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Figure 9: Case 3: Following the sudden onset hemiparesis in the young girl, (a) A left carotid three-dimensional computed tomographic (CT) angiogram showed an irregular fusiform dilatation of the paraclinoid segment of internal carotid artery (ICA) distal to the anterior clinoid process (ACP). There is a small sessile aneurysm also arising from the dorsal surface of this fusiform dilatation of the ICA. The distal vessels show a distinct narrowing. (b) Left carotid angiogram antero-posterior image; and, (c) Lateral image showed the dissection of supraclinoid internal carotid artery (ICA) with the anterior cerebral artery and the middle cerebral artery not filling from the left side. The posterior communicating and posterior cerebral arteries, however, show a good filling from the left internal carotid artery (ICA). Endovascular nimodipine was instilled into the lumen of ICA. Her hemiparesis improved. (d) The right internal carotid artery (ICA) injection showed a good flow through bilateral middle cerebral arteries and anterior cerebral arteries. (e and f) However, within six-hours of the procedure, the patient again developed hemiparesis and the DSA images of right ICA showed a recurrence of spasm of the left-sided middle cerebral artery (MCA). The patient was retaken to the angiogram suit and intra-arterial nimodipine was reinstilled. Following the second intervention, the patient improved to near-normal motor power. (g and h) The right internal carotid artery angiogram showed a good filling of bilateral middle cerebral and anterior cerebral arteries.

Figure 9: Case 3: Following the sudden onset hemiparesis in the young girl, (a) A left carotid three-dimensional computed tomographic (CT) angiogram showed an irregular fusiform dilatation of the paraclinoid segment of internal carotid artery (ICA) distal to the anterior clinoid process (ACP). There is a small sessile aneurysm also arising from the dorsal surface of this fusiform dilatation of the ICA. The distal vessels show a distinct narrowing. (b) Left carotid angiogram antero-posterior image; and, (c) Lateral image showed the dissection of supraclinoid internal carotid artery (ICA) with the anterior cerebral artery and the middle cerebral artery not filling from the left side. The posterior communicating and posterior cerebral arteries, however, show a good filling from the left internal carotid artery (ICA). Endovascular nimodipine was instilled into the lumen of ICA. Her hemiparesis improved. (d) The right internal carotid artery (ICA) injection showed a good flow through bilateral middle cerebral arteries and anterior cerebral arteries. (e and f) However, within six-hours of the procedure, the patient again developed hemiparesis and the DSA images of right ICA showed a recurrence of spasm of the left-sided middle cerebral artery (MCA). The patient was retaken to the angiogram suit and intra-arterial nimodipine was reinstilled. Following the second intervention, the patient improved to near-normal motor power. (g and h) The right internal carotid artery angiogram showed a good filling of bilateral middle cerebral and anterior cerebral arteries.