Superficial Temporal Artery-Middle Cerebral Artery Anastomosis for Internal Carotid Artery Occlusion by Subacute In-Stent Thrombosis after Carotid Artery Stenting
A 68-year-old male patient was admitted to the hospital with asymptomatic bilateral carotid stenosis. Severe stenosis at the right proximal ICA (94%) and stenosis at the left proximal ICA (34%) were identified in cerebral angiography. Right CAS and balloon angioplasty were performed. After 5 month, aggravated left proximal ICA stenosis (72%) was found during the follow-up (). Left CAS and balloon angioplasty were also performed (). He was discharged after starting dual antiplatelet medication. Four days after CAS, sudden right hemiparesis, dysarthria, and right facial palsy were noted. The patient was brought to the emergency department. NIHSS score at the admission was 2 points and NIHSS score in 6 hours from onset of symptom was 16 points which indicated that the symptoms were progressed. Proximal ICA occlusion was identified in neck angio CT (). Intravenous tissue plasminogen activator and Intra-arterial thrombolysis were failed (). Diffusion-perfusion mismatch was seen on perfusion CT image. Therefore, urgent STA-MCA anastomosis was performed (). Aspirin and clopidogrel resistance test showed that the patient was resistant to both drugs. Triple antiplatelet medication therapy was started. The symptoms improved, but right hemiparesis was remained. Three months after the surgery, his mRS score was 3 points.