682
revue neurologique 171 (2015) 674–684
herpes simplex encephalitis on CT scan: an analysis of 23 patients. Pak J Med Sci 2012;28(3):441–4.
S. Zabrouga,*,b M. Idale`nea,b S. Azmouna,b F. Ihbibanea,b N. Tassia,b a Service des maladies infectieuses, hoˆpital Me`re–Enfant, CHU Mohammed VI, avenue Ibn Sina Ammerchich, BP 2360, Marrakech, Maroc b Universite´ Cadi Ayyad, avenue Prince Moulay Abdellah, BP 511, 40000 Marrakech, Maroc *Auteur correspondant. Service des maladies infectieuses, hoˆpital Me`re–Enfant, CHU Mohammed VI, avenue Ibn Sina Ammerchich, BP 2360, Marrakech, Maroc. Adresse e-mail : [email protected] (S. Zabroug) Rec¸u le 24 de´cembre Rec¸u sous la forme re´vise´e le 8 mars Accepte´ le 16 mars Disponible sur Internet le 27 avril
2014 2015 2015 2015
http://dx.doi.org/10.1016/j.neurol.2015.03.012 0035-3787/# 2015 Elsevier Masson SAS. Tous droits re´serve´s.
Repeated Solitaire mechanical thrombectomy in an acute anterior stroke patient Thrombectomie me´canique re´currente avec le stent Solitaire pour un infarctus de la circulation ante´rieur Mechanical thrombectomy (MT) using stent-retrievers is a promising adjuvant or stand-alone therapy for acute ischemic stroke caused by occlusion of a large vessel [1]. Recurrent MT within 24 hours has never been reported. We report a case of proximal middle cerebral artery (MCA) occlusion successfully mechanically recanalized twice in short time interval. A 72-year-old man presented with an acute left hemiparesis. NIHSS score was 21. CT scan was performed 60 minutes after onset and revealed no ischemic damage (ASPECTS score 10) and a complete occlusion of M1 segment of MCA with severe stenosis of extracranial right internal carotid artery (Fig. 1A and B). Intravenous thrombolysis was initiated 105 minutes after onset. Solitaire FR thrombectomy was performed under conscious sedation and complete recanalization of the M1 occlusion was obtained 3 hours after onset (Fig. 1C–F). After multidisciplinary discussion, no angioplasty of the cervical carotid artery stenosis was performed and
Fig. 1 – A and B. Angio-CT at baseline reveals complete right M1 occlusion and near-occlusion stenosis of the extracranial internal carotid artery. C and D. Initial angiogram confirms similar findings. E and F. Angiogram during mechanical thrombectomy with Solitaire FR stent demonstrates a complete recanalization of M1. G, H, and I. Post-operative MRI, diffusion sequences, show no significant ischemic lesion in the right anterior circulation.
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Fig. 2 – A. Angio-CT 20 hours later reveals new M1 occlusion. B and C. Angiogram shows M1 occlusion and near-occlusion of the internal carotid artery. D and E. Recurrent mechanical thrombectomy demonstrates a complete recanalization of M1. F. Angiogram after angioplasty reveals improvement with an intra-plaque dissection. G, H, and I. Post-operative MRI, diffusion sequences, show small ischemic lesions in the right frontal area and junctional zone. J. Post-operative angio-MRI after gadolinium injection, show persistent severe right extracranial internal carotid artery stenosis.
endarterectomy was scheduled for the next day. The patient was asymptomatic post-procedurally (NIHSS 0) and brain MRI 6 hours from recanalization showed 2 lacunar cortical infarcts (Fig. 1G–I). Twenty hours later, the patient developed recurrent left hemiparesis (NIHSS 3). CT scan revealed ischemic changes (ASPECTS score 8) and a recurrent M1 occlusion (Fig. 2A). A second MT was performed with Solitaire FR stent and complete recanalization was achieved after one pass, 120 minutes from the second event (Fig. 2C–E). An angioplasty of the cervical internal carotid artery stenosis was then performed without distal protection (Fig. 2F). Following the procedure the patient was asymptomatic, and brain MRI showed new small frontal ischemic lesions (Fig. 2G–I). Endarterectomy was performed 3 days later. At 3 months, the modified Rankin Scale score was 1 due to fatigue. This case illustrates that stent-retriever thrombectomy can achieve fast and complete recanalization of M1 occlusion in the same patient for 2 consecutive strokes within 20 hours interval. However, the patient presented, in both cases, favorable profile and reperfusion was obtained early (within 3 hours). In addition, it highlights the importance of a close monitoring for detection of early complications. The outcome of acute symptomatic tandem occlusion or near-occlusion of internal carotid artery and MCA is poor [2]. Intracranial recanalization (M1 segment) is the most important objective to be achieved, as early as possible. The optimal approach for treating the cervical internal carotid artery lesion is not well established in the setting of
acute phase of stroke. To date, for symptomatic carotid stenosis, endarterectomy is the gold standard but stenting might be as safe as endarterectomy in younger patients ( 70 years) [3]. However, endarterectomy cannot be performed in the acute phase due to thrombolysis. As shown here, not treating the stenosis expose the patient to the high risk of early recurrent embolism with a second intracranial occlusion. Although dual antiplatelet regimen needed, acute stenting of the cervical stenosis, seems a better therapeutic option in order to avoid recurrent thrombus migration especially in case of limited initial brain damage with low risk of hemorrhagic transformation [4]. Undoubtedly, the optimal management of this type of patient in acute phase needs to be determined.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
references
[1] Gory B, Riva R, Turjman F. Endovascular treatment in patients with acute ischemic stroke: technical aspects and results. Diagn Interv Imaging 2014;95:561–8.
684
revue neurologique 171 (2015) 674–684
[2] Paciaroni M, Agnelli G, Caso V, Pieroni A, Bovi P, Cappellari M, et al. Intravenous thrombolysis for acute ischemic stroke associated to extracranial internal carotid artery occlusion: the ICARO-2 study. Cerebrovasc Dis 2012;34: 430–5. [3] Carotid Stenting Trialists’ Collaboration, Bonati LH, Dobson J, Algra A, Branchereau A, Chatellier G, et al. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned metaanalysis of individual patient data. Lancet 2010;376: 1062–73. [4] Stampfl S, Ringleb PA, Mo¨hlenbruch M, Hametner C, Herweh C, Pham M, et al. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2014;35:741–6.
B. Gory* R. Sivan-Hoffmann R. Riva P.E. Labeyrie N. Huguet
Service de neuroradiologie interventionnelle, hoˆpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France N. Nighoghossian Service de neurologie, urgences neuro-vasculaires, hoˆpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France F. Turjman Service de neuroradiologie interventionnelle, hoˆpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France *Corresponding author. E-mail address: [email protected] (B. Gory) Received 21 November Received in revised form 29 January Accepted 16 March Available online 24 April
2014 2015 2015 2015
http://dx.doi.org/10.1016/j.neurol.2015.03.013 0035-3787/# 2015 Elsevier Masson SAS. All rights reserved.
revue neurologique 171 (2015) 674–684
herpes simplex encephalitis on CT scan: an analysis of 23 patients. Pak J Med Sci 2012;28(3):441–4.
S. Zabrouga,*,b M. Idale`nea,b S. Azmouna,b F. Ihbibanea,b N. Tassia,b a Service des maladies infectieuses, hoˆpital Me`re–Enfant, CHU Mohammed VI, avenue Ibn Sina Ammerchich, BP 2360, Marrakech, Maroc b Universite´ Cadi Ayyad, avenue Prince Moulay Abdellah, BP 511, 40000 Marrakech, Maroc *Auteur correspondant. Service des maladies infectieuses, hoˆpital Me`re–Enfant, CHU Mohammed VI, avenue Ibn Sina Ammerchich, BP 2360, Marrakech, Maroc. Adresse e-mail : [email protected] (S. Zabroug) Rec¸u le 24 de´cembre Rec¸u sous la forme re´vise´e le 8 mars Accepte´ le 16 mars Disponible sur Internet le 27 avril
2014 2015 2015 2015
http://dx.doi.org/10.1016/j.neurol.2015.03.012 0035-3787/# 2015 Elsevier Masson SAS. Tous droits re´serve´s.
Repeated Solitaire mechanical thrombectomy in an acute anterior stroke patient Thrombectomie me´canique re´currente avec le stent Solitaire pour un infarctus de la circulation ante´rieur Mechanical thrombectomy (MT) using stent-retrievers is a promising adjuvant or stand-alone therapy for acute ischemic stroke caused by occlusion of a large vessel [1]. Recurrent MT within 24 hours has never been reported. We report a case of proximal middle cerebral artery (MCA) occlusion successfully mechanically recanalized twice in short time interval. A 72-year-old man presented with an acute left hemiparesis. NIHSS score was 21. CT scan was performed 60 minutes after onset and revealed no ischemic damage (ASPECTS score 10) and a complete occlusion of M1 segment of MCA with severe stenosis of extracranial right internal carotid artery (Fig. 1A and B). Intravenous thrombolysis was initiated 105 minutes after onset. Solitaire FR thrombectomy was performed under conscious sedation and complete recanalization of the M1 occlusion was obtained 3 hours after onset (Fig. 1C–F). After multidisciplinary discussion, no angioplasty of the cervical carotid artery stenosis was performed and
Fig. 1 – A and B. Angio-CT at baseline reveals complete right M1 occlusion and near-occlusion stenosis of the extracranial internal carotid artery. C and D. Initial angiogram confirms similar findings. E and F. Angiogram during mechanical thrombectomy with Solitaire FR stent demonstrates a complete recanalization of M1. G, H, and I. Post-operative MRI, diffusion sequences, show no significant ischemic lesion in the right anterior circulation.
revue neurologique 171 (2015) 674–684
683
Fig. 2 – A. Angio-CT 20 hours later reveals new M1 occlusion. B and C. Angiogram shows M1 occlusion and near-occlusion of the internal carotid artery. D and E. Recurrent mechanical thrombectomy demonstrates a complete recanalization of M1. F. Angiogram after angioplasty reveals improvement with an intra-plaque dissection. G, H, and I. Post-operative MRI, diffusion sequences, show small ischemic lesions in the right frontal area and junctional zone. J. Post-operative angio-MRI after gadolinium injection, show persistent severe right extracranial internal carotid artery stenosis.
endarterectomy was scheduled for the next day. The patient was asymptomatic post-procedurally (NIHSS 0) and brain MRI 6 hours from recanalization showed 2 lacunar cortical infarcts (Fig. 1G–I). Twenty hours later, the patient developed recurrent left hemiparesis (NIHSS 3). CT scan revealed ischemic changes (ASPECTS score 8) and a recurrent M1 occlusion (Fig. 2A). A second MT was performed with Solitaire FR stent and complete recanalization was achieved after one pass, 120 minutes from the second event (Fig. 2C–E). An angioplasty of the cervical internal carotid artery stenosis was then performed without distal protection (Fig. 2F). Following the procedure the patient was asymptomatic, and brain MRI showed new small frontal ischemic lesions (Fig. 2G–I). Endarterectomy was performed 3 days later. At 3 months, the modified Rankin Scale score was 1 due to fatigue. This case illustrates that stent-retriever thrombectomy can achieve fast and complete recanalization of M1 occlusion in the same patient for 2 consecutive strokes within 20 hours interval. However, the patient presented, in both cases, favorable profile and reperfusion was obtained early (within 3 hours). In addition, it highlights the importance of a close monitoring for detection of early complications. The outcome of acute symptomatic tandem occlusion or near-occlusion of internal carotid artery and MCA is poor [2]. Intracranial recanalization (M1 segment) is the most important objective to be achieved, as early as possible. The optimal approach for treating the cervical internal carotid artery lesion is not well established in the setting of
acute phase of stroke. To date, for symptomatic carotid stenosis, endarterectomy is the gold standard but stenting might be as safe as endarterectomy in younger patients ( 70 years) [3]. However, endarterectomy cannot be performed in the acute phase due to thrombolysis. As shown here, not treating the stenosis expose the patient to the high risk of early recurrent embolism with a second intracranial occlusion. Although dual antiplatelet regimen needed, acute stenting of the cervical stenosis, seems a better therapeutic option in order to avoid recurrent thrombus migration especially in case of limited initial brain damage with low risk of hemorrhagic transformation [4]. Undoubtedly, the optimal management of this type of patient in acute phase needs to be determined.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
references
[1] Gory B, Riva R, Turjman F. Endovascular treatment in patients with acute ischemic stroke: technical aspects and results. Diagn Interv Imaging 2014;95:561–8.
684
revue neurologique 171 (2015) 674–684
[2] Paciaroni M, Agnelli G, Caso V, Pieroni A, Bovi P, Cappellari M, et al. Intravenous thrombolysis for acute ischemic stroke associated to extracranial internal carotid artery occlusion: the ICARO-2 study. Cerebrovasc Dis 2012;34: 430–5. [3] Carotid Stenting Trialists’ Collaboration, Bonati LH, Dobson J, Algra A, Branchereau A, Chatellier G, et al. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned metaanalysis of individual patient data. Lancet 2010;376: 1062–73. [4] Stampfl S, Ringleb PA, Mo¨hlenbruch M, Hametner C, Herweh C, Pham M, et al. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2014;35:741–6.
B. Gory* R. Sivan-Hoffmann R. Riva P.E. Labeyrie N. Huguet
Service de neuroradiologie interventionnelle, hoˆpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France N. Nighoghossian Service de neurologie, urgences neuro-vasculaires, hoˆpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France F. Turjman Service de neuroradiologie interventionnelle, hoˆpital neurologique Pierre-Wertheimer, 59, boulevard Pinel, 69003 Lyon, France *Corresponding author. E-mail address: [email protected] (B. Gory) Received 21 November Received in revised form 29 January Accepted 16 March Available online 24 April
2014 2015 2015 2015
http://dx.doi.org/10.1016/j.neurol.2015.03.013 0035-3787/# 2015 Elsevier Masson SAS. All rights reserved.
