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Emergency Carotid Stenting for Acute Stroke Patients
- Operator: Jae-Hwan Lee, MD
Case summary
A 71-year old woman was found fell down on the bathroom floor at 6:00 a.m. She had been treated for hypertension for several years. She was visited to our ER at 9:30 a.m. with an ambulance. Her mentality was stuporous and her left side motor power was grade I (upper) and III (lower). Diffusion weighted MR brain image revealed multiple scattered high signal intensities in the whole right hemisphere (Figure 1). MR angiogram revealed invisible right ICA (Figure 2). Brain perfusion image revealed perfusion-volume mismatch at the right hemisphere. Mean time and time to peak map showed delayed perfusion at right side (Figure 3 and Figure 4), but cerebrovascular volume map showed near equal blood volume at the both hemispheres (Figure 5). Neurologist notified us at 11:00 a.m. and we punctured right femoral artery and inserted 5 Fr sheath.
After identification of subtotal occlusion of right proximal ICA, we engaged 7 Fr Shuttle sheath to the common carotid artery by ECA anchoring technique with a 0.035 stiff Amplatzer wire. The right proximal ICA was subtotally occluded with sluggish antegrade flow (TIMI 1) and the fresh thrombi was suspected (Figure 6). We inserted FilterWire EZTM (BSC) to protect distal embolization (Figure 7). After predilation with a 3.5 X 20 mm coronary balloon at 10 atm, the following angiogram revealed improved antegrade flow (TIMI 3) and visible filling defect (captured thrombi) in the FilterWire (Figure 8). We deployed self expandable 8.0 X 30 mm sized Smart stent (Figure 9). The postdilatation was performed 5.0 X 20 mm UDT peripheral balloon at 8 atm.(Figure 10) The final angiogram revealed about 30% diameter stenosis at the lesion site and normalized antegrade flow; lesion site and intracranial. (Figure 11, Figure 12, Figure 13) After retrieval of the FilterWire, we found large amount of white thrombi capture by FilterWire (Figure 14). Her motor power was improved right after stenting procedure and nearly normalized within several days. Eighteen months later, she visited to the outpatient department healthy status without any neurologic sequelae.
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