Page 38 - Inaugural Lecture Prof Dr Ahmad Sobri Muda

Neurointervention

included a severe headache and decreased sensation throughout
his body and face, but no limb paralysis. A computed tomography
(CT) scan on the day of admission indicated an acute subarachnoid
bleed in the left side that expanded to the left frontal and parietal
regions without creating an obvious mass effect. (Figure 12a).
A 3D CT angiography detected a probable distal left internal
carotid artery (ICA) aneurysm along with stenosis due to an uneven
luminal defect in the M1 segment. (Figure 12b). Perfusion imaging
and ASL on MRI showed reduced calibre of the left MCA’s proximal
with a decrease in the relative cerebral blood volume (rCBV) (Figure
12c). He was then worked out in another facility for diagnostic
angiography. With noticeable enhancement on BB post-contrast
and a post-stenotic area with intraluminal intimal flap, the VWMRI
illustrates clearly the focal circumferential wall thickening of the
affected segment (Figure 12d). The severe stenosis in the left M1
segment was confirmed by AP projection in the digital subtraction
angiography (DSA). Initial dual antiplatelet therapy was prescribed
as a result of the TIA symptoms, with absence of an acute infarction
on the MRI. The DSA also showed a very good collateral supply.
However, several days later, the patient experienced an unexpected
and rapid development of dysarthria without any evidence of
muscle weakness, which resolved spontaneously within 24 hours.
A completely new lacunar was reported in the centrum semiovale
on urgent MRI (Figure 12e).
A decision was made to undertake intracranial stenting after
diagnostic cerebral angiography confirmed no change in the degree
of the MCA stenosis. Due to the relatively narrow real lumen seen
well in the 3D-RA endoluminal view, technical difficulties were
encountered throughout the procedure when navigating the wire
into the M2 segment. (Figure 12f). A compliance intracranial non-
detachable balloon was used for angioplasty, and subsequently a
3mm Wingspan stent was delivered.

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