Sentinel Angiographic Signs of Cerebral Hyperperfusion after Angioplasty and Stenting of Intracranial Atherosclerotic Stenosis: A Technical Note

A 66-year-old female patient (patient 1) who presented with left-sided transient ischemic symptoms. A, Noncontrast CT of the brain shows hypodensity consistent with previous ischemic infarct in the right corona radiata in the cerebral internal watershed zone. CT angiography and CT perfusion (not shown) revealed high-grade stenosis of right mid-M1 segment of the MCA with corresponding large areas of perfusion mismatch suggestive of salvageable ischemia, B and C, Pre- and postangioplasty right ICA angiograms demonstrate restoration of the severely compromised lumen of the proximal M1 MCA (white arrow), following angioplasty and stent placement. Note the medial shift of the watershed zone after revascularization, D, Late arterial phase angiographic image immediately postangioplasty and stent placement at a baseline systolic blood pressure of 158 mm Hg demonstrates early opacification of a vein that drains into the deep venous system (black arrows) with prominent capillary blush in the central MCA territory (white arrowheads). E and F, Capillary and venous phase images obtained at a systolic blood pressure of 100 mm Hg depict resolution of early arteriovenous shunting and restoration of homogeneity of the capillary stain, with the filling of the index vein in the normal venous phase. SBP indicates systolic blood pressure.