Angioplasty in acute middle cerebral artery stroke due to atrial fibrillation selected by CT perfusion: a case report
© Saletti et al; licensee Springer. 2011
Received: 30 November 2010
Accepted: 6 June 2011
Published: 6 June 2011
We report the experience of a case of acute stroke in a patient affected by Rendu Osler syndrome and atrial fibrillation. The combination of dynamic computerized tomography perfusion scans and the use of a high-compliance balloon allowed increasing the treatment window for intra-arterial recanalization over 6 h after stroke onset in a patient with middle cerebral artery occlusion.
Stroke is the third leading cause of death in the United States, Canada, Europe, and Japan.
Currently, thrombolysis of the clot responsible for an ischemic event is proving to be an effective therapy for improving the patients' condition following an acute stroke.
One of the most important elements in obtaining clinical success is how early treatment is first established: early treatment within 3 h for intravenous recombinant tissue plasminogen activator (rt PA) and within 6 h for IA (intra-arterial) thrombolysis shows significant post-clinical improvement after 90 days and reduced incidence of cerebral hemorrhage.
Improved imaging, distinguishing ischemic penumbra from irreversibly infarcted tissue, could be a criterion more accurate than the duration of symptoms for selecting patients to undergo therapy .
Recent advances in the field of neurointerventional radiology, with the development of different clot retrievers, and high-compliance balloons and stents, have made IA recanalization feasible and afford safe access to the major intracranial blood vessels by a percutaneous transfemoral approach under local anesthesia.
Successful recanalization is associated with improved outcome after acute ischemic stroke . Treatment with mechanical thromboembolectomy techniques is proposed for failed recanalization after thrombolysis or for patients with contraindications for thrombolytic therapy. However, mechanical recanalization techniques are not always successful.
In a MERCI trial, the association of mechanical recanalization and IA therapy showed an overall recanalization rate of 68% .
In this case report we show angiographic recanalization and clinical improvement in a patient on anticoagulant therapy who had suffered an acute MCA (middle cerebral artery) stroke because of atrial fibrillation and who benefitted from angioplasty.
The purpose of this paper is to document a case of acute stroke in a patient with middle cerebral artery occlusion using a combination of dynamic CT (computerized tomography) perfusion scans to perform tissue perfusion and high-compliance balloon techniques, with a treatment window for intra-arterial thrombolysis longer than 6 h from the stroke onset.
A 70-year-old right-handed female was brought to the emergency room 35 min after the sudden onset of a stroke. She arrived at the hospital at 11.35 a.m. with dysarthria, right homonymous hemianopsia, dense right hemiplegia, and partial gaze palsy.
Neurological deficit on presentation was assessed using the National Institutes of Health Stroke Scale (NIHSS) with a score of 24. She had a past medical history of hypertension, hyperlipidemia, atrial fibrillation, and hereditary hemorrhagic telangiectasia.
On general medical evaluation she was alert but disorientated. Her blood pressure was 170/80, serum glucose value 89 mg/dl, and cholesterol 213 mg/dl.
All stroke patients arriving at our hospital undergo an emergent brain CT scan, CT angiogram (CTA), and CT perfusion (CTP), according to a protocol agreed upon by neurologists and intensivists.
On the basis of the presence of penumbra, the decision was taken to transfer the patient to an angiographic ward.
Because the angiographic suite was busy with other procedures, an angiography was performed 6 h after the onset of symptoms without any change in her clinical condition. It confirmed an occlusion of the main M1 trunk with excellent collateral circulation from the leptomeningeal anterior cerebral artery and retrograde opacification of the distal M1 segment.
An angiogram was obtained by pulling back the microcatheter to show the extent of the thrombus.
According to exclusion criteria of the SITS-MOST Study Protocol , Rendu Osler syndrome represents an absolute contraindication for rt PA infusion.
We opted for a mechanical thrombectomy performed more than 6 h after the onset of the stroke with a Hyperform 4 mm × 7 mm balloon angioplasty (EV3) positioned inside the thrombus. Recanalization was achieved with rapid inflations (duration of the inflation, maximum 10 s) at different levels of the M1 trunk.
NIHSS score at 24 h was 8, and the Rankin scale at 3 months documented a slight disability (Modified Rankin Score 2).
This case shows that angioplasty of an acute embolic occlusion of the MCA may represent the correct course of action to rapidly restore cerebral flow, especially when the thrombus extends beyond the lenticulostriate arteries and in patients with contraindications for thrombolysis or who are on anticoagulant therapy, since drug reduction would be detrimental to the patient's health.
Nakano et al. performed a retrospective comparison of 34 patients with acute MCA trunk occlusion who had been treated with direct PTA (followed by thrombolytic therapy in 21 patients) with 36 similar patients who had been treated with thrombolytic therapy alone .
Partial or complete recanalization was achieved in 91.2% of the first group as opposed to 63.9% of the second. Symptomatic intracerebral hemorrhage was observed in 2.9% versus 19.4%, and a good outcome (Modified Rankin Score ≤ 2) was reached in 73.5% versus 50% of the patients, respectively.
The majority of patients were treated with semicompliance balloons, typically coronary balloons, whereas Mangiafico et al.  and Lum et al. documented a series of 21 and 9 patients, respectively, treated with a combination of IA drugs and HyperGlide balloons.
The Multi MERCI trial, designed in part to test the performance of a new generation of thrombectomy devices, found an increased though not statistically significant rate of recanalization of intracranial vessels .
In embolic occlusion, the balloon catheter should only penetrate the embolus, and dilatation force applied to the vessel wall is usually less than that used in the treatment of intracranial vascular stenosis .
Another potential drawback of this technique is the theoretical risk of occluding the lenticulostriate arteries because of the displacement of the clot. The use of thrombolytic agents, particularly local intra-arterial infusion of highly concentrated or high-dose thrombolytic agents into the ischemic tissue, may be the greatest risk factor in symptomatic hemorrhage.
For these reasons, mechanical clot removal without the use of thrombolytic agents may be the ideal treatment for acute ischemic stroke, especially in patients with a high hemorrhagic risk and increasing time from stroke onset, when the risk of hemorrhage increases.
In addition to clinical features, perfusion imaging techniques combined with MRI (magnetic resonance imaging) or CT are mandatory to recognize a clear demarcation of irreversible damaged infarcted and ischemic but still recoverable tissue, to accurately determine which patients may benefit from reperfusion, especially those with unknown time of stroke onset or who are outside the recommended 6-h time window for therapy [16–18].
The new MR techniques of diffusion-weighted and perfusion-weighted imaging, including in a diagnostic protocol of acute stoke patients, identified ischemic brain regions and detected impaired perfusion. CT is an essential diagnostic requirement in a stroke center to exclude patients with intracerebral hemorrhage and extensive demarcation of ischemic infarction.
In these instances, the presence of mismatch may justify mechanical revascularization in order to reduce potential hemorrhagic complications, as in our case.
Salvage angioplasty of acutely occluded intracranial arteries with a high-compliance balloon may represent an option for a correct first course of action to achieve rapid recanalization, especially in MCA occlusion beyond the lenticulostriate arteries and in patients on anticoagulant therapy or having other contraindications for thrombolysis.
Perfusion imaging techniques are fundamental in assisting decision-making in cases of arterial occlusion.
Written consent for the publication of this case report and any accompanying images was obtained from the patient. A copy of the written consent is available for review from the Editor-in Chief of this journal.
magnetic resonance imaging
middle cerebral artery
National Institutes of Health Stroke Scale
perfusion computerized tomography
cerebral blood flow
mean transit time
cerebral blood volume
- rt PA:
recombinant tissue plasminogen activator
Cerebral Infarction Perfusion Categories
Safe Implementation of Treatment in Stroke-Monitor Observational Study.
We would like to thank Drs M. Borrelli, A. Bernardoni, E. Paolino, C. Azzini, and R. Tamarozzi for their help.
- Higashida RT, Furlan AJ: Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 2003, 34: e109-e137. 10.1161/01.STR.0000082721.62796.09View ArticlePubMed
- Rha JH, Saver JL: The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007, 38: 967–973. 10.1161/01.STR.0000258112.14918.24View ArticlePubMed
- Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, Lutsep HL, Rymer MM, Higashida RT, Starkman S, Gobin YP: Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI Trial. Stroke 2008, 39: 1205–1212. 10.1161/STROKEAHA.107.497115View ArticlePubMed
- Nedeltchev K, Remonda L, Do DD, Brekenfeld C, Ozdoba C, Arnold M, Mattle HP, Schroth G: Acute stenting and thromboaspiration in basilar artery occlusions due to embolism from the dominating vertebral artery. Neuroradiology 2004, 46: 686–691. 10.1007/s00234-004-1217-zView ArticlePubMed
- Eckert B, Koch C, Thomalla G, Kucinski T, Grzyska U, Roether J, Alfke K, Jansen O, Zeumer H: Aggressive therapy with intravenous abciximab and intra-arterial rtPA and additional PTA/stenting improves clinical outcome in acute vertebrobasilar occlusion combined local fibrinolysis and intravenous abciximab in acute vertebrobasilar stroke treatment (FAST): results of a multicenter study. Stroke 2005, 36: 1160–1165. 10.1161/01.STR.0000165918.80812.1eView ArticlePubMed
- Levy EI, Mehta R, Gupta R, Hanel RA, Chamczuk AJ, Fiorella D, Woo HH, Albuquerque FC, Jovin TG, Horowitz MB, Hopkins LN: Self-expanding stents for recanalization of acute cerebrovascular occlusions. Am J Neuroradiol 2007, 28: 816–822.PubMed
- Safe Implementation of Treatment in Stroke [http://sitsinternational.org]
- Ueda T, Sakaki S, Nochide I, Kumon Y, Kohno K, Ohta S: Angioplasty after intra-arterial thrombolysis for acute occlusion of intracranial arteries. Stroke 1998, 29: 2568–2574.View ArticlePubMed
- Lum C, Stys PK, Hogan MJ, Nguyen TB, Srinivasan A, Goyal M: Acute anterior circulation stroke: recanalization using clot angioplasty. Can J Neurol Sci 2006, 33: 217–222.View ArticlePubMed
- Nakano S, Iseda T, Yoneyama T, Kawano H, Wakisaka S: Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis. Stroke 2002, 33: 2872–2876. 10.1161/01.STR.0000038985.26269.F2View ArticlePubMed
- Mangiafico S, Cellerini M, Nencini P, Gensini G, Inzitari D: Intravenous glycoprotein IIb/IIIa inhibitor (Tirofiban) followed by intra-arterial urokinase and mechanical thrombolysis in stroke. Am J Neuroradiol 2005, 26: 2595–2601.PubMed
- Tsai FY, Berberian B, Matovich V, Lavin M, Alfieri K: Percutaneous transluminal angioplasty adjunct to thrombolysis for acute middle cerebral artery rethrombosis. Am J Neuroradiol 1994, 15: 1823–1829.PubMed
- Purdy PD, Devous MD Sr, Unwin DH, Giller CA, Batjer HH: Angioplasty of an atherosclerotic middle cerebral artery associated with improvement in regional cerebral blood flow. Am J Neuroradiol 1990, 11: 878–880.PubMed
- Higashida RT, Tsai FY, Halbach VV, Dowd CF, Smith T, Fraser K, Hieshima GB: Transluminal angioplasty for atherosclerotic disease of the vertebral and basilar arteries. J Neurosurg 1993, 78: 192–198. 10.3171/jns.1993.78.2.0192View ArticlePubMed
- Yoneyama T, Nakano S, Kawano H, Iseda T, Ikeda T, Goya T, Wakisaka S: Combined direct percutaneous transluminal angioplasty and low-dose native tissue plasminogen activator therapy for acute embolic middle cerebral artery trunk occlusion. Am J Neuroradiol 2002, 23: 277–281.PubMed
- Hellier KD, Hampton JL, Guadagno JV, Higgins NP, Antoun NM, Day DJ, Gillard JH, Warburton EA, Baron JC: Perfusion CT helps decision making for thrombolysis when there is no clear time of onset. J Neurol Neurosurg Psychiatry 2006, 77: 417–419.PubMed CentralView ArticlePubMed
- Provenzale JM, Wintermark M: Optimization of perfusion imaging for acute cerebral ischemia: review of recent clinical trials and recommendations for future studies. Am J Roentgenol 2008, 191(Suppl 4):1263–70.View Article
- Schellinger PD, Fiebach JB, Hacke W, Röther J: Imaging-based decision making in thrombolytic therapy for ischemic stroke: present status. Stroke 2003, 34: 575–583. 10.1161/01.STR.0000051504.10095.9CView ArticlePubMed
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