57y WRH woman, controlled HTN only, presents with sudden LOC, fixed and dilated, quadraplegic Intubated on arrival and CT is negative CTA and CTP
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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
10
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
39
40
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45 Treatment
46
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50
51
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
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