Pure posterior communicating artery occlusion treated with mechanical thrombectomy

Abstract

There has been no report of mechanical thrombectomy for a pure posterior communicating artery (PComA) occlusion. Here, we report the case of an 87-year-old woman with a disturbance of consciousness and left hemiparesis diagnosed with a right PComA occlusion. The patient was successfully treated using mechanical thrombectomy in combination with a stent retriever and the Penumbra system. A CT perfusion image showed cerebral blood flow reduction in the ipsilateral occipital lobe and thalamus. A CT angiography supported the diagnosis of an occlusion of fetal type PComA. The PComA could not be detected by internal carotidangiogram, but after deployment of stent retriever, the PComA was recanalised and distal embolus at the right posterior cerebral artery was visualised. The thrombus was then removed using the Penumbra system. Although the treatment for a PComA occlusion requires further investigation, the present case supports a thrombectomy as an effective rescue strategy for PComA occlusions.

Endovascular intervention of acute ischemic stroke due to occlusion of fetal posterior cerebral artery

“…The patient reported by Otsuji et al. 23 presented with a mural thrombus in the ICA extending into the FPCA ostium, which was similar to our first patient. In both cases, the thrombus was likely initially located at the ICA-FPCA bifurcation and then migrated into the larger-diameter FPCA.…”

“…Interestingly, in the only other report of a FPCA emergent thrombectomy, Otsuji et al experience a similar clinical-imaging discrepancy, and postulate that occlusion of the tuberothalamic artery and other perforating thalamic vessels, which originate from the middle third of the PcomA, may explain a presentation of diminished consciousness along with a MCA-syndrome. 23 Occlusions of these perforating vessels may cause acute perseverative behavior with abnormal cognition and speech, and inability to perform memory-related and executive tasks. 24 If a combination of hemianopsia, hemiparesis and neuropsychological deficits occur, clinicians should suspect an insult to the PCA territory, as well as to the thalamus and posterior limb of the internal capsule.…”

Flow dynamics in acute ischemic stroke due to embolic occlusion of a fetal posterior cerebral artery treated with endovascular thrombectomy - report of two cases

“…Nevertheless, the major ICA flow component still points toward the homolateral ACA- and MCAterritories, since the active vascular cross section of the distal ICA is usually larger than that of the fPCA. Therefore, in a typical fPCA variant, thromboembolism exclusively to the fPCA territory is extremely rare unless other flow modifications occur [ 1 , 14 ].…”

“…Though in both cases recanalisation of the fPCA was achieved quickly by ivTL and cTE respectively, a severe lack of collateral blood flow together with the postulated unfavourable shift of the embolic trajectory from the cranial ICA to the fPCA seems to potentially limit the success of treatment in case of an occluded fPCA. Concordantly, reported success rates for endovascular and intravenous treatment of fPCA occlusions remain variable, ranging from successful stable recanalisation to fatal courses of ischemia due to malignant brain oedema [ 1 , 14 , 17 ]. Unlike than in occlusion of large cerebral vessels, namely, the intracranial ICA, the proximal MCA or the basilar artery, endovascular treatment of an occluded fPCA is currently not explicitly recommended [18] .…”

Posterior Communicating Artery Aneurysm: Progressively Enlarging, Symptomatic, and Partially Thrombosed Fusiform True Posterior Communicating Artery Aneurysm, Treated by Coil Occlusion of the Parent Artery and Disconnection of the Posterior Communicating Artery by Parallel Flow Diversion in Two Treatment Sessions; Complete Aneurysm Occlusion, Aneurysm Shrinkage, and Good Clinical Recovery

“…An occlusion of the PcomA and the perforating branches (e.g., the tuberothalamic artery) could cause infarction in the surrounding structures. Hemiparesis, impaired consciousness, hemiballism, disturbed cognition, and poor mnestic function may occur (Endo et al 2012;Otsuji et al 2017).…”