Presentation
Aphasia and right-sided weakness.
Patient Data
Non-contrast CT head:
Hyperdense thrombus from the left supraclinoid ICA though to the origin of the left M1 segment.
No sign of infarct, neither acute nor chronic.
CT angiography of neck and head arteries:
Filling defect from the origin of the left ICA though to the left M1.
Separate origin of the right internal carotid artery (ICA) and external carotid artery (ECA) from the brachiocephalic artery (BCA), i.e. absent right common carotid artery (CCA).
CT perfusion:
Decreased blood flow with normal volume in the left MCA territory, substantially lengthened mean transit time and Tmax.
right femoral access, F8
catheterization of left ICA and placement of Guider F8 catheter
acquisition of images in several planes and positions
thrombectomy utilizing Sofia 6F aspiration catheter, single pass
right groin closure with Angioseal 8F
no immediate complications
Left carotid very tortuous. Occlusion of proximal left M1 demonstrated, with partial collaterals from ACA. Release on first pass, utilizing the ADAPT technique. Long thrombus retrieved, 18 mm in length.
Angiographic result at conclusion - TICI 3.
Case Discussion
Lucid and independently functioning elderly woman brought to the ER with a history of suddenly-appearing right-sided limb weakness, right facial asymmetry, and mutism, a half hour before arrival.
Neurologic exam: fully alert, comprehension intact, follows orders; motor aphasia; central facial nerve palsy; leftward gaze deviation; right-sided hemiplegia with hypotony; positive right Babinski reflex. NIHSS 17.
CT-CTA-CTP showed the occluding thrombus and a large penumbra of salvageable brain. On CTA, there was an incidental finding of absent right common carotid artery, namely, the right ICA and ECA arise separately from the brachiocephalic artery.
She was treated with tPA and rushed to another medical center for cerebral angiography, where NIHSS was 13 and on repeat imaging, the core infarct was calculated to be 30-100 ml and the penumbra was 100-120 ml.
Thrombectomy was carried out with satisfactory results, both short and long term. Over 2 years later, she survived small bowel resection for small bowel obstruction.
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