.
case_images: SNI-13-183-g003.jpg
case_images: PMC9063025_01_SNI-13-183-g003.jpg
case_images: F3
case_images: Post stenting angiogram showed no distal embolization at the intracranial arteries and postoperative iodoamphetamine single-photon emission computed tomography (IMP-SPECT) showed recovered left CBF [Figure 3].