- Email: [email protected]
Contralateral Mechanical Thrombectomy of Partial Deployed Stent Retrieval for Acute Anterior Inferior Cerebellar Artery Occlusion
Case Report
Contralateral Mechanical Thrombectomy of Partial Deployed Stent Retrieval for Acute Anterior Inferior Cerebellar Artery Occlusion Byung-Sam Choi, Hyungon Lee, Sung-Chul Jin
Key words Anterior inferior cerebellar artery - Posterior inferior cerebellar artery - Thrombectomy -
Abbreviations and Acronyms AICA: Anterior inferior cerebellar artery MT: Mechanical thrombectomy PICA: Posterior inferior cerebellar artery Department of Neurosurgery, Inje University Haeundae Paik Hospital, Busan, Republic of Korea To whom correspondence should be addressed: Sung-Chul Jin, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 129:318-321. https://doi.org/10.1016/j.wneu.2019.06.044 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
INTRODUCTION Medical treatment is regarded as the treatment of choice in most cases involving the occlusion of arterial branches in the posterior circulation, such as occlusion of the posterior inferior cerebellar artery (PICA) or an anterior inferior cerebellar artery (AICA).1,2 The neurologic status of the patient is not generally grave, but the procedural risk of mechanical thrombectomy (MT) is high. Given the development of MT devices, good radiologic and clinical outcomes have been reported after the treatment of distal small arterial occlusions, such as A23 or M2-3 occlusions, which could not have been treated previously with MT.3,4 In addition, stent-assisted coiling, in which the stent is deployed into the PICA and posterior communicating artery, has been shown to have favorable technical feasibility and safety when the stent is deployed into a branched artery with a small caliber.5 Here, we report a case of contralateral MT
318
www.SCIENCEDIRECT.com
- BACKGROUND:
Acute anterior inferior cerebellar artery (AICA) occlusion is considered an acute ischemic stroke requiring medical treatment without mechanical thrombectomy (MT). There is a procedural risk of parent vessel rupture, but neurologic deficits are not generally severe. Here, we report a case of MT performed using partially deployed stent retrieval for acute AICA occlusion.
- CASE
DESCRIPTION: A 53-year-old male patient presented with acute-onset drowsiness and visual disturbance. The initial National Institutes of Health Stroke Scale score of the patient was 5. Computed tomography angiography showed no definite vascular occlusion, but computed tomography perfusion imaging suggested decreased cerebral blood flow and cerebral blood volume, with an increased mean transit time and time to peak in the left posterior inferior cerebellar artery territory. Conventional angiography showed occlusion of the left proximal AICA and posterior inferior cerebellar artery cortical branches, which were reconstituted by the muscular branches of the left vertebral artery. We decided to perform intra-arterial thrombectomy for proximal left AICA occlusion because the patient’s symptoms seemed to be aggravated, and neurologic deficits were not expected. MT was performed using a Trevo stent (Stryker Neurovascular, Fremont, California, USA) in the left proximal AICA via a right vertebral artery approach and resulted in complete recanalization of the occluded AICA. The patient recovered and had an National Institutes of Health Stroke Scale score of 0 at 1 day after MT.
- CONCLUSIONS:
Our case suggests that MT can be performed in a highly selective manner in patients with the occlusion of a posterior circulation branch, such as the AICA, and yield a good clinical outcome.
performed during partially deployed stent retrieval for acute AICA occlusion.
CASE REPORT A 53-year-old male patient presented with acute-onset drowsiness, dizziness, and visual disturbance. The duration from the last normal time to arrival at the hospital was 2 hours, 30 minutes. The initial National Institutes of Health Stroke Scale score of the patient was 5, in part because he had a drowsy mentality, partial neglect, a partial visual field defect, incomplete facial palsy, and an ataxic gait. We could not find the thromboembolic source, including the heart. His electrocardiogram
findings were normal. He only had a 30 pack-year smoking history; he did not have any other history. Therefore, we considered the Trial of ORG 10172 in the Acute Stroke Treatment (TOAST) classification to be 5. Initial computed tomography angiography showed no definite vascular occlusion, but computed tomography perfusion imaging suggested decreased cerebral blood flow and cerebral blood volume, with an increased mean transit time and time to peak in the left PICA territory. Intravenous thrombolysis was not performed because it was not a large artery (Figure 1). Conventional angiography was performed 1 hour, 20 minutes after the
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.06.044
CASE REPORT BYUNG-SAM CHOI ET AL.
A
MT FOR ACUTE AICA OCCLUSION
B
Figure 1. (A) Preoperative computed tomography (CT) angiography showed no definite large-artery occlusion. (B) CT perfusion imaging showed that decreased cerebral blood flow and blood volume, with an increased mean
patient arrived at the hospital. Conventional angiography showed that the left proximal AICA and proximal PICA were occluded and that the cortical branches of the left PICA were reconstituted by the muscular branches of the left vertebral artery (Figure 2). We decided to perform intra-arterial thrombectomy for the proximal left AICA occlusion because the mental status of the patient seemed to be aggravated after conventional angiography, which was associated with deep drowsiness concomitant with intractable nausea and vomiting; in addition, the possibility of decompressive suboccipital craniectomy was high if the AICA and PICA occlusions remained untreated. With the patient under local anesthesia, MT was performed using a 3-mm 20-cm Trevo stent (Stryker Neurovascular, Fremont, California, USA) in the left proximal AICA via a right vertebral artery approach. We retrieved a partially deployed Trevo stent that had covered the full length of the AICA occlusion, resulting in complete recanalization of the occluded AICA
transit time and time to peak in the left posterior inferior cerebellar artery territory.
(Figure 3). The patient recovered fully without neurologic deficits at 1 day after MT. The patient showed no neurologic deficits (modified Rankin scale score of 0) at 1 month after MT after thrombectomy (Figure 4). DISCUSSION Acute posterior circulation branch occlusions, such as PICA or AICA occlusions, are generally regarded as diseases requiring medical treatment; however, the symptoms of such occlusions are initially mild, resulting in delayed detection, which renders treatment with intravenous thrombolysis using a tissue plasminogen activator no longer an option. In addition, there is no previous evidence showing that the application of MT in the treatment of these lesions is clinically beneficial. Accordingly, for posterior circulation branch occlusions detected within 8 hours after symptom onset that would otherwise be treatable via MT, medical treatment is routinely favored over MT.
WORLD NEUROSURGERY 129: 318-321, SEPTEMBER 2019
Given the development of stent-delivery systems, lower-profile stent delivery devices may enable access to arteries with smaller calibers that could not have been treated previously by stenting. A few reports have shown that the application of stent-assisted coiling to branch aneurysm sacs produced favorable technical and clinical results that may support the technical feasibility and safety of stent deployment into small-diameter arteries.6,7 MT for treating the acute occlusion of the anterior cerebral artery or distal middle cerebral artery, which are relatively small in diameter, has been reported to have favorable technical and angiographic outcomes.3,4 On the basis of this evidence, MT using low-profile stents can be a practical approach for treating small-diameter branch vessel occlusions. Because this is the first case report of the use of MT for treating AICA occlusion, there has been no comparison between our MT modality and other MT modalities. Because a partially deployed stent may be tapered in
www.journals.elsevier.com/world-neurosurgery
319
CASE REPORT BYUNG-SAM CHOI ET AL.
MT FOR ACUTE AICA OCCLUSION
A
B
Figure 2. Preoperative conventional angiography. (A) In the left vertebral artery angiogram, the left proximal anterior inferior cerebellar artery (AICA) and proximal posterior inferior cerebellar artery (PICA) were occluded
appearance, which may be associated with less friction and reduced vessel injury during MT, we prefer to perform MT using the partial deployment method to treat the occlusion of small vessels, such as the
(red arrow), and the cortical branches of the left PICA were reconstituted by the muscular branches of the left vertebral artery (black arrow). (B) In the right vertebral artery angiogram, the right vertebral artery was dominant.
CONCLUSIONS
distal middle cerebral artery or anterior cerebral artery. On the basis of our experiences, we also used MT with the partially deployed stent method in treating acute AICA occlusion.
In the occlusion of a lation branch, such performing MT using may be feasible as
A
B
C
D
E
F
Figure 3. During mechanical thrombectomy (MT). (A) A microcatheter was inserted into the left anterior inferior cerebellar artery (AICA) via the right vertebral artery. (B) A Trevo stent was deployed in the proximal left AICA. (C) After the microcatheter was passed into the lesion, distal flow was intact
320
www.SCIENCEDIRECT.com
posterior circuas the AICA, stent retrieval a therapeutic
on the control angiogram. (D) The flow of the left AICA was observed after the stent was deployed. (E) After stent retrieval, the proximal left AICA was recanalized. (F) After MT, no complications were observed on the postoperative left vertebral angiogram.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.06.044
CASE REPORT BYUNG-SAM CHOI ET AL.
MT FOR ACUTE AICA OCCLUSION
A
B
Figure 4. (A) Magnetic resonance angiography 3 days after mechanical thrombectomy (MT). The proximal left anterior inferior cerebellar artery was patent. (B) Four days after MT, computed
option. However, it should be highly selectively applied and can, in appropriate cases, be expected to achieve good clinical outcomes and successful recanalization. REFERENCES 1. Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014;32:979-991. 2. Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008;7:951-964. 3. Chen C-J, Wang C, Buell TJ, et al. Endovascular mechanical thrombectomy for acute middle cerebral artery M2 segment occlusion: a systematic review. World Neurosurg. 2017;107:684-691.
tomography of the brain showed that the left cerebellar cortex had developed a small infarction, but it was not progressing.
4. Crockett MT, Phillips TJ, Chiu AHY. Dual suction Headway27 microcatheter thrombectomy for the treatment of distal intracranial arterial occlusion strokes: initial experience with the micro-ADAPT technique. J Neurointerv Surg. 2019;11:714-718. 5. Tang J, Wei L, Li L, et al. Endovascular treatment of distal posterior inferior cerebellar artery aneurysms. Neurosciences (Riyadh). 2016;21:236-240. 6. Cho DY, Choi JH, Kim BS, et al. Comparison of clinical and radiologic outcomes of diverse endovascular treatments in vertebral artery dissecting aneurysm involving the origin of PICA. World Neurosurg. 2019;121:e22-e31.
cerebellar artery. AJNR Am J Neuroradiol. 2012;33: 348-352.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 1 April 2019; accepted 3 June 2019 Citation: World Neurosurg. (2019) 129:318-321. https://doi.org/10.1016/j.wneu.2019.06.044 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
7. Kim MJ, Chung J, Kim SL, et al. Stenting from the vertebral artery to the posterior inferior
WORLD NEUROSURGERY 129: 318-321, SEPTEMBER 2019
www.journals.elsevier.com/world-neurosurgery
321
Contralateral Mechanical Thrombectomy of Partial Deployed Stent Retrieval for Acute Anterior Inferior Cerebellar Artery Occlusion Byung-Sam Choi, Hyungon Lee, Sung-Chul Jin
Key words Anterior inferior cerebellar artery - Posterior inferior cerebellar artery - Thrombectomy -
Abbreviations and Acronyms AICA: Anterior inferior cerebellar artery MT: Mechanical thrombectomy PICA: Posterior inferior cerebellar artery Department of Neurosurgery, Inje University Haeundae Paik Hospital, Busan, Republic of Korea To whom correspondence should be addressed: Sung-Chul Jin, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 129:318-321. https://doi.org/10.1016/j.wneu.2019.06.044 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
INTRODUCTION Medical treatment is regarded as the treatment of choice in most cases involving the occlusion of arterial branches in the posterior circulation, such as occlusion of the posterior inferior cerebellar artery (PICA) or an anterior inferior cerebellar artery (AICA).1,2 The neurologic status of the patient is not generally grave, but the procedural risk of mechanical thrombectomy (MT) is high. Given the development of MT devices, good radiologic and clinical outcomes have been reported after the treatment of distal small arterial occlusions, such as A23 or M2-3 occlusions, which could not have been treated previously with MT.3,4 In addition, stent-assisted coiling, in which the stent is deployed into the PICA and posterior communicating artery, has been shown to have favorable technical feasibility and safety when the stent is deployed into a branched artery with a small caliber.5 Here, we report a case of contralateral MT
318
www.SCIENCEDIRECT.com
- BACKGROUND:
Acute anterior inferior cerebellar artery (AICA) occlusion is considered an acute ischemic stroke requiring medical treatment without mechanical thrombectomy (MT). There is a procedural risk of parent vessel rupture, but neurologic deficits are not generally severe. Here, we report a case of MT performed using partially deployed stent retrieval for acute AICA occlusion.
- CASE
DESCRIPTION: A 53-year-old male patient presented with acute-onset drowsiness and visual disturbance. The initial National Institutes of Health Stroke Scale score of the patient was 5. Computed tomography angiography showed no definite vascular occlusion, but computed tomography perfusion imaging suggested decreased cerebral blood flow and cerebral blood volume, with an increased mean transit time and time to peak in the left posterior inferior cerebellar artery territory. Conventional angiography showed occlusion of the left proximal AICA and posterior inferior cerebellar artery cortical branches, which were reconstituted by the muscular branches of the left vertebral artery. We decided to perform intra-arterial thrombectomy for proximal left AICA occlusion because the patient’s symptoms seemed to be aggravated, and neurologic deficits were not expected. MT was performed using a Trevo stent (Stryker Neurovascular, Fremont, California, USA) in the left proximal AICA via a right vertebral artery approach and resulted in complete recanalization of the occluded AICA. The patient recovered and had an National Institutes of Health Stroke Scale score of 0 at 1 day after MT.
- CONCLUSIONS:
Our case suggests that MT can be performed in a highly selective manner in patients with the occlusion of a posterior circulation branch, such as the AICA, and yield a good clinical outcome.
performed during partially deployed stent retrieval for acute AICA occlusion.
CASE REPORT A 53-year-old male patient presented with acute-onset drowsiness, dizziness, and visual disturbance. The duration from the last normal time to arrival at the hospital was 2 hours, 30 minutes. The initial National Institutes of Health Stroke Scale score of the patient was 5, in part because he had a drowsy mentality, partial neglect, a partial visual field defect, incomplete facial palsy, and an ataxic gait. We could not find the thromboembolic source, including the heart. His electrocardiogram
findings were normal. He only had a 30 pack-year smoking history; he did not have any other history. Therefore, we considered the Trial of ORG 10172 in the Acute Stroke Treatment (TOAST) classification to be 5. Initial computed tomography angiography showed no definite vascular occlusion, but computed tomography perfusion imaging suggested decreased cerebral blood flow and cerebral blood volume, with an increased mean transit time and time to peak in the left PICA territory. Intravenous thrombolysis was not performed because it was not a large artery (Figure 1). Conventional angiography was performed 1 hour, 20 minutes after the
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.06.044
CASE REPORT BYUNG-SAM CHOI ET AL.
A
MT FOR ACUTE AICA OCCLUSION
B
Figure 1. (A) Preoperative computed tomography (CT) angiography showed no definite large-artery occlusion. (B) CT perfusion imaging showed that decreased cerebral blood flow and blood volume, with an increased mean
patient arrived at the hospital. Conventional angiography showed that the left proximal AICA and proximal PICA were occluded and that the cortical branches of the left PICA were reconstituted by the muscular branches of the left vertebral artery (Figure 2). We decided to perform intra-arterial thrombectomy for the proximal left AICA occlusion because the mental status of the patient seemed to be aggravated after conventional angiography, which was associated with deep drowsiness concomitant with intractable nausea and vomiting; in addition, the possibility of decompressive suboccipital craniectomy was high if the AICA and PICA occlusions remained untreated. With the patient under local anesthesia, MT was performed using a 3-mm 20-cm Trevo stent (Stryker Neurovascular, Fremont, California, USA) in the left proximal AICA via a right vertebral artery approach. We retrieved a partially deployed Trevo stent that had covered the full length of the AICA occlusion, resulting in complete recanalization of the occluded AICA
transit time and time to peak in the left posterior inferior cerebellar artery territory.
(Figure 3). The patient recovered fully without neurologic deficits at 1 day after MT. The patient showed no neurologic deficits (modified Rankin scale score of 0) at 1 month after MT after thrombectomy (Figure 4). DISCUSSION Acute posterior circulation branch occlusions, such as PICA or AICA occlusions, are generally regarded as diseases requiring medical treatment; however, the symptoms of such occlusions are initially mild, resulting in delayed detection, which renders treatment with intravenous thrombolysis using a tissue plasminogen activator no longer an option. In addition, there is no previous evidence showing that the application of MT in the treatment of these lesions is clinically beneficial. Accordingly, for posterior circulation branch occlusions detected within 8 hours after symptom onset that would otherwise be treatable via MT, medical treatment is routinely favored over MT.
WORLD NEUROSURGERY 129: 318-321, SEPTEMBER 2019
Given the development of stent-delivery systems, lower-profile stent delivery devices may enable access to arteries with smaller calibers that could not have been treated previously by stenting. A few reports have shown that the application of stent-assisted coiling to branch aneurysm sacs produced favorable technical and clinical results that may support the technical feasibility and safety of stent deployment into small-diameter arteries.6,7 MT for treating the acute occlusion of the anterior cerebral artery or distal middle cerebral artery, which are relatively small in diameter, has been reported to have favorable technical and angiographic outcomes.3,4 On the basis of this evidence, MT using low-profile stents can be a practical approach for treating small-diameter branch vessel occlusions. Because this is the first case report of the use of MT for treating AICA occlusion, there has been no comparison between our MT modality and other MT modalities. Because a partially deployed stent may be tapered in
www.journals.elsevier.com/world-neurosurgery
319
CASE REPORT BYUNG-SAM CHOI ET AL.
MT FOR ACUTE AICA OCCLUSION
A
B
Figure 2. Preoperative conventional angiography. (A) In the left vertebral artery angiogram, the left proximal anterior inferior cerebellar artery (AICA) and proximal posterior inferior cerebellar artery (PICA) were occluded
appearance, which may be associated with less friction and reduced vessel injury during MT, we prefer to perform MT using the partial deployment method to treat the occlusion of small vessels, such as the
(red arrow), and the cortical branches of the left PICA were reconstituted by the muscular branches of the left vertebral artery (black arrow). (B) In the right vertebral artery angiogram, the right vertebral artery was dominant.
CONCLUSIONS
distal middle cerebral artery or anterior cerebral artery. On the basis of our experiences, we also used MT with the partially deployed stent method in treating acute AICA occlusion.
In the occlusion of a lation branch, such performing MT using may be feasible as
A
B
C
D
E
F
Figure 3. During mechanical thrombectomy (MT). (A) A microcatheter was inserted into the left anterior inferior cerebellar artery (AICA) via the right vertebral artery. (B) A Trevo stent was deployed in the proximal left AICA. (C) After the microcatheter was passed into the lesion, distal flow was intact
320
www.SCIENCEDIRECT.com
posterior circuas the AICA, stent retrieval a therapeutic
on the control angiogram. (D) The flow of the left AICA was observed after the stent was deployed. (E) After stent retrieval, the proximal left AICA was recanalized. (F) After MT, no complications were observed on the postoperative left vertebral angiogram.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.06.044
CASE REPORT BYUNG-SAM CHOI ET AL.
MT FOR ACUTE AICA OCCLUSION
A
B
Figure 4. (A) Magnetic resonance angiography 3 days after mechanical thrombectomy (MT). The proximal left anterior inferior cerebellar artery was patent. (B) Four days after MT, computed
option. However, it should be highly selectively applied and can, in appropriate cases, be expected to achieve good clinical outcomes and successful recanalization. REFERENCES 1. Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014;32:979-991. 2. Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008;7:951-964. 3. Chen C-J, Wang C, Buell TJ, et al. Endovascular mechanical thrombectomy for acute middle cerebral artery M2 segment occlusion: a systematic review. World Neurosurg. 2017;107:684-691.
tomography of the brain showed that the left cerebellar cortex had developed a small infarction, but it was not progressing.
4. Crockett MT, Phillips TJ, Chiu AHY. Dual suction Headway27 microcatheter thrombectomy for the treatment of distal intracranial arterial occlusion strokes: initial experience with the micro-ADAPT technique. J Neurointerv Surg. 2019;11:714-718. 5. Tang J, Wei L, Li L, et al. Endovascular treatment of distal posterior inferior cerebellar artery aneurysms. Neurosciences (Riyadh). 2016;21:236-240. 6. Cho DY, Choi JH, Kim BS, et al. Comparison of clinical and radiologic outcomes of diverse endovascular treatments in vertebral artery dissecting aneurysm involving the origin of PICA. World Neurosurg. 2019;121:e22-e31.
cerebellar artery. AJNR Am J Neuroradiol. 2012;33: 348-352.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 1 April 2019; accepted 3 June 2019 Citation: World Neurosurg. (2019) 129:318-321. https://doi.org/10.1016/j.wneu.2019.06.044 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
7. Kim MJ, Chung J, Kim SL, et al. Stenting from the vertebral artery to the posterior inferior
WORLD NEUROSURGERY 129: 318-321, SEPTEMBER 2019
www.journals.elsevier.com/world-neurosurgery
321