Introduction Several guidelines have addressed symptomatic or asymptomatic carotid artery stenosis treatment with intensive medical management and surgical management based on the severity of stenosis [1]. In acute occlusions, endovascular treatment (EVT) and carotid endarterectomy (CEA) with or without prior thrombolytics provide the best recanalization and functional outcomes when compared to intravenous or intra‐arterial thrombolysis alone. There is, however, less robust evidence on management of symptomatic chronic internal carotid artery (ICA) occlusion occurring in tandem with significant contralateral ICA stenosis [2]. In chronic ICA occlusion (ICAO), EVT and carotid endarterectomy (CEA) are technically unfeasible, but indirect procedures have been arising as safe and effective alternatives, notably CEA or stenting of contralateral stenotic ICA [3] and CEA or stenting of ipsilateral external carotid artery (ECA) [4]. We hereby report a case of symptomatic chronic ICAO that was managed with staggered angioplasty and stenting of bilateral common carotid artery (CCA) bifurcations. Methods We hereby present a case report. Results A 62‐year‐old male with atrial fibrillation and hypertension woke up with sudden dysarthria and right upper extremity and facial weakness. NIHSS at presentation was 4. Last seen normal 9 hours prior. Non‐contrast head computerized tomography (CT) did not show acute intracranial abnormality, CT angiogram of head and neck showed severe right ICA stenosis and complete occlusion of the left ICA at cervical, petrous and cavernous segments, with distal reconstitution at the supraclinoid segment with left proximal middle cerebral artery (MCA) thrombus. CT perfusion showed a core infarct volume of 8cc in left MCA territory, mismatch volume of 78cc and ratio of 10.8. Risks of acute neuro‐intervention were deemed to outweigh benefits. Given favorable perfusion imaging, and in concordance with the EXTEND trial [5], tPA was administered. The patient remained stable without hemorrhagic complications with residual deficits of mild right upper extremity weakness and mild expressive aphasia. MRI confirmed left ICA territory ischemic infarcts. Patient underwent stenting of the asymptomatic right ICA at the CCA bifurcation first, followed by left CCA stent after one month with impressive improvement in subsequent perfusion imaging. Conclusions Our case encourages consideration of well‐timed angioplasty and stenting in cases of chronic bilateral carotid artery disease especially when the asymptomatic side is also significantly stenotic
Background: Recent patient series have shown IV tPA to more often lyse cerebral thrombi when started sooner after symptom onset in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). This association has been attributed to less fibrin-cross-linking and less compaction of thrombi. We sought to determine if this phenomenon would make endovascular thrombectomy less often needed among AIS-LVO patients treated hyperacutely with IV tPA. Methods: In a prospectively maintained registry, we identified patients receiving IV tPA at 2 academic medical centers from March 2005 - May 2015. Inclusion criteria were: 1) LVO seen on CTA or MRA before (or early during) infusion of IV tPA and 2) follow-up vessel imaging within 6h of IV tPA initiation, using CT, MR or catheter angiogram. Degree of thrombus lysis with IV tPA alone was rated using the arterial occlusive lesion (AOL) Scale. Results: Among the 166 patients, average age was 72.4 (±13.4), 52.4% were female and pretreatment NIHSS was 13.9 (±8.4). Onset to needle time (OTN) was median 105 min (IQR 79-129) and door to needle time 44 min (27-65). Initial vessel imaging modality was MRA in 68.7% and CTA in 31.3%. Early post-tPA vessel imaging modality was catheter angiogram in 63.8%, MRA in 33.7% and CTA in 2.4%. Time from tPA initiation to recanalization assessment was faster when post-tPA vessel imaging was catheter angiogram vs MRA/CTA, 72 min (45.5-116.5) vs 232 min (185-283), p<0.001. In cases assessed with early post-treatment catheter angiogram, IV tPA yielded complete recanalization in 17%, partial in 6.6%, and none in 76.4%. In cases assessed with MRA/CTA, IV tPA yielded complete recanalization in 30%, partial in 35%, and none in 35%. Recanalization within the 6h window was visualized more often when imaged with later CTA/MRA than with earlier catheter angiogram (p<0.001). Among patients going directly to catheter angiography, OTN for IV tPA was not different between recanalizers and non-recanalizers, 106 vs 98 min, p = 0.53. Discussion: Among large vessel acute ischemic stroke patients, the rate of complete recanalization with IV tPA alone is only 1 in 6, and faster OTN time is not associated with increased recanalization. All AIS-LVO patients should proceed to thrombectomy as swiftly as possible.
Background Reversible cerebral vasoconstriction syndrome (RCVS) is a disease characterized by reversible multifocal narrowing of the cerebral arteries with clinical manifestations that typically include thunderclap headache and occasionally brain edema, stroke, or seizure. The exact pathophysiology of RCVS is not well known. Case A 46‐year‐old female with history of episodic migraine presented with 1‐month duration of worsening headaches that had become more severe over the past 2 weeks. The headaches were episodic and thunderclap in onset and aggravated by physical exertion or emotional situations. A neurological examination was unremarkable including initial head computed tomography (CT). A CT angiogram of the head showed multifocal stenosis in the right anterior cerebral artery, bilateral middle cerebral arteries, and right posterior cerebral artery. Cerebral angiogram confirmed the CT angiogram findings. A repeated CT angiogram a few days later showed improvement in the multifocal cerebral arterial stenosis. Lumbar puncture and autoimmune workup were not suggestive of neuroinflammatory etiology. She had one generalized tonic–clonic seizure during her second day of hospitalization. The patient's thunderclap onset headaches resolved in 1 week after she was managed with blood pressure control and pain medication. She denied any illicit drug use or any new medications other than the placement of a levonorgestrel‐releasing intrauterine device (IUD) about 6 weeks prior to her presentation. Conclusions Our case suggests a possible link between RCVS and levonorgestrel‐releasing IUDs.
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