Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 1050.e21-1050.e24
World Neurosurgery

Case Report
Trans-Anterior Communicating Artery Primary Stenting in Acute Tandem Middle Cerebral Artery–Internal Carotid Artery Occlusion Due to Thoracic Aortic Stent Graft

https://doi.org/10.1016/j.wneu.2017.06.187Get rights and content

Background

The main target of stroke intervention is the revascularization of occluded vessels, usually achieved with thrombectomy or thrombus aspiration. Despite good results in limited series, intracranial primary stenting is controversial for increased hemorrhagic risk owing to the need for dual antiplatelet therapy.

Case Description

We present a case of trans-anterior communicating artery primary stenting in an acute tandem middle cerebral artery–internal carotid artery occlusion in a patient harboring a thoracic aortic stent graft partially covering the origin of the left common carotid artery.

Conclusion

Our experience with this patient demonstrates that primary intracranial stenting shoud be considered in selected cases when other revascularization techniques are difficult or impossible to perform owing to anatomic reasons. Extreme care should be taken in patient selection because of the risks associated with antiplatelet therapy. In particular, it may be recommended in patients with a small core on computed tomography perfusion or diffusion-weighted magnetic resonance imaging and in whom thrombectomy and thromboaspiration are impossible for anatomic reasons.

Introduction

The main target of stroke intervention is the revascularization of an occluded vessel, usually achieved with thrombectomy1 or thrombus aspiration.2 Despite good results in limited series,3, 4, 5, 6 intracranial primary stenting is controversial for increased hemorrhagic risk owing to the need for dual antiplatelet therapy.7 Other problems concern the risk of early thrombosis and long-term durability. We present a case of trans-anterior communicating artery (AComA) primary stenting in acute tandem middle cerebral artery (MCA)–internal carotid artery (ICA) occlusion in a patient harboring a thoracic aortic stent graft partially covering the origin of the left common carotid artery (CCA).

Section snippets

Case Presentation

A 53-year-old man was admitted to our hospital with right-sided hemiplegia and aphasia on awakening. Two years earlier, he had undergone thoracic aorta aneurysm stent grafting with left CCA debranching and reimplantation. He was receiving anticoagulant therapy with warfarin. At admission (4 hours after awakening), his National Institutes of Health Stroke Scale was 18, and he underwent a stroke diagnostic protocol with plain brain computed tomography (CT), CT angiography (CTA), and CT perfusion

Discussion

Recanalization has been identified as the most important modifiable prognostic factor for favorable outcomes in ischemic stroke treatment.8 Bailout intracranial stenting is emerging as a feasible solution in patients with acute large-vessel occlusion after stentriever thrombectomy failure.9 On the other hand, studies of primary intracranial stenting remain limited. Our review of the recent literature found only 1 series4, 5 and 1 trial3, 6 of primary intracranial stenting in acute ischemic

Conclusion

Our experience with this patient suggests that primary intracranial stenting may be considered in selected cases, when other revascularization techniques are difficult or impossible to perform owing to anatomic reasons. Extreme care should be taken in patient selection owing to the risks related to antiplatelet therapy and transcirculation navigation.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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