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Delayed Vasospasm Associated with Mechanical Thrombectomy for Acute Ischemic Stroke
Clinical Images
Delayed Vasospasm Associated with Mechanical Thrombectomy for Acute Ischemic Stroke Yuki Matsunaga, Yoichi Morofuji, Nobutaka Horie
Key words Acute ischemic stroke - Mechanical thrombectomy - Vasospasm -
Abbreviations and Acronyms MRA: Magnetic resonance angiography MT: Mechanical thrombectomy
Vasospasm related to mechanical thrombectomy for acute ischemic stroke sometimes occurs as a periprocedural complication, although it is usually a transient and asymptomatic event. Herein we describe the second case of symptomatic delayed vasospasm associated with mechanical thrombectomy, highlighting its unique device-related adverse event. When intraoperative vasospasm occurs, we should pay attention to this phenomenon, and close follow-up is necessary.
Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan To whom correspondence should be addressed: Yuki Matsunaga, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2020) 138:197-199. https://doi.org/10.1016/j.wneu.2020.03.027 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved.
INTRODUCTION A 42-year-old woman was undergoing chemotherapy for advanced ovarian cancer. She presented with sudden-onset global aphasia. Magnetic resonance imaging revealed infarction of the left insular cortex and temporal lobe, and magnetic resonance angiography (MRA) showed left middle
Figure 1. Initial assessment. (A) Magnetic resonance angiography indicates left M1 occlusion. (B) Diffusion-weighted image shows hyperintense lesions at the left temporal lobe and insular cortex. (C) Preoperative left internal carotid artery angiography (ICAG) shows M1 occlusion. (D) Left
WORLD NEUROSURGERY 138: 197-199, JUNE 2020
cerebral artery occlusion (Figure 1A and B). Angiography showed left M1 occlusion (Figure 1C). Mechanical thrombectomy (MT) with combined technique was performed using EmboTrap II (Cerenovus, Galway, Ireland) and Penumbra ACE 68 system (Penumbra, Alameda, California, USA) (Figure 1D). Thrombolysis in cerebral infarction 2B recanalization was obtained, but severe stenosis remained at the site of
ICAG after deploying stent retriever shows immediate restoration (dash line: the site of stent deployment). (E) Final angiogram shows thrombolysis in cerebral infarction 2B recanalization with severe stenosis. (cee) Enlarged views of each image.
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CLINICAL IMAGES YUKI MATSUNAGA ET AL.
DELAYED VASOSPASM ASSOCIATED WITH MT
Figure 2. (A) Magnetic resonance angiography (MRA) on the next day after the mechanical thrombectomy (MT) indicates improved severe stenosis at the M1 segment. (B) MRA on the third day after the MT reveals severe restenosis at the M1 segment, suggesting delayed vasospasm. (C) MRA
stent deployment (Figure 1E). Considering the effects of vasospasm, we infused nicardipine 2 mg via the internal carotid artery. After 30 minutes of follow-up, the procedure was finished because M1 stenosis improved slightly. After 12 hours of MT, global aphasia improved almost completely. MRA on the next day after MT showed improved severe stenosis (Figure 2A). On the third postoperative day, global aphasia recurred. MRA demonstrated restenosis at the M1 segment (Figure 2B). T1-weighted imaging revealed no hyperintense lesion suggesting arterial dissection (Figure 2D). Her global aphasia disappeared after the magnetic resonance imaging scan. The patient was diagnosed with symptomatic vasospasm and conservatively treated with antithrombotic medication. Ten days after MT, MRA showed patent M1 segment without any stenotic lesion (Figure 2C). Vasospasm usually occurs owing to the catheter and guidewire manipulation. Some trials reported arterial vasospasm occurred in 3.1%e23%.1-6 In particular, 2 clinical trials using the EmboTrap system reported intraoperative vasospasm occurred in 3.1%e3.4%.3,6 Intraoperative arterial vasospasm sometimes occurs; in most cases, vasospasm is transient within minutes and normally does not cause any clinical symptoms.7 Some cases with chronic restenosis after MT have also been reported.8 However, to the best of our knowledge, there is only
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10 days after the MT shows improved vasospasm. (aec) Enlarged views of each image. (D) T1-weighted image on the third day after MT reveals no hyperintensity lesion suggestive of arterial dissection.
1 case report of symptomatic delayed vasospasm after MT.9 Therefore this is the second case of this phenomenon. We strongly believe that this vasospasm occurred due to 2 main causes. One is mechanical stimulation caused by stent retriever. Animal studies have shown that stent retriever thrombectomy devices induce vessel wall injury.10 Some histopathologic reports from autopsy reveal vessel wall injury after stent retriever thrombectomy.11-13 The other cause is systematic inflammation caused by advanced ovarian cancer. Inflammation has been shown to be implicated in vasospasm.14,15 Although it is known that intraoperative arterial vasospasm diminishes within a short time and is normally asymptomatic, the possibility of delayed vasospasm should be considered, and serial imaging followup is mandatory. ACKNOWLEDGMENTS The authors thank Tadashi Kanamoto, Yohei Tateishi, Tsuyoshi Izumo, and Takayuki Matsuo for providing insight and expertise that assisted this article. REFERENCES 1. Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016;15: 1138-1147.
2. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306. 3. Mattle HP, Scarrott C, Claffey M, et al. Analysis of revascularisation in ischaemic stroke with EmboTrap (ARISE I study) and meta-analysis of thrombectomy. Interv Neuroradiol. 2019;25:261-270. 4. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285-2295. 5. Valente I, Nappini S, Renieri L, et al. Initial experience with the novel EmboTrap II clotretrieving device for the treatment of ischaemic stroke. Interv Neuroradiol. 2019;25:271-276. 6. Zaidat OO, Bozorgchami H, Ribo M, et al. Primary results of the multicenter ARISE II study (analysis of Revascularization in ischemic stroke with EmboTrap). Stroke. 2018;49:1107-1115. 7. Akpinar SH, Yilmaz G. Periprocedural complications in endovascular stroke treatment. Br J Radiol. 2016;89:20150267. 8. Kurre W, Perez MA, Horvath D, Schmid E, Bazner H, Henkes H. Does mechanical thrombectomy in acute embolic stroke have long-term side effects on intracranial vessels? An angiographic follow-up study. Cardiovasc Intervent Radiol. 2013;36:629-636. 9. Goda T, Kobayashi J, Watanabe A, Takahashi D. A patient with delayed cerebral vasospasm after mechanical thrombectomy. J Neuroendovasc Ther. 2018;12:254-259. 10. Arai D, Ishii A, Chihara H, Ikeda H, Miyamoto S. Histological examination of vascular damage caused by stent retriever thrombectomy devices. J Neurointerv Surg. 2016;8:992-995. 11. Koge J, Kato S, Hashimoto T, Nakamura Y, Kawajiri M, Yamada T. Vessel wall injury after
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.03.027
CLINICAL IMAGES YUKI MATSUNAGA ET AL.
stent retriever thrombectomy for internal carotid artery occlusion with duplicated middle cerebral artery. World Neurosurg. 2019;123:54-58. 12. Nishino W, Tajima Y, Inoue T, et al. Severe vasospasm of the middle cerebral artery after mechanical thrombectomy due to infective endocarditis: an autopsy case. J Stroke Cerebrovasc Dis. 2017;26:e186-e188. 13. Yin NS, Benavides S, Starkman S, et al. Autopsy findings after intracranial thrombectomy for acute ischemic stroke: a clinicopathologic study of 5 patients. Stroke. 2010;41:938-947.
DELAYED VASOSPASM ASSOCIATED WITH MT
14. Dumont A, Dumont R, Chow M, Lin C, Calisaneller T, Ley K. Cerebral vasospasm after subarachnoid hemorrhage: putative role of inflammation. Neurosurgery. 2003;53:123-135.
commercial or financial relationships that could be construed as a potential conflict of interest. Received 16 January 2020; accepted 4 March 2020 Citation: World Neurosurg. (2020) 138:197-199. https://doi.org/10.1016/j.wneu.2020.03.027
15. Provencio J, Vora N. Subarachnoid hemorrhage and inflammation; bench to bedside and back. Semin Neurol. 2005;25:435-444.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any
WORLD NEUROSURGERY 138: 197-199, JUNE 2020
Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved.
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199
Delayed Vasospasm Associated with Mechanical Thrombectomy for Acute Ischemic Stroke Yuki Matsunaga, Yoichi Morofuji, Nobutaka Horie
Key words Acute ischemic stroke - Mechanical thrombectomy - Vasospasm -
Abbreviations and Acronyms MRA: Magnetic resonance angiography MT: Mechanical thrombectomy
Vasospasm related to mechanical thrombectomy for acute ischemic stroke sometimes occurs as a periprocedural complication, although it is usually a transient and asymptomatic event. Herein we describe the second case of symptomatic delayed vasospasm associated with mechanical thrombectomy, highlighting its unique device-related adverse event. When intraoperative vasospasm occurs, we should pay attention to this phenomenon, and close follow-up is necessary.
Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan To whom correspondence should be addressed: Yuki Matsunaga, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2020) 138:197-199. https://doi.org/10.1016/j.wneu.2020.03.027 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved.
INTRODUCTION A 42-year-old woman was undergoing chemotherapy for advanced ovarian cancer. She presented with sudden-onset global aphasia. Magnetic resonance imaging revealed infarction of the left insular cortex and temporal lobe, and magnetic resonance angiography (MRA) showed left middle
Figure 1. Initial assessment. (A) Magnetic resonance angiography indicates left M1 occlusion. (B) Diffusion-weighted image shows hyperintense lesions at the left temporal lobe and insular cortex. (C) Preoperative left internal carotid artery angiography (ICAG) shows M1 occlusion. (D) Left
WORLD NEUROSURGERY 138: 197-199, JUNE 2020
cerebral artery occlusion (Figure 1A and B). Angiography showed left M1 occlusion (Figure 1C). Mechanical thrombectomy (MT) with combined technique was performed using EmboTrap II (Cerenovus, Galway, Ireland) and Penumbra ACE 68 system (Penumbra, Alameda, California, USA) (Figure 1D). Thrombolysis in cerebral infarction 2B recanalization was obtained, but severe stenosis remained at the site of
ICAG after deploying stent retriever shows immediate restoration (dash line: the site of stent deployment). (E) Final angiogram shows thrombolysis in cerebral infarction 2B recanalization with severe stenosis. (cee) Enlarged views of each image.
www.journals.elsevier.com/world-neurosurgery
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CLINICAL IMAGES YUKI MATSUNAGA ET AL.
DELAYED VASOSPASM ASSOCIATED WITH MT
Figure 2. (A) Magnetic resonance angiography (MRA) on the next day after the mechanical thrombectomy (MT) indicates improved severe stenosis at the M1 segment. (B) MRA on the third day after the MT reveals severe restenosis at the M1 segment, suggesting delayed vasospasm. (C) MRA
stent deployment (Figure 1E). Considering the effects of vasospasm, we infused nicardipine 2 mg via the internal carotid artery. After 30 minutes of follow-up, the procedure was finished because M1 stenosis improved slightly. After 12 hours of MT, global aphasia improved almost completely. MRA on the next day after MT showed improved severe stenosis (Figure 2A). On the third postoperative day, global aphasia recurred. MRA demonstrated restenosis at the M1 segment (Figure 2B). T1-weighted imaging revealed no hyperintense lesion suggesting arterial dissection (Figure 2D). Her global aphasia disappeared after the magnetic resonance imaging scan. The patient was diagnosed with symptomatic vasospasm and conservatively treated with antithrombotic medication. Ten days after MT, MRA showed patent M1 segment without any stenotic lesion (Figure 2C). Vasospasm usually occurs owing to the catheter and guidewire manipulation. Some trials reported arterial vasospasm occurred in 3.1%e23%.1-6 In particular, 2 clinical trials using the EmboTrap system reported intraoperative vasospasm occurred in 3.1%e3.4%.3,6 Intraoperative arterial vasospasm sometimes occurs; in most cases, vasospasm is transient within minutes and normally does not cause any clinical symptoms.7 Some cases with chronic restenosis after MT have also been reported.8 However, to the best of our knowledge, there is only
198
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10 days after the MT shows improved vasospasm. (aec) Enlarged views of each image. (D) T1-weighted image on the third day after MT reveals no hyperintensity lesion suggestive of arterial dissection.
1 case report of symptomatic delayed vasospasm after MT.9 Therefore this is the second case of this phenomenon. We strongly believe that this vasospasm occurred due to 2 main causes. One is mechanical stimulation caused by stent retriever. Animal studies have shown that stent retriever thrombectomy devices induce vessel wall injury.10 Some histopathologic reports from autopsy reveal vessel wall injury after stent retriever thrombectomy.11-13 The other cause is systematic inflammation caused by advanced ovarian cancer. Inflammation has been shown to be implicated in vasospasm.14,15 Although it is known that intraoperative arterial vasospasm diminishes within a short time and is normally asymptomatic, the possibility of delayed vasospasm should be considered, and serial imaging followup is mandatory. ACKNOWLEDGMENTS The authors thank Tadashi Kanamoto, Yohei Tateishi, Tsuyoshi Izumo, and Takayuki Matsuo for providing insight and expertise that assisted this article. REFERENCES 1. Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016;15: 1138-1147.
2. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306. 3. Mattle HP, Scarrott C, Claffey M, et al. Analysis of revascularisation in ischaemic stroke with EmboTrap (ARISE I study) and meta-analysis of thrombectomy. Interv Neuroradiol. 2019;25:261-270. 4. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285-2295. 5. Valente I, Nappini S, Renieri L, et al. Initial experience with the novel EmboTrap II clotretrieving device for the treatment of ischaemic stroke. Interv Neuroradiol. 2019;25:271-276. 6. Zaidat OO, Bozorgchami H, Ribo M, et al. Primary results of the multicenter ARISE II study (analysis of Revascularization in ischemic stroke with EmboTrap). Stroke. 2018;49:1107-1115. 7. Akpinar SH, Yilmaz G. Periprocedural complications in endovascular stroke treatment. Br J Radiol. 2016;89:20150267. 8. Kurre W, Perez MA, Horvath D, Schmid E, Bazner H, Henkes H. Does mechanical thrombectomy in acute embolic stroke have long-term side effects on intracranial vessels? An angiographic follow-up study. Cardiovasc Intervent Radiol. 2013;36:629-636. 9. Goda T, Kobayashi J, Watanabe A, Takahashi D. A patient with delayed cerebral vasospasm after mechanical thrombectomy. J Neuroendovasc Ther. 2018;12:254-259. 10. Arai D, Ishii A, Chihara H, Ikeda H, Miyamoto S. Histological examination of vascular damage caused by stent retriever thrombectomy devices. J Neurointerv Surg. 2016;8:992-995. 11. Koge J, Kato S, Hashimoto T, Nakamura Y, Kawajiri M, Yamada T. Vessel wall injury after
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.03.027
CLINICAL IMAGES YUKI MATSUNAGA ET AL.
stent retriever thrombectomy for internal carotid artery occlusion with duplicated middle cerebral artery. World Neurosurg. 2019;123:54-58. 12. Nishino W, Tajima Y, Inoue T, et al. Severe vasospasm of the middle cerebral artery after mechanical thrombectomy due to infective endocarditis: an autopsy case. J Stroke Cerebrovasc Dis. 2017;26:e186-e188. 13. Yin NS, Benavides S, Starkman S, et al. Autopsy findings after intracranial thrombectomy for acute ischemic stroke: a clinicopathologic study of 5 patients. Stroke. 2010;41:938-947.
DELAYED VASOSPASM ASSOCIATED WITH MT
14. Dumont A, Dumont R, Chow M, Lin C, Calisaneller T, Ley K. Cerebral vasospasm after subarachnoid hemorrhage: putative role of inflammation. Neurosurgery. 2003;53:123-135.
commercial or financial relationships that could be construed as a potential conflict of interest. Received 16 January 2020; accepted 4 March 2020 Citation: World Neurosurg. (2020) 138:197-199. https://doi.org/10.1016/j.wneu.2020.03.027
15. Provencio J, Vora N. Subarachnoid hemorrhage and inflammation; bench to bedside and back. Semin Neurol. 2005;25:435-444.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any
WORLD NEUROSURGERY 138: 197-199, JUNE 2020
Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
199