Basilar artery stenosis with bilateral cerebellar strokes on coumadin

Transcription

1 Qaisar A. Shah, MD

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3 Patient Profile 68 years old female with a history of; Basilar artery stenosis with bilateral cerebellar strokes on coumadin Diabetes mellitus Hyperlipidemia Hypertension She developed Dysarthria bilateral ptosis right pupil dilatation Evaluated at a regional hospital, not considered a candidate for IV rtpa, because of >4.5hours time of onset.

4 Patient Profile While at an outside hospital she became Obtunded and weak on the left side National Institute of Health Stroke Scale (NIHSS) was 17 Emergent MRI and MRA of the brain demonstrated infarctions in the Pons, midbrain, and bilateral thalamus Complete basilar artery occlusion. Patient was transferred to Abington Memorial Hospital Upon arrival her exam worsened and now she developed Unresponsiveness and complete left sided weakness and partial right sided weakness NIHSS = 33

5 Pons Thalami

6 AP Lateral Basilar A. Basilar A. Microwire Microcatheter Guide catheter

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8 Intervention Diagnostic angiography demonstrated complete occlusion of the basilar artery An angioplasty was performed at the proximal basilar artery This was followed by thrombolysis (tpa) and vasodilator (Nicardipine) infusion. Mechanical thrombectomy with Penumbra Reperfusion system was performed

9 AP Lateral Gateway 1.5mm x 9mm balloon

10 041 separator 041 Reperfusion catheter AP Lateral

11 Angiographic Outcome There was complete recanalization of the basilar artery and LPCA. RPCA remain occluded Followup CT angiogram demonstrated complete recanalization in 24 hours

12 L. PCA Occluded R. PCA Basilar A. Basilar A. stenosis Vertebral A. AP Lateral

13 R.PCA L.PCA Basilar A

14 Patient Outcome Patient was discharged 6 days later to an inpatient rehab. She had an outstanding neurological recovery. She was able to walk with assistance and was able to converse fully. Her disability included left eye ptosis and partial ophthalmoparesis NIHSS: 5 (upon discharge)

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16 Patient Profile Female 51 years old, with past medical history of; Hypertension Hyperlipidemia Atrial fibrillation Right internal carotid artery occlusion Left carotid endarterectomy Coronary artery bypass graft Presented to Phoenixville Hospital with Dysarthria Tinnitis Right face/arm/leg weakness Initial NIHSS was 16. She was given IV rt-pa using Telemedicine system.

17 Patient Profile Her symptoms started to resolve after rt-pa, and upon arrival to Abington Memorial Hospital her neurological exam completely reverted and her NIHSS was 0.

18 Progression of symptoms Two hours after her presentation she experienced similar symptoms and was then rushed to the cath lab for further treatment. In the lab her exam continued to worsened and she started having extensor posturing and became comatose (NIHSS 34)

19 Intervention While she was in the lab she underwent intubation for airway protection Diagnostic angiography demonstrated critical stenosis involving the origin of left vertebral artery. There was complete occlusion of the basilar artery.

20 Basilar A. Vertebral A. Figure 1a

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22 Intervention Patient underwent intra-arterial therapy with rt-pa with minimal recanalization It was also noted that there was critical stenosis at the proximal basilar artery.

23 Basilar A. AP Lateral

24 Further intervention Intracranial balloon angioplasty was performed

25 Microwire Angioplasty Balloon

26 Basilar A. AP Vertebral A. Lateral

27 AP Angioplasty Balloon

28 Left vertebral A. L. Subclavian A. Stent

29 Patient Outcome Patient was extubated within 24 hours and had a complete reversal of her neurological exam (NIHSS 0) Post-operative CT scan showed a small left occipital infarction She was discharged home on day 3 and did not require any inpatient rehabilitation.

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32 Patient Profile 70 years old man with the past medical history of Hypertension Hyperlipidemia Parkinson s disease Initial presentation left facial droop left sided neglect (NIHSS 3), was found by his wife on the floor. He was last seen normal a night prior. While in the ETC his symptoms worsened (NIHSS 18) Right gaze preference, neglect and visual field loss Dysarthria Left hemiplegia

33 Imaging CTA/CTP was emergently performed, which demonstrated complete occlusion of supraclinoid segment of internal carotid artery (Carotid T- occlusion) Patient was emergently taken to the cath lab for revascularization, as he was not considered candidate for IV rt-pa (wake up stroke)

34 Intervention Cerebral angiogram confirmed the CTA findings Penumbra reperfusion system was used along with IA rt-pa

35 Ophthalmic A. Ophthalmic A R. internal carotid A. AP R. Internal carotid A Lateral

36 RMCA (M2 segment) 18L microcatheter 054 reperfusion catheter 054 reperfusion catheter separator

37 Findings There was a 80-85% intracranial stenosis noted in the supraclinoid segement (RICA)

38 AP AP Lateral Intracranial stenosis

39 Within 24 hours the symptoms completely resolved NIHSS 0. Non-contrast CT scan of the head demonstrated no evidence of stroke

40 Further intervention Because of the underlying high grade intracranial stenosis he was brought for subsequent angioplasty after 1 month. Post angioplasty there was a residual <50% stenosis noted in the RICA (supraclinoid segment)

41 Microwire Gateway 3mmx 15mm AP Lateral

42 Middle cerebral A. Ophthalmic A. R. Internal carotid A. <50% residual stenosis

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