Stroke

Case Report :

A sixty five-year-old man, not a known case of hypertension or diabetes presented with complaints of giddiness, loss of speech and sudden onset weakness of the right side of the body since one and half hours followed by altered sensorium .The weakness had not improved over the period of time.

The patient was disoriented, aphasic with right sided facial weakness and a dense right hemiplegia suggesting an anterior circulation stroke, NIHSS score at admission was 22. A cranial CT scan revealed blurred left lenticular nucleus with dense a Lt. MCA (Figs 1-2). Based on the clinical and radiological findings and absence of any criteria for exclusion, we planned for intra-arterial recanalization.

Fig 1	Fig 2

Diagnostic angiography showed occlusion of ICA top with minimal flow in the Lt. ACA

Fig 3

Moderate reformation of MCA branches through ACA –MCA , PCA –MCA pial –pial collaterals was seen on the right CCA & Lt. VA angiograms respectively (Figure 4 & 5).

Fig 4	Fig 5

Intra-arterial recanalization was undertaken three and a half hours after stroke onset. Keeping in view , proximal occlusion and thrombus load, a combination therapy of injection of intra arterial thrombolytic agent ( rTPA) and mechanical balloon angioplasty was planned.

A 6F Envoy guide catheter (Cordis Corp) was positioned at the origin of the left internal carotid artery. An Echelon-14 microcatheter and a X-Pedion 0.014” microwire (EV3) combination was passed through the guiding catheter to reach the thrombus.The microcatheter was pushed to the distal end of the thrombus in the MCA (Figure 6) and the ACA.

Contrast was injected to visualize the exact location and size of the thrombus and the condition of the vascular bed distal to the thrombus . The tip of the microcatheter was then pulled back into the thrombus and microwire manipulations were used to disintegrate the thrombus. The aim in this procedure was to try to maximize the area of thrombus facing the thrombolytic agent that was to be injected subsequently. Thrombolytic agent r-TPA (Actilyse, Boehringer Ingelheim) 10 mg (5 mg each in MCA & ACA). was then injected through the microcatheter. After every 5 mg infusion, test angiography was performed through the guiding catheter. Thrombolytic therapy was ended even as minimal recanalization of Lt. ACA with no recanalisation of the MCA noted (Figure 6, 7) was seen.

Fig 6	Fig 7

No mechanical retriever device was available. Hence, it was decided to perform primary

mechanical angioplasty using a Coronary balloon. A Sapphire catheter mounted on a 0.014” X-Pedion wire (EV3) was used for this. .The micro guidewire was positioned distal to the thrombus and the balloon was gently inflated manually within the thrombus starting from the horizontal segment of the MCA continuing proximally till the Lt. supraclinod ICA (Figure 8)

Fig 8

At this time, fragmented thrombus migration into the in MCA (Figure 9) and ACA was apparent.

Fig 9

Finally, there was re-establishment of flow noted in MCA distal to the lateral lenticulostriate arteries (except the smaller inferior division of the MCA) (Figure 10).

Fig 10

But, when balloon and Microwire were withdrawn , stump occlusion of the Lt. MCA was noted with a patent Lt. ACA and temporal branch of Lt. MCA (Figure 11,12).

Fig 11	Fig 12

Minimal reformation of the Lt. MCA branches through ACA –MCA , PCA –MCA pial –pial collaterals was noted on the Rt. CCA & Lt. VA angiogram respectively.

The final angiographic result for ACA was TIMI 3 from TIMI 0 and for MCA was TIMI 1 fromTIMI 0 (at the beginning of the procedure).

Clinically, the patient was unconscious without recovery in motor power of the Rt. UL, LL. Immediate NIHSS score was unchanged (22). Immediate post procedure CT Brain showed hyper attenuation in Lt. basal region with impending Lt. MCA territory infarct (Figure 13),

Fig 13

Heparin was withheld till the next scan. The following day, the CT scan of the brain showed diminution of the hyper attenuation in the Lt. basal region with ant. and middle third Lt. MCA territory infarct. The posterior MCA & ACA territories were intact. After confirmation of diminution of Lt. basal ganglia hyper attenuation (Figure 14), Heparin and anti platelet therapy were started.

Fig 14

 

Over the next several days, the patient made gradual recovery in the level of consciousness and Rt. Lower limb power.

On 42 nd day follow up, there was minimal residual facial weakness. The patient was able to pronounce monosyllables, sit in bed on his own and take few steps with support.

DISCUSSION: