case_images: PMC10858786_01
case_images: Images taken at the previous hospital: (a) the sagittal section of cervical computed tomography (CT) shows vertebral fractures of the 6th and 7th cervical vertebrae and ossification of the posterior longitudinal ligament at the level of the 4th-7th cervical vertebrae. (b and c) The axial section of cervical CT at the level of the 6th cervical vertebra shows a fracture of the left transverse process and a slightly high-density area within the left transverse foramen. (d) Cervical spine T2-weighted magnetic resonance imaging shows no signs of compression of the spinal cord and a hyperintense area at the level of the 4th/5th cervical vertebrae. (e) Diffusion-weighted imaging at the time of loss of consciousness shows a slightly high-intensity area in the left cerebellum (posterior circulation acute stroke prognosis early CT score 9 points). (f) Magnetic resonance angiography at the time of loss of consciousness shows occlusion of the left vertebral and basilar arteries.
case_images: SNI-15-12-g001.jpg
case_images: PMC10858786_01_SNI-15-12-g001.jpg
case_images: F1
case_images: Cervical spine computed tomography (CT) showed vertebral body fractures at the 6th and 7th cervical vertebrae, a fracture of the left transverse process of the 6th cervical vertebra, and ossification of the posterior longitudinal ligament at the 4th-7th cervical spine levels [Figure 1a and b]. A slightly high-density area was noted within the foramen transversarium of the 6th cervical vertebra [Figure 1c]. Still, a high signal area was noted in the cervical cord at the intervertebral level between the 4th and 5th cervical vertebrae [Figure 1d]. A slightly high-intensity area in the left cerebellum (posterior circulation acute stroke prognosis early CT score [pc-ASPECTS] 9 points) was observed on diffusion-weighted imaging 70 min after the onset of altered consciousness, and occlusion of the left vertebral and basilar arteries was observed on magnetic resonance angiography (MRA) [Figure 1e and f].
case_images: Preoperative and intraoperative images at our hospital: (a) preoperative head computed tomography (CT) shows a hyperdense sign at the tip of the basilar artery and hypodense areas in the left cerebellum and midbrain (posterior circulation acute stroke prognosis early CT score 7 points). (b) Before thrombectomy, right vertebral artery angiography shows occlusion at the tip of the basilar artery. (c) After thrombectomy, right vertebral artery angiography shows complete recanalization of the tip of the basilar artery. (d and e) Left subclavian artery angiography shows occlusion at the origin of the left vertebral artery. Collateral blood flow from the left deep cervical artery to the left vertebral artery is observed, with anterograde flow beyond the level of the 6th cervical vertebra (arrow). Thrombi (arrowheads) are seen within the left vertebral artery at the level of the 4th-6th cervical vertebrae. (f) Coil embolization was performed in the distal part of the left vertebral artery from the level of the 3rd/4th cervical vertebra to the V3 segment. (g) After coil embolization, right vertebral artery angiography shows retrograde blood flow of the left posterior inferior cerebellar artery through the left vertebral artery.
case_images: SNI-15-12-g002.jpg
case_images: PMC10858786_01_SNI-15-12-g002.jpg
case_images: F2
case_images: At 310 min after the onset of altered consciousness, a head CT showed a hyperdense sign at the tip of the basilar artery and low-density areas in the left cerebellum and midbrain (pc-ASPECTS 7 points) [Figure 2a]. Right vertebral artery angiography showed occlusion at the tip of the basilar artery [Figure 2b]. Using a React 71 (Medtronic, Minneapolis, MN, USA) and Solitaire X 4 x 40 mm (Medtronic) in two passes, complete recanalization was achieved 43 min after femoral artery puncture and 430 min after the onset of altered consciousness [Figure 2c]. The left vertebral artery had anterograde blood flow distal to the 6th cervical vertebra level and thrombi at the 4th-6th cervical vertebra levels [Figure 2d and e]. Coil embolization was performed from the level of the 3rd/4th cervical vertebrae, the distal end of the thrombus in the left vertebral artery V2 segment, to the left vertebral artery V3 segment [Figure 2f]. Perfusion in the left posterior inferior cerebellar artery region through the left vertebral artery was confirmed, which was visualized in reverse on the right vertebral artery angiography, with no interruption of the peripheral vessels in the basilar artery region [Figure 2g].
case_images: Photograph and histopathological findings with hematoxylin-eosin staining of the retrieved thrombi: (a) the photograph shows a predominantly red thrombus with interspersed white thrombus. (b-d) b shows the entire thrombus under hematoxylin-eosin staining. c is a magnified view of the black rectangle in b, while d is a magnified view of the gray rectangle in b. The thrombus surface is dominated by platelets and fibrin, with neutrophils interspersed. Red blood cells are mixed in the thrombus.
case_images: SNI-15-12-g003.jpg
case_images: PMC10858786_01_SNI-15-12-g003.jpg
case_images: F3
case_images: The retrieved thrombus was macroscopically a red thrombus with a partial mixture of white thrombus [Figure 3a]. Hematoxylin-eosin staining revealed that the surface of the thrombus consisted mainly of platelets and fibrin with a mixture of neutrophils and red blood cells mixed within the thrombus [Figure 3b-d].
case_images: Magnetic resonance imaging findings 13 h after the onset of altered consciousness disturbance: (a) diffusion-weighted imaging shows hyperintense areas in the midbrain, pons, bilateral cerebellum, bilateral occipital lobes, and left thalamus. (b) Magnetic resonance angiography shows patency of the right vertebral and basilar arteries and occlusion of the left vertebral artery.
case_images: SNI-15-12-g004.jpg
case_images: PMC10858786_01_SNI-15-12-g004.jpg
case_images: F4
case_images: Diffusion-weighted imaging performed 13 h after the onset of altered consciousness showed infarction in the midbrain, pons, both occipital lobes, both cerebellar hemispheres, and the left thalamus [Figure 4a]. Patency of the right vertebral and basilar arteries and occlusion of the left vertebral artery were confirmed by MRA [Figure 4b].