Article Figures & Data
Figures
- Fig 1.
A, Diagnostic angiogram of the left internal carotid artery (ICA) reveals good flow across the anterior communicating artery (AcomA) but poor filling of the right MCA territory because of a thrombus demonstrated on an earlier CT angiogram.
B, Successful recanalization of right MCA is seen after administration of 9 mg of tissue plasminogen activator (tPA) into the middle cerebral artery (MCA).
C, Diagnostic angiogram of the left ICA reveals cross-filling through the AcomA into the right MCA. There is probably dilution of contrast in the MCA by nonopacified blood from the ipsilateral posterior communicating artery because good patency of the MCA was demonstrated on the earlier microcatheter injection.
- Fig 2.
A, Lateral angiogram of the left common carotid artery (CCA) in a 24-year-old man with acute left hemiplegia reveals a pseudoaneurysm (arrow) in the distal cervical internal carotid artery (ICA) with narrowing of the parent artery.
B, The right CCA angiogram shows complete occlusion of the right ICA (arrow) just beyond the bulb.
C, Microcatheter injection demonstrates a thrombus in the distal M1 segment (arrow) of the middle cerebral artery (MCA).
D, Administration of 7.5 mg of intra-arterial tissue plasminogen activator (IA tPA) through the microcatheter, which was advanced into the face of the thrombus, resulted in lysis of thrombus and restoration of antegrade flow.
E, Microcatheter injections demonstrate a pseudoaneurysm in the distal cervical right ICA (arrow).
F and G, Repeat angiogram through the guiding catheter after successful treatment by using 2 overlapping covered stents reveals no filling of the pseudoaneurysm and normal flow in the MCA. The patient recovered complete power on the left side within minutes of the procedure. The left ICA dissection and pseudoaneurysm were managed conservatively and, at 2 months after the procedure, the patient had no neurologic deficits.
Tables
- Table 1:
Clinical and imaging features of 7 patients with occluded internal carotid artery and acute stroke
Patient No./Age (y)/Sex Site of Occlusion (CTA) Presence of Penumbra (CTP) NIHSS at Presentation NIHSS at Follow-up 1/54/M LICA and LMCA: M1 Yes 22 15 (1 mo) 2/51/M LICA and LMCA: M1 and M2 Yes 15 1 (14 mo) 3/62/F RICA and RMCA: M1 Yes 21 0 (6 mo) 4/78/F LICA and LMCA: M1 Yes 11 0 (5 mo) 5/70/F RICA* Yes† 17 1 (14 mo) 6/28/F LICA and LMCA: M1 No perfusion study‡ 17 0 (40 mo) 7/24/M RICA and RMCA: M1 No perfusion study 12 0 (1 mo) Note:—CTA indicates computed tomographic angiography; CTP, computed tomographic perfusion; NIHSS, National Institutes of Health Stroke Scale; RICA, right internal carotid artery; LICA, left internal carotid artery; RMCA, right middle cerebral artery; LMCA, left middle cerebral artery.
* Seen on MR angiogram.
† Seen on MR perfusion study.
‡ No perfusion imaging performed since the intervention “pre-dated routine perfusion imaging.”
- Table 2:
Intervention and outcomes in the 7 patients with acute stroke due to occluded ICA
Patient No. IA tPA (mg) Stenting and angioplasty of ICA Lysis of MCA Clot through occluded ICA TIMI Flow after Thromboysis Post Rx CT Outcome (mRS) at 30 days 1 20 Yes Yes 2 Basal ganglia infarct 4 2 10 Yes Yes 3 Patchy parietal infarcts 3 3 9 No Yes 3 Basal ganglia infarct 0 4 0* Yes No 3 Basal ganglia infarct 0 5 18 No Yes 3 Basal ganglia infarct 0 6 10 No No 3 Evolving frontal bleed 1 7 15 Yes† Yes 3 Small frontal lobe infarct 0 Note:—ICA indicates internal carotid artery; IA tPA, intra-arterial tissue plasminogen activator; MCA, middle cerebral artery; CT, computed tomography; mRS, modified Rankin Scale.
* This patient received 38 mg intravenous tPA prior to angiography.
† ICA pseudoaneurysm was treated with 2 overlapping covered stents.
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