57y WRH woman, controlled HTN only, presents with sudden LOC, fixed and dilated, quadraplegic Intubated on arrival and CT is negative CTA and CTP

Transcription

1 Case # 1

2 Hx 57y WRH woman, controlled HTN only, presents with sudden LOC, fixed and dilated, quadraplegic Intubated on arrival and CT is negative CTA and CTP show left PCA occlusion, some basilar stenosis, large area at risk

3 CTP

4 Angiography

5 Intervention Three stent-retreiver passes with only reopening of the P1 and temporal branch Basilar kept occluding with the midsize catheter across the stenosis and vessel irritation and spasm

6 Angiography

7 Intervention Verapamil given and another pass in the left PCA made

8 Angiography

9 Intervention Intraarterial tpa given into the distal PCA

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11 Next morning Extubated, intact with questionable left gaze mild nystagmus MRI normal without any damage other than a small punctate right cerebellar stroke

12 Follow up MRI

13 Case # 2

14 History 51yWRHM with HTN acute onset of right hemiparesis and numbness two weeks prior lasting one day and resolving PCP saw and added ASA Presented to ER after 2 days of slurred speech and right hemiparesis (NIHSS = 4) CT was negative MR showed MCA stenosis and corona patchy infarcts CTA showed a left MCA occlusion and large mismatch Taken for angio

15 LCCA

16 LCCA

17 Vert collaterals

18 ICA

19 MCA 054 over 032 Penumbra System over Headliner 016 wire

20 Post aspiration

21 Post head shots

22 Post head shots

23 Course Clinically improved Remained inpatient though TCDs showed significant increased MCA velocities Followed clinically and reimaged at 3 days

24 LICA

25 Course Treated with IA Reopro with improvement Started on Plavix and monitored Reimaged at 1 week with persistent TCD elevated velocities

26 LICA

27 Post stenting

28 Case # 3

29 History 71y WRHM with repeated and bilateral retinal hemorrhages HTN, HPL, 3cm AAA ASA, Norvasc, Pravachol With each bleed loses vision though has recovered each time Etiology is neovascularization of the retina from ischemia Treated with laser ablation

30 Exam Detects light and counts fingers at two feet Been improving Otherwise neurologically intact

31 R subclavian

32 R vert neck

33 Ascending cervical

34 R vert head

35 Lvert and LCCA

36 Angio summary R vert >L vert 65% stenosis of R vert origin RCCA and LCCA stumps in low neck Vertebral and cervical anastomoses to ECA No large STA clearly visible No large ECA to ICA collateral flow (ie retrograde ophthalmic, skull base etc)

37 Case # 4

38 57y RHM with ataxia, imbalance and diplopia, quadraparesis, pressure sensitive

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45 Treatment

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52 Case # 5

53 Hx 45 WRHM presented with HA and dizziness for 2 days Symptoms progressed to right hemibody paresis for which he presented PMH/PSH: MI, coronary stent, HTN poorly controlled, B/L THR, R TKR Smoker On ASA at home

54 Hx CT negative and MR suggesting basilar occlusion Plavix started Worsened to severe motor dysarthric speech, right facial, right arm 1/5, leg 3/5 Repeat MRI showed left pontine infarct Taken for angio

55 MRI/A

56 Lvert

57 Lvert

58 RICA

59 Procedure 6F guide into Lvert and 5F vert into ICA Double map from RICA and Lvert Significant difficulty in traversing chronic occlusion with repeated microwire catheterization of left SCA only

60 Midbasilar

61 Procedure Further attempt to navigate Mirage wire failed with wire fracture Wire pinned by plaque, required snare to retrieve No difference in occlusion

62 L SCA

63 Procedure Reattempt to navigate across occlusion Unable to cross Microcatheter run showed spiral basilar dissection 20mg of protamine given No platelets in hospital

64 Basilar run

65 Basilar run

66 Post procedure CT showed minimal contrast/blood in interpeduncular fossa and intramural basilar contrast Clinically unchanged and remained intubated overnight Next AM became locked in MRI obtained

67 MRI