Cerebral hyperperfusion syndrome after endovascular covered stent grafting for a giant extracranial aneurysm of the internal carotid artery Sakyo Hirai,

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Cerebral hyperperfusion syndrome after endovascular covered stent grafting for a giant extracranial aneurysm of the internal carotid artery Sakyo Hirai, MD, Kuniyasu Saigusa, MD, PhD, Yasuhiro Norisue, MD, Shigeru Nemoto, MD, PhD Journal of Vascular Surgery Cases Volume 1, Issue 1, Pages 46-49 (March 2015) DOI: 10.1016/j.jvsc.2014.11.004 Copyright © 2015 The Authors Terms and Conditions

Fig 1 A, Axial magnetic resonance diffusion-weighted imaging on admission showed a slightly hyperintense lesion in the left corona radiata (arrow). B, Magnetic resonance angiography on admission revealed occlusion of a left M1 segment of the middle cerebral artery (MCA; arrow). C, Axial computed tomography (CT) scan on the day after intravenous thrombolysis showed no hemorrhagic change or new ischemic lesion other than the infarction of the left corona radiata (arrow). D, Cerebral CT angiography revealed recanalized but poorly visualized left MCA and internal carotid artery (ICA; dotted circle) on the day after intravenous thrombolysis. E, Cervical CT angiography revealed a left giant extracranial ICA aneurysm (arrow). F-I, CT perfusion imaging 3 weeks after stroke onset demonstrated decreased ipsilateral cerebral blood flow (CBF; F), cerebral blood volume (CBV) in the normal range (G), delayed mean transit time (MTT; H), and delayed time to peak (TTP; I). Journal of Vascular Surgery Cases 2015 1, 46-49DOI: (10.1016/j.jvsc.2014.11.004) Copyright © 2015 The Authors Terms and Conditions

Fig 2 Left common carotid angiography during endovascular surgery. A, Left common carotid angiography demonstrated that the aneurysm (arrow) arose from a tortuous left internal carotid artery (ICA), whose distal portion (arrowhead) was poorly visualized because of stagnant flow in the aneurysm. B, After deployment of the first covered stent (Niti-S combi stent 8 × 50 mm). Minor endoleakage (arrow) was observed. C, The first covered stent showed shortening immediately after placement with major endoleakage (arrow) in the proximal end of the aneurysm. D, After deployment of the second covered stent (Niti-S combi stent 10 × 50 mm). Some endoleakage (arrow) between the first and second covered stents was observed. E, After deployment of the third covered stent (Niti-S combi stent 8 × 50 mm). Subsequent angiography showed complete occlusion of the aneurysm and restoration of the anterograde ICA flow. Journal of Vascular Surgery Cases 2015 1, 46-49DOI: (10.1016/j.jvsc.2014.11.004) Copyright © 2015 The Authors Terms and Conditions

Fig 3 A-D, Computed tomography (CT) perfusion imaging on postoperative day (POD) 1 showed increased ipsilateral cerebral blood flow (CBF; A) and cerebral blood volume (CBV; B) and shortened mean transit time (MTT; C) and time to peak (TTP; D). E, Axial magnetic resonance fluid attenuation inversion recovery images on POD 7 showed no new ischemic or hemorrhagic lesions. F, Magnetic resonance angiography on POD 7 revealed improved left internal carotid artery (ICA) flow (dotted circle). G-I, Left common carotid CT angiography before placement of the covered stent (G), on POD 1 (H), and 8 months after treatment (I). CT angiography performed 8 months after treatment revealed no evidence of stent graft stenosis or thrombus formation. The aneurysm was markedly smaller than the size measured before treatment and on POD 1. The white points indicate the outlines of the thrombosed aneurysm. Journal of Vascular Surgery Cases 2015 1, 46-49DOI: (10.1016/j.jvsc.2014.11.004) Copyright © 2015 The Authors Terms and Conditions