J Neurocrit Care.  2019 Dec;12(2):108-112. 10.18700/jnc.190103.

Intraarterial therapy for middle cerebral artery dissection with intramural hematoma detection on susceptibility-weighted imaging

• Yoon C
• Jung S
• Jeong H
• Cho E
• Yang TW
• Kim SJ
• Park KJ
• Kim SS
• Park H

• KMID: 2470473
• DOI: http://doi.org/10.18700/jnc.190103

Abstract

BACKGROUND
Intracranial artery dissection (IAD) may be an underdiagnosed cause of large vessel occlusion. The safety and efficacy of intra-arterial therapy (IAT) in patients with IAD are largely unknown. We report the case of a patient with IAD who was successfully treated with IAT.
CASE REPORT
A 27-year-old man with a sudden-onset sensory dominant aphasia was admitted to our hospital around 16 hours after disease onset. Brain magnetic resonance angiography revealed an occlusion in the left distal middle cerebral artery (MCA). On the susceptibility-weighted imaging, bead-shaped dark signals were observed in the left MCA bifurcation, and intramural hematoma was suspected. We performed thrombectomy and permanent stenting for the dissecting MCA occlusion and achieved complete recanalization.
CONCLUSION
The IMH on susceptibility-weighted imaging led us to suspect that the large vessel occlusion was due to the IAD. Further research is needed to address the efficacy and safety of IAT in patients with IAD.

Keyword

Middle cerebral artery; Blood vessel dissection; Thrombectomy

MeSH Terms

Adult
Aphasia
Arteries
Brain
Hematoma*
Humans
Magnetic Resonance Angiography
Middle Cerebral Artery*
Stents
Thrombectomy

Figure

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  Fig. 1. Magnetic resonance (MR) imaging scans of the brain performed in another hospital before admission. (A, B) The diffusion-weighted image shows multiple infarctions in the left temporoparietal lobes. (C) Hyperintense vessel signs (white arrowhead) on fluid-attenuated inversion recovery imaging. (D) MR angiogram showing an occlusion in the left distal middle cerebral artery. (E, F) Perfusion computed tomography (CT) image showing perfusion delay, defined as a relative mean transit time of >145% when compared with that on the contralateral side (green color), in the left middle cerebral arterial territory. No core infarct lesions, defined as a cerebral blood volume of <2 mL/100 g in the region on interest, were found. (G, H) Focal enlarged vessels with contrast enhancement (white arrows) on the CT angiography source images.

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  Fig. 2. (A–D) Susceptibility-weighted image demonstrating bead-shaped dark signals in the area of the bifurcation site of the left middle cerebral artery. (E–H) Corresponding bright signal intensities on the phase map.

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  Fig. 3. Left internal carotid artery angiography (ICAG) images (A–C: frontal view; D–F: lateral view). (A, D) The initial ICAG image shows an occlusion in the left distal middle cerebral artery (MCA). (B, E) After the thrombectomy using a stent retriever, a partial filling defect in the left distal M1 and an occlusion in the left M2 superior division were found. (C, F) Final angiogram after permanent stenting between the left distal M1 and M2 superior divisions, showing complete recanalization of the left MCA.

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