Vessel perforation during withdrawal of Trevo ProVue stent retriever during mechanical thrombectomy for acute ischemic stroke

Case report

View More View Less
  • Department of Neuro-Interventional Surgery, Christiana Care Hospital, Newark, Delaware
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

The authors report a case of an intracranial extravasation during the withdrawal of a Trevo ProVue stent retriever device in a patient being treated for acute ischemic stroke. An 82-year-old woman developed sudden left hemiparesis and aphasia during an urgent cardiac catheterization procedure for a non–ST elevation myocardial infarction. She had a baseline National Institutes of Health Stroke Scale (NIHSS) score of at least 10 and no improvement with intravenous administration of tissue plasminogen activator (tPA). Cerebral angiography was performed with conscious sedation, confirming an occlusion of the superior division of the right middle cerebral artery (MCA). Using standard technique, a Trevo thrombectomy device was deployed across the clot. Post-thrombectomy control angiography demonstrated complete revascularization of the right MCA. The device was then gently withdrawn without difficulty. Immediately afterward the patient's blood pressure showed a sudden and significant elevation. Immediate posttreatment angiography demonstrated active extravasation from the posterior wall of the communicating segment of the right internal carotid artery. Rapid cessation of bleeding was achieved with intravenous administration of protamine and induced hypotension. Immediate neurological assessment was performed, which showed motor improvement. An immediate postintervention CT scan confirmed a moderate-sized subarachnoid hemorrhage and contrast in the prepontine cistern. The patient was discharged home on postoperative Day 3 with an NIHSS score of zero. At 6-month follow-up in the neurointerventional clinic, her NIHSS and modified Rankin Scale scores were both zero.

Endovascular stent retriever devices are increasingly being used as first-line thrombectomy devices in acute embolic strokes. A unique and previously undescribed complication is vessel perforation during withdrawal of a stent retriever. Conservative treatment options and reversal of anticoagulation should be the first line of treatment for such complications. In the authors' case, performing the procedure without anesthesia was helpful in assessing the patient's neurological status.

Abbreviations used in this paper:ICA = internal carotid artery; IV = intravenous; MCA = middle cerebral artery; NIHSS = National Institutes of Health Stroke Scale; TICI = thrombolysis in cerebral infarction; tPA = tissue plasminogen activator.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Sudhakar R. Satti, M.D., Department of Neuro Interventional Surgery, Christiana Care Hospital, 4755 Ogletown-Stanton Rd., Newark, DE 19718. email: ssatti@christianacare.org.

Please include this information when citing this paper: published online June 13, 2014; DOI: 10.3171/2014.4.JNS132187.

  • 1

    Adams HP Jr, , del Zoppo G, , Alberts MJ, , Bhatt DL, , Brass L, & Furlan A, : Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 38:16551711, 2007

    • Search Google Scholar
    • Export Citation
  • 2

    Cloft HJ, , Rabinstein A, , Lanzino G, & Kallmes DF: Intra-arterial stroke therapy: an assessment of demand and available work force. AJNR Am J Neuroradiol 30:453458, 2009

    • Search Google Scholar
    • Export Citation
  • 3

    Hacke W, , Kaste M, , Bluhmki E, , Brozman M, , Dávalos A, & Guidetti D, : Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:13171329, 2008

    • Search Google Scholar
    • Export Citation
  • 4

    Kent C: Stryker receives FDA approval for its Trevo Pro Retriever mechanical thrombectomy device. The Advisory Board August 15 2012. (http://www.advisory.com/Research/Service-Line-Strategy-Advisor/The-Pipeline/2012/08/Stryker-Receives-FDA-Approval-for-its-Trevo-Pro-Retriever-Mechanical-Thrombectomy-Device) [Accessed April 24, 2014]

    • Search Google Scholar
    • Export Citation
  • 5

    Martins SC, , Freitas GR, , Pontes-Neto OM, , Pieri A, , Moro CH, & Jesus PA, : Guidelines for acute ischemic stroke treatment: part II: stroke treatment. Arq Neuropsiquiatr 70:885893, 2012

    • Search Google Scholar
    • Export Citation
  • 6

    Murphy SL, , Xu J, & Kochanek KD: Deaths: Final Data for 2010. National Vital Statistics Report May 8 2013. (http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf) [Accessed April 24, 2014]

    • Search Google Scholar
    • Export Citation
  • 7

    Nogueira RG, , Lutsep HL, , Gupta R, , Jovin TG, , Albers GW, & Walker GA, : Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 380:12311240, 2012

    • Search Google Scholar
    • Export Citation
  • 8

    Noorian AR, , Gupta R, & Nogueira RG: Acute stroke: techniques and results with the Merci retriever. Tech Vasc Interv Radiol 15:4752, 2012

    • Search Google Scholar
    • Export Citation
  • 9

    Rohde S, , Bösel J, , Hacke W, & Bendszus M: Stent retriever technology: concept, application and initial results. J Neurointerv Surg 4:455458, 2012

    • Search Google Scholar
    • Export Citation
  • 10

    Saver JL, , Jahan R, , Levy EI, , Jovin TG, , Baxter B, & Nogueira RG, : Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380:12411249, 2012

    • Search Google Scholar
    • Export Citation
  • 11

    Smith WS, , Sung G, , Starkman S, , Saver JL, , Kidwell CS, & Gobin YP, : Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 36:14321438, 2005

    • Search Google Scholar
    • Export Citation
  • 12

    Towfighi A, & Saver JL: Stroke declines from third to fourth leading cause of death in the United States: historical perspective and challenges ahead. Stroke 42:23512355, 2011

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 284 284 30
Full Text Views 529 53 4
PDF Downloads 294 37 4
EPUB Downloads 0 0 0