64-year-old female patient suffered from sudden aphemia, drowsiness and left limb paralysis for 40 minutes, with rightward gaze deviation.
Pre-procedural cerebral CT scan showed no ischemic lesion or infarction (fig. 2). An intravenous 3D syngo DynaPBV Neuro examination was performed under general anesthesia to exam the viability of the brain parenchyma. It showed an enormously low perfusion area around the right middle cerebral artery (R-MCA) (fig. 4).
The right common carotid artery (R-CCA) digital subtraction angiography (DSA) demonstrated a total occlusion in the initial part of the R-ICA. The left internal carotid artery (L-ICA) angiography showed there was a severe stenosis at the M1 segment of the right middle cerebral artery (R-MCA). The R-MCA dominated cerebral area was partially compensated by right-ACA and softmeninx micro-vessels (fig. 1).
According to the pre-procedural DSA findings, stent-assisted mechanical recanalization was performed with a 4.0 x 20 mm self-expanding retrievable intracranial stent (Solitaire AB, Covidien, USA) within R-ICA and R-MCA. The following DSA examination showed a morphological improvement of the M1 segment of the R-MCA while the R-ICA was not totally recanalized withonly an opacification of the distal part of the communicating segment of the R-ICA. Moreover, DSA roughly showed that not only the left-ICA area but also the right-ICA area was supplied by L-ICA through the anterior communicating artery with sufficient blood filling (fig. 3).
A second syngo DynaPBV Neuro run was performed with the same acquisition and injection protocol to verify the improvement of parenchymal perfusion. CBV images illustrated that the perfusion of the right brain hemisphere was dramatically improved and the CBV values were similar to those on the left side (fig. 5).
The pre- and post-L-ICA angiographies were post-processed by syngo iFlow (fig. 6, 7). The prolonged blood flow and the improved perfusion in the ipsilateral side were vividly demonstrated by the color-coded images. In addition, there was an obvious delay of time-to-peak (TTP) value in the M2 segment of the R-MCA compared to the contralateral side pre-procedurally while the post-procedural TTP of the bilateral sides turned into the same level, manifesting the improvement of the hemodynamic status.
To avoid the risk of re-thrombosis induced by further recanalization, a clinical decision was made to terminate the procedure as the anticipated clinical outcome was already achieved despite the remaining occlusion in the R-ICA. Post-procedural MR images showed an evident shrinkage of the infarction area compared to the pre-procedural syngo DynaPBV Neuro (fig. 8).
The acute stroke symptoms were clearly relieved after the procedure the patient recovered well was discharged from hospital within nine days.
syngo DynaPBV Neuro allows physicians to evaluate cerebral blood volume (CBV) directly in the catheter suite. It can save precious time for physicians to make a credible clinical decision or to determine the end point of interventional procedures when treating patients with acute ischemic stroke. As reported in this case, syngo DynaPBV Neuro may also overcome the limitation of DSA by illustrating functional improvement instead of the morphological change in the vessels, which is more critical and meaningful for evaluating the curative effect for acute stroke. It assists physicians for better diagnosis, treatment check-up and prognosis prediction.
The CBV improvement varies from patient to patient depending on several factors especially the door-to-balloon time; for these reasons, more data is needed for further study.
Pre-treatment: [left] a total occlusion in the initial part of the R-ICA; [right] a severe stenosis at the M1 segment of the right middle cerebral artery.
Pre-procedural CT: no ischemic lesion or infarction was found. [left] Cross-sectional image at the middle lateral ventricles level, [right] cross-sectional image at basal ganglia level.
Post-treatment: Despite the occlusion on the R-ICA, M1 segment of the R-MCA was re-opened by stent-assisted mechanical recanalization and the right intracranial vasculature was improved. [left] Post-procedural angiography in early arterial phase; [right] post-procedural angiography in late arterial phase.
Pre-treatment syngo DynaPBV Neuro imaging. [left] syngo DynaPBV Neuro image at corpus callosum level; [right] syngo DynaPBV Neuro image at the middle lateral ventricles level.
Post-treatment syngo DynaPBV Neuro imaging.
Pre-treatment syngo iFlow imaging.
Post-treatment syngo iFlow imaging.