Intra-Arterial Thrombolysis of Occluded Middle Cerebral Artery by Use of Collateral Pathways in Patients with Tandem Cervical Carotid Artery/Middle Cerebral Artery Occlusion

Article Figures & Data

Download figure
Open in new tab
Download powerpoint
Fig 1.
A, The right vertebral artery injection shows bilateral filling of the PcomA arteries that supply both internal carotid arteries. The left MCA M1 segment is occluded (small black arrow). B, Microcathether injection demonstrates a thrombus in the M1 segment (arrow) of the MCA. C, The right vertebral artery injection shows successful recanalization of the left MCA (arrow).
Download figure
Open in new tab
Download powerpoint
Fig 2.
A, The left vertebral angiogram demonstrates an occlusion of the proximal MCA M1 segment (arrow). B, Administration of 15 mg of intra-arterial rtPA through a microcathether by use of the AcomA and PcomA arteries resulted in partial lysis of thrombus in the left M1 segment with restoration of flow within the inferior division of the left MCA. C, Follow-up CT angiogram 24 hours after stroke shows a complete recanalization of the M1 segment of the left MCA (arrow).

Table 1.

Patient characteristics, preprocedure and postprocedure angiographic and imaging findings

Case No	Age yr/sex	Onset to IA Treatment (min)	Site of Occlusion	Collateral Pathway	Initial ASPECT	Cause of Stroke
Case 1	53/M	342	LICA/LMCA:M1	AcomA	7	Atherothrombotic
Case 2	42/M	360	LICA/LMCA:M1	PcomA	6	Unknown
Case 3	64/M	250	LICA/LMCA:M1	PcomA	8	Atherothrombotic
Case 4	46/M	300	LICA/LMCA:M1	AcomA	7	Unknown
Case 5	55/M	300	LICA/LMCA:M1	AcomA	9	Cardioembolic
Case 6	65/M	250	LICA/LMCA;M1	AcomA/PcomA	8	Atherothrombotic
Case 7	68/F	300	LICA/LMCA:M1	AcomA	8	Atherothrombotic
Case 8	71/M	240	RICA/RMCA:M1	PcomA	8	Atherothrombotic

Note:—ASPECT indicates Alberta Stroke Program Early CT score; RICA, right internal carotid artery; LICA, left internal carotid artery; LMCA, left middle cerebral artery; RMCA, right middle cerebral artery; AcomA, anterior communicating artery; PcomA, posterior communicating artery; IA, intra-arterial.

Table 2.

Outcome and clinical features of 8 patients with acute stroke and occluded internal carotid/middle cerebral arteries

Case No	Initial NIHSS	24-Hour NIHSS	1-Month Outcome NIHSS/mRS	3-Month Outcome NIHSS/mRS	Thrombolytic Agent Route/Dose of rtPA/mg	Post Thrombolysis TIMI /MCA
1	8	4	1/1	1/1	IA 25	2
2	15	12	5/2	4/2	IA 8	2
3	21	7	3/1	3/1	IV 8.7/IA 15	3
4	16	8	5/2	5/2	IV 7.5/IA 15	1
5	14	2	2/1	1/0	IV 49.2/IA 2	2
6	18	14	5/2	3/1	IV 60/IA 15	2
7	8	1	1/0	1/0	IA 10	2
8	7	2	1/0	1/0	IA 4	3

Note:—NIHSS indicates National Institutes of Health Stroke Scale; mRS, modified Rankin scale; IA, intra-arterial; rtPA, tissue plasminogen activation; TIMI, Thrombolysis in Myocardial Infarction Scores; MCA, middle cerebral artery; IV, intravenous.