case_images: PMC10695346_01
case_images: (a-c) Magnetic resonance imaging on admission revealed acute cerebral infarction in the PCA territory. A mismatch was detected between the high-intensity area of the diffusion-weighted image and the right P1 segment occlusion (c, arrow) with the right vertebral artery origin stenosis (c, arrowhead) shown by computed tomographic angiography. (d-f) MT was performed for the P1 segment of the right PCA occlusion (d, arrow). During MT, recanalization of PCA was accomplished once, but basilar artery occlusion occurred (e, asterisk). Recanalization of the thrombolysis index cerebral infarction score 2b was obtained (f).PCA: posterior cerebral artery, MT: Mechanical thrombectomy.
case_images: SNI-14-406-g001.jpg
case_images: PMC10695346_01_SNI-14-406-g001.jpg
case_images: F1
case_images: Magnetic resonance imaging (MRI) and computed tomographic angiography (CTA) revealed acute cerebral infarction caused by occlusion of the P1 segment of the right posterior cerebral artery (PCA) with a suspicious finding of the right VAOS [Figures 1a-c]. III and further A-to-A embolism with lesion cross of the right VAOS [Figure 1c]. In addition to this, because the fastest recanalization of the right PCA was pursued as far as possible, treatment of the right VAOS was considered elective [Figure 1d]. Recanalization of the right PCA was achieved once, but basilar artery occlusion (BAO) occurred during MT [Figure 1e]. Finally, effective recanalization was achieved (thrombolysis index cerebral infarction score; 2b) [Figure 1f]. Subsequently, A-to-A embolism caused by the right VAOS was revealed as the etiology of the PCA occlusion [Figure 1c].
case_images: (a-c) For the Mo.MA  Ultra placement, the traction route of Radifocus  stiff wire, was made using Amplatz Goose Neck  Microsnare because its tortuosity was prominent. In digital subtraction angiography, (d) VAOS was evident (arrow) and considered the cause of the A-to-A embolism. (e) Under the flow-reversal protection, contrast agent pooled (asterisk) by retrograde flow from the right VA. (f and g) Percutaneous transluminal angioplasty was performed, leading to an improvement of VAOS (g, arrow) and antegrade flow of the right VA (g, arrowhead). (h) The patency of VAOS in the right VA was confirmed by follow-up computed tomographic angiography. A-to-A: Artery to artery, VA: Vertebral artery, VAOS: Vertebral artery origin stenosis.
case_images: SNI-14-406-g002.jpg
case_images: PMC10695346_01_SNI-14-406-g002.jpg
case_images: F2
case_images: CTA showed type III aortic arch and prominent tortuosity of the right brachiocephalic artery (BRCA), which was selected as the approach route; therefore, we presumed that it would be difficult to place Mo.MA  Ultra. Consequently, we used the snare traction technique [Figures 2a-c]. Using the right RA route, we placed a SIM 2 in the right brachial artery using an Amplatz Goose Neck  Microsnare (Medtronic, Dublin, Ireland) [Figure 2a]. To create the traction route of the Mo.MA  Ultra, we placed a Radifocus  stiff 0.035 300 cm (Terumo, Tokyo, Japan) through the SIM 2 and a 5Fr short sheath in the right RA using an Amplatz Goose Neck  Microsnare [Figures 2b and c]. After inflating the distal and proximal balloons, we confirmed the appropriate placement of the Mo.MA  Ultra and flow-reversal protection [Figures 2d and e]. We connected the CHIKAI extension to CHIKAI, induced Gateway 3.5 x 15 mm, and performed PTA (10 atm, nominal pressure 6 atm, 30 s) [Figure 2f]. After PTA, the right BRCA angiography showed improvement in the VAOS and VA flow [Figure 2g]. No evidence of treatment-related infarction was detected on the follow-up MRI, and the improvement in the patency of the right VAOS was maintained [Figure 2h].