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Efficacy of thrombectomy with mechanical devices for acute ischemic stroke due to intracranial large artery occlusion is demonstrated in randomized controlled trials in recent studies. There is an emphasis on the use of newer-generation devices such as a stent retriever which significantly reduced disability rates . There is a proven benefit of endovascular thrombectomy up to 7.3 h after onset of stroke due to intracranial large-vessel occlusions. It includes the lower degrees of disability at three months . However, the main aim of stent retriever–based thrombectomy is the removal of embolic clots, and there is a tendency toward re-occlusion in patients with underlying intracranial atherosclerosis .
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Endovascular revascularization treatment (ERT) needs a careful approach since it is known that intracranial atherosclerotic occlusion (ICAS-O) itself is an independent predictor for the poor outcomes including complications . The first step of the ERT is the initial thrombectomy to remove in situ thrombi. Although stent retrievers are generally reported to be safe and feasible treatment for ICAS-O, there is an occasional complication by rupture of the basilar artery and led to a neurological injury . Next is the stabilization using antithrombotic (antiplatelet and/or anticoagulant) agents. This aims to reduce the risk of re-occlusion despite it may increase the risks of bleeding . Further aggressive treatment includes angioplasty using balloons with or without stenting. However, since most of the angioplasty balloons are designed for use in coronary vessels, and, hence, complication rates like vessel rupture, dissection, and intimal tear are more when used in cerebral circulation . In the case of using stent, continued antiplatelet administration is required to maintain intracranial stenting .
Herewith, we present the case with ICAS-O in the long and tortuous region where we successfully performed angioplasty with stent retriever instead of balloon alone which may increase the risk of dissection due to the tortuous characteristic of the region.
A 51-year-old male with the history of dyslipidemia, hypertension, diabetes mellitus, and previous ischemic stroke presented with sudden onset of right facial droop, left arm weakness, diarrhea, nausea and vomiting was admitted to the ED by the ambulance. Upon arrival, the patient was alert, responsive, denied any acute pain though he reported generalized weakness and fatigue, The National Institute of Health Stroke Scale (NIHSS) score was 0 and tPA was not administered. The patient refused diagnostic cerebral angiogram and was transferred to the floor. In “this morning”, the patient deteriorated to NIHSS:8 and showed right middle cerebral artery (MCA) territory stroke. Decision was made to intubate and do a detailed digital subtraction angiography (DSA). He has infarcts but still, there is penumbra.
The microcatheter and guidewire were used to select the right MCA, thus crossing M1 segment steno-occlusive lesion with placement of the system beyond the stenosis into the distal M1 segment. The microwire was then pulled back and removed and a MindFrame capture revascularization device 3 mm x 15 mm was advanced into the microcatheter to cross the stenosis. The MindFrame revascularization device was then deployed in the area of stenosis. After waiting for approximately 3 minutes, the MindFrame revascularization device was retrieved and completely withdrawn. Post MindFrame deployment right internal carotid artery (ICA) angiogram was performed which showed improvement in the stenotic area caliber with improved transit time; however, another control ICA angiogram which was performed after 3 minutes showed more prolonged transit time.
This made us to proceed with re-angioplasty with Gateway balloon. An Echelon 14 microcatheter was preloaded with an X-pedion 14 microwire and the microsystem was introduced and advanced into the Benchmark guide catheter. The microcatheter and guidewire were used to select the right MCA, thus crossing M1 segment stenosis with placement of the system beyond the stenosis into the distal M1 segment. The microwire was then exchanged for a floppy choice exchange length micro guidewire and a 1.5 x 9 mm Gateway balloon was advanced over the exchange wire to cross the stenosis. A slow balloon angioplasty was performed to nominal inflation of 6 atmospheres, over the course of several minutes, with no evidence for contrast extravasation or significant arterial dissection. Post-angioplasty right ICA biplane angiography was performed. The Gateway balloon angioplasty was repeated once again. Despite multiple angioplasty attempts, there was evidence of recoiling. Thus, a decision was made to proceed with stenting. The balloon system was then removed, and a 3.0 x 15 mm Wingspan stent system was advanced under fluoroscopic guidance through the sheath and right internal carotid artery into the MCA where the stenosis was re-crossed over the wire. The stent was then deployed on both sides of the stenosis with adequate coverage and no untoward complications. A total of 2 right ICA post-stenting angiogram was performed. Next, A 2.0 x 9 mm Gateway balloon was advanced sequentially over the exchange wire to perform post-stenting angioplasty. A slow balloon angioplasty was performed to nominal inflation of 6 atmospheres, over the course of several minutes, with no evidence for contrast extravasation or significant arterial dissection. Post angioplasty right ICA biplane angiography was performed. A final angiogram of the right common carotid artery, both in cerebral and cervical views showed no arterial injury or extravasation and a recanalized stenosis. The sheath was entered with a Bentson wire and exchanged for a 6F Perclose device which resulted in good hemostasis
There were no immediate complications. The patient was discharged in good condition, neurologically unchanged. 63.8 minutes of fluoroscopy time and 270 cc of Omnipaque 300 contrast were used. Successful balloon angioplasty and Wingspan stent recanalization of a critical stenosis of the right MCA, M1 segment. There is significantly improved transit time in the right MCA with a residual mild stenosis.
This case presented the successful attempt of angioplasty of intracranial atherosclerotic occlusion (ICAS-O) in the long torturous region using 3.0 x 15 mm Wingspan stent system where 1.5 x 9 mm balloon was potentially insufficient. The decision of switching was made based on the convoluted nature of the lesion.
The underlying ICAS gradually lead to progressive stenosis due to formation of atheromatous plaque. Secondary to the endovascular treatment, a plaque rupture or intraplaque hemorrhage occurs, causing a superimposed thrombosis and acute occlusion of the vessel . Patients with lesions classified as the Mori Type C (diffuse lesions longer than 10 mm, extremely angulated (>90°) lesions with excessive tortuosity of the proximal segment or totally occluded lesions, for over 3 months) either suffered ipsilateral stroke or needed bypass surgery or repeated angioplasty [8–10]. The investigators in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial found that percutaneous transluminal angioplasty and stenting (PTAS) showed poorer outcomes than the aggressive medical therapy (combination antiplatelet therapy and intensive management of risk factors) alone . However, recent study suggests that for those patients with hyperacute stroke secondary to underlying ICAS underwent emergent intracranial angioplasty, with or without stent placement, the successful revascularization was achieved with low rates of symptomatic hemorrhage and mortality .
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Previously in the cases of acute stroke, the use of the Enterprise stent as a temporary endovascular bypass was thought to provide the advantages of stent-assisted revascularization without the need for antiplatelet therapy and avoided the complication of in-stent restenosis. In these cases, the Enterprise stent was partially deployed for some time and retrieved with successful recanalization of the occluded vessel [13,14]. There is a potential risk of excessive bleeding upon stent being fully deployed due to the larger stent size. Although the primary intended use of stent retrievers is for mechanical thrombectomy, Bhogal et al used them for the angioplasty. The advantages include no flow obstruction, minimal user discretion, and availability of vasodilator drug injection . Also, it can be safely operated in convoluted locations where balloon angioplasty is not ideal.
While stents can offer advantages over medical therapy or balloon angioplasty alone, in some cases, using the commercially available stent may result in inadequate dilation due to insufficient radial force compared to the force necessary to dilate the artery properly . For the purpose of angioplasty, there needs to be a specialized stent to achieve desirable level of vasodilation.
Wingspan stent retrievers may be used in conjunction with balloon to achieve safer angioplasty in the long and tortuous region where the risk of dissection is high given the short and convoluted characteristic of the location.
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