Slides Endovascular Carotid

Emergency Carotid Stenting for Acute Stroke Patients

- Operator : Jae-Hwan Lee

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.

Comments

  • dswho@mac.com 2008-12-19 Good case Dr Lee. 1) Were you concerned about haemorrhagic transformation at >5 hrs post attack ? and what do you estimate that risk to be in general for such cases ? 2) Did you use the standard anti-platelet loading treatment (Plavix x4 or 8, plus aspirin) plus heparin to keep the ACT >300secs during the procedure ? 3) is there a significant lesion in her left ICA (fig 2) Dr David Ho
  • dswho@mac.com 2008-12-19
  • Jae-Hwan Lee 2008-12-22 Thanks for good questions, Dr Ho. (1) I have no data about the result of emergency carotid stenting for the proximal ICA occlusion yet. I didn't know about the possibility of hemorrahgic transformation, but cerebral salvage from the ischemia was more important at that time. Intracarotid thrombolysis might be considered, but It could also induce hemorrhage. (2) Antiplatelets were loaded with both aspirin and clopidogrel at 300 mg. UFH was used 5,000 IU without ACT monitoring. The total procedural time was about 35 minutes and Filterwire loading time was 6.5 minutes. During the procdure, I took care not to embolize any material from the sheath. (3) On the MR angiogram, usually We could find stenosis-like lesion at the cavernous portion without true stenosis. This lesion was artifact due to the bony structure and her left ICA was also normal. Thanks, Jae-Hwan Lee, MD, PhD

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