So much about stroke is who can do it faster, bigger, longer… Â Even so, it is still worthwhile to show this kind of case. Â There are learning points and, as usual, stroke cases offer something for everyone.
This patient presents with a dense Wernicke’s aphasia and some degree of field cut. Â How much is hard to say due to Wernicke’s, but looks like a complete hemianopsia. Last known well 5 hours ago. Â Noncontrast head CT is fine
CT angiogram shows no major vessel occlusion. Â It takes time to find the right branch. CT perfusion makes it easy. Â There is a perfectly vascular distribution lesion in the left posterior temporal lobe. Â So you know that the lesion must be in the corresponding branch of the MCA
Here is an Olea Map. Â Red is dead brain, yellow is penumbra. Â If you are wondering how on Earth Olea came up with this curious map, so am I. Â Pretty much every Olea map is premium fodder for those who advocate against perfusion. Â The one place where we would expect dead brain is marked as penumbra, while there are apparently several islands of irreversible damage in the frontal lobe. Â Many times Olea would mark eyes, skin, and ventricles as dead brain. Â This time, irreversible damage is limited to the small left frontal arachnoid cyst. However, the maps just above actually do make sense. Â There is very little penumbra, however it is in the Wernicke area, so we go for it.
Angio shows expected angular branch occlusion, with poor leptomeningeal collaterals. Â Should we try to open it? Â I think the answer is yes, based on both CT and penumbra appearance. Â As of 2017 we do not have good evidence for what to do here, yet a broad consensus among stroke neurologists and interventionalists at our institution supports aggressive measures to get this done.
A Synchro 2 wire is used to macerate the clot. Â We brought up an Echelon catheter to enable intra-arterial thrombolysis. Â We felt this was too distal for mechanical thrombectomy as a first line. Â Very rarely do we give IA lysis but this was one of the cases.
Very distal occlusion indeed.
The Echelon is long enough to get distal. Â The clot is rather short.
IA tPA and Reopro are given (4 mg each) with no change after 30 min. Â Very reasonable to give up but we decided to see if an XT-27 could go beyond the thrombus. Unfortunately we did not have a 160 cm Marksman at the time which would have done the same for sure. Â The XT makes it just beyond the clot. Â Next comes a 4×15 Solitaire. Â In my opinion it is the best thrombectomy device for distal access on US market. Â The others, even if specked at 3 mm, are much stiffer. Â As you can see, the Solitaire is deployed just fine.
Angio with solitaire in place
Here are snapshots of the “pull” — removing the Solitaire with hopefully the clot attached to it. Â As you can see, the entire system is straightened, including the loops in the Sylvian fissure. Â This is the most important image of the case — a pull like this is almost guaranteed to produce small vessel avulsions and Sylvian fissure hemorrhage. Â If the patient were on confirmed anticoagulation or dual antiplatelets or still had tPA on board i would not do it. Â He was not and the IA doses are low in my opinion. Â So we took the risk.
Angio after clot removal (it was mixed yellow-red thrombus). Â Notice diminished parenchymal blush in the reopened brain, the majority of which i think is already dead.
CT shows what was predicted — a mix of contrast and blood in the Sylvian fissure. Â Notice that the extravasation is greatest in the area where the MCA loop was straightened out. Â It is not a “hemorrhagic conversion” of revascularized posterior temporal and angular regions, but subarachnoid hemorrhage due to avulsion of small vessels off the MCA during the Solitaire pull. Â This is seen quite often and does not qualify as a significant event unless the NIHSS goes up more than 4 points. In fact, his went down 2. Â Most of what is seen in the fissure is hyperdense contrast.
24 hours later, it is clearing well.
There is an evolving stroke in the angular region. Â Exam improved over the next 3 days, with mild residual receptive aphasia and a quadrantanopsia.
Certainly there is room for doing nothing here, or doing IA only, or whatever. Â The takeaway point is that distal mechanical thrombectomy is quite feasible, particularly with the smaller Solitaire devices (in United States, other places have other choices), but does come with a real and even predictable consequence of subarachnoid extravasation. Â It is typically tolerated extremely well, but factors such as presence of therapeutic level anticoagulation or systemic tPA can make hemorrhage less forgiving. Â The choice is yours.
For additional reading, see other Case Archives, including the Stroke section