Technically Uncomplicated Treatment of a Severe Symptomatic Intracranial Stenosis of the Internal Carotid Artery; Fatal Outcome Due to Periprocedural Hemodynamic Compromise with Diffuse Cortical Ischemia

An 86-year-old woman was referred for potential endovascular treatment of a high-grade, symptomatic atherosclerotic stenosis of the left internal carotid artery (ICA). Diagnostic workup revealed a 60% stenosis of the proximal and a 90% stenosis of the intradural ICA. The patient presented recurrent episodes of right-hand hemiparesis and aphasia despite oral anticoagulation and antiaggregation with Edoxaban and aspirin, respectively. The proximal ICA stenosis was left untreated, and the intradural stenosis was treated with balloon angioplasty and deployment of a self-expanding stent. The procedure was performed without an apparent issue. The patient, however, did not wake up from general anesthesia. Diffusion-weighted magnetic resonance imaging on day 1 after the endovascular treatment revealed widespread ischemic damage to the left hemispheric cortex. The patient received palliative care and passed away on postprocedural day 3. Periprocedural hemodynamic compromise is a rare but maybe underreported complication of the endovascular treatment of symptomatic intracranial atherosclerotic stenoses.