Rationale: Carotid web, a known source of thrombus for embolic stroke, presents a considerable risk of stroke recurrence. While case reports have demonstrated the safety and effectiveness of mechanical thrombectomy in treating carotid web-related stroke, the need for concurrent carotid artery stenting to prevent recurrent stroke immediately after thrombectomy remains unclear. This study aims to underscore the importance of immediate carotid artery stenting in preventing recurrent stroke following mechanical thrombectomy in patients with carotid web-related stroke. Patient concerns: A 43-year-old woman with acute onset of left limb weakness and slurred speech within 3 hours was admitted to the emergency department. Diagnoses: Computed tomographic angiography confirmed the M1 segment occlusion of the right middle cerebral artery. Interventions: The patient received intravenous thrombolysis in the local hospital and mechanical thrombectomy in our stroke center. Outcomes: Three days post-mechanical thrombectomy, there was a sudden exacerbation of her neurological deficit symptoms. A reexamination via computed tomographic angiography revealed a re-occlusion in M1 segment of the right middle cerebral artery, despite the implementation of stringent anticoagulation therapy for carotid web-related stroke. Lessons: Stroke patients with carotid web had a high risk of stroke recurrence and it was necessary to conduct carotid artery stenting to prevent stroke recurrence secondary to the carotid web immediately after mechanical thrombectomy.

Cerebral venous sinus thrombosis (CVST) in pregnancy was common and endovascular treatment (EVT) could be an effective and safe treatment for patients with severe and refractory CVST. However, the efficacy and safety of hybrid EVT (craniotomy + endovascular treatment) for CVST were unknown. We represented a rare case of hybrid EVT through the incision of the superior sagittal sinus in a pregnant woman with CVST who failed to EVT through the femoral vein pathway. A 26-year-old woman, in her second month of pregnancy, complained of a headache for 5 days and aggravation with coma combined with convulsions for 2 days. She was diagnosed with CVST in the local hospital by digital subtraction angiography (DSA) and treated with anticoagulation. She had no history of illness and the biochemical tests were normal. Hybrid EVT (craniotomy + EVT) was attempted after failing to conduct EVT through the femoral vein pathway due to difficulty to reach the target cerebral venous sinus. Briefly, a small hole was made in the frontotemporal head to expose the superior sagittal sinus and a 6F sheath was inserted into 2cm of superior sagittal sinus incision and fixed on the scalp, after repeated aspiration by 5F intermediate catheter and balloon dilatation of stenosis in the right transverse sinus and right sigmoid sinus, the cerebral venous system got successful recanalization. No obvious complications were found and the patient recovered very well after the surgery. Anticoagulation was the standard treatment for CVST. EVT could rapidly restore venous flow and improve the prognosis for refractory and severe CVST. EVT by hybrid surgery through the superior sagittal sinus incision may be safe and effective for desperate patients with severe CVST.

Background: Middle cerebral artery (MCA) fenestration is a rare vascular variant that can mimic stenosis. Its association with cerebral ischemia remains controversial. Method: We report the case of a 53-year-old man with a history of transient ischemic attack (TIA), initially misdiagnosed with left MCA occlusion, who presented with sleep disturbances due to fear of stroke recurrence. A definitive diagnosis of MCA fenestration was established by digital subtraction angiography (DSA) and high-resolution magnetic resonance vessel-wall imaging (HRMR-VWI). Perfusion-weighted imaging (PWI) was employed to evaluate the associated hemodynamic compromise. A literature review was conducted to identify all reported cases of MCA fenestration associated with cerebral ischemia. Results: A total of 19 cases (including ours) from 12 studies were identified. Patients were predominantly male, with ages ranging from 4 to 85 years. All fenestrations were located in the M1 segment. Slit-like morphology was observed in 73.7% of patients and was more frequent in acute ischemic stroke (AIS) than in TIA (91.7% vs. 42.9%). Eleven patients (57.9%) were definitively diagnosed via DSA. Mechanical thrombectomy was performed in six patients with concurrent MCA occlusion, yielding favorable functional outcomes in five (83.3%). Overall, 73.7% of patients achieved favorable outcomes at follow-up. Conclusion: MCA fenestration should be considered in the differential diagnosis for patients presenting with cerebral ischemia and M1 stenosis or occlusion, particularly in the absence of conventional vascular risk factors. A slit-like morphology may be associated with a higher risk of stroke. Multimodal imaging is essential to avoid misdiagnosis and guide appropriate clinical management.