Intracranial intraarterial thrombolysis facilitated by microcatheter navigation through an occluded cervical internal carotid artery

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✓ This report covers a series of four patients with acute cervical carotid occlusion and profound neurological deficits who were treated with intracranial intraarterial thrombolysis. All of the patients presented with arm plegia with variable leg involvement and two of them had global aphasia. Angiography identified occlusion of the proximal internal carotid artery (ICA) in each case and intracranial thromboembolus of the supraclinoid ICA and/or its branches.

Catheter navigation through the occluded ICA segment was straightforward in three patients and somewhat difficult in one patient with an 80% ICA stenosis. Intraarterial urokinase infusion along with mechanical clot disruption was performed at the clot site in the middle cerebral artery, supraclinoid ICA, and/or anterior cerebral artery. All patients had recanalization of the treated artery after urokinase infusion. Antegrade flow through the ICA was reestablished in two patients, and good collateral filling across the anterior communicating artery was established in the other two. All patients had major pretreatment deficits (mean National Institutes of Health (NIH) Stroke Score 24 ± 4) with significant improvement noted at 3 months posttreatment (NIH Stroke Score 7 ± 6; p = 0.03). Two patients made a dramatic early recovery. Postprocedure computerized tomography revealed no abnormality in one and asymptomatic basal ganglia high density from repeated local contrast injections in two patients.

On the basis of their findings in this small study group the authors suggest that catheter navigation through a presumably occluded carotid artery is feasible and possibly effective in thrombolytic therapy of intracranial thrombolysis. Further study with clinical trials is necessary to determine the safety and efficacy of this technique.

Article Information

Address reprint requests to: Gary M. Nesbit, M.D., The Dotter Interventional Institute, L605, Oregon Health Sciences University, 3181 Southwest Sam Jackson Park Road, Portland, Oregon 97201.

© AANS, except where prohibited by US copyright law.

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    Case 3. Left internal carotid artery (ICA) occlusion. A: Lateral digital subtraction angiogram (DSA) of the left common carotid artery revealing tapered occlusion (arrow) of the left ICA, suggestive of an arterial dissection. B: Anteroposterior DSA of the right ICA showing the A1 segment of the left anterior cerebral artery (ACA) as it fills across the anterior communicating artery and abruptly stops (arrow). C: Lateral DSA of the left ICA showing the tip of the guiding catheter (arrow) in the lateral petrous segment across a high-grade stenosis. The ACA (arrowheads) fills but no middle cerebral artery (MCA) is seen. The proximal ICA contains nonocclusive thrombus (open arrow) but is otherwise patent. D: Anteroposterior DSA of the left MCA displaying the microcatheter tip (arrow) in the M1 segment. A few anterior division branches (arrowhead) fill and thrombus (open arrows) is seen in the proximal ACA and MCA, which is occlusive in the distal M1 segment. E: Anteroposterior DSA of the right ICA after thrombolysis revealing the left MCA (arrows) now filling with no residual thrombus. Given this excellent collateral filling, the high-grade stenosis in the ICA, seen in Fig. 1B, was not treated.

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