Presentation
Wake up stroke. NIHSS 15. COVID day 5 .
Patient Data
Non-contrast CT demonstrates hyperdensity in the supraclinoid internal carotid artery on the right extending into the M1 segment of the middle cerebral artery. There is no definite loss of a grey-white matter differentiation. No hemorrhage.
CT perfusion demonstrates prolongation of MTT and Tmax in the right middle cerebral artery territory. Cerebral blood flow is reduced, with reduction also seen in cerebral blood volume, particularly in the frontal operculum and white matter of the superior division of the middle cerebral artery territory. The caudate head also appears to have reduced CBV, suggesting a moderate core with substantial penumbra. This is confirmed on automated segmentation.
CT angiography confirms a filling defect in the supraclinoid, internal carotid artery extending up to the M1. No contrast can be seen within the internal carotid artery down to the carotid bulb.
In this instance, a delayed post contrast scan was also performed that shows contrast pooling dependently within the cervical internal carotid artery consistent with a carotid pseudo-occlusion.
The right CCA was catheterized, and angiography demonstrated occlusion of the right supraclinoid ICA with contrast pooling in the cervical ICA due to lack of flow (pseudo-occlusion). The ophthalmic artery arises at the site of occlusion.
A stent retriever was deployed. The distal aspiration catheter was subsequently advanced to the proximal clot face, and 2 passes with concomitant aspiration resulted in good reperfusion.
Case Discussion
This case nicely demonstrates how a complete occlusion of the carotid in the supraclinoid region can result in absence of opacification of the cervical artery, mimicking a tandem lesion or dissection. This is known as a pseudo-occlusion.
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