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Improved cerebral perfusion after stenting of a petrous carotid stenosis: technical case report
R D Fessler1, G Lanzino, L R Guterman
1Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 14209-1194, USA.
Insights
Endovascular stenting successfully improved cerebral blood flow in a patient with severe petrous carotid stenosis, leading to better perfusion and no neurological deficits post-procedure. This demonstrates the technical feasibility of intracranial stenting for atherosclerotic disease.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Cardiology
Background:
- Intracranial atherosclerotic stenosis poses a significant risk for stroke and systemic vascular events.
- Current treatments include anticoagulation, antiplatelet therapy, and limited use of extracranial-intracranial bypass.
- Severe carotid stenosis necessitates intervention before major cardiac surgery.
Observation:
- A 73-year-old male presented with severe coronary artery disease and a 90% stenosis in the right petrous carotid artery.
- Cerebral perfusion scans indicated diminished blood flow in the right internal carotid artery territory, particularly in watershed zones.
- The patient underwent endovascular stenting of the carotid stenosis.
Findings:
- Selective internal carotid artery angiography confirmed markedly improved flow post-stenting.
- Post-stent perfusion scans showed significantly enhanced cerebral perfusion in the affected territory.
- The patient experienced two clinically silent embolic strokes but maintained independent living with intact neurological function five months later.
Implications:
- Endovascular stenting is a technically feasible option for treating severe intracranial atherosclerotic stenosis.
- This case highlights a potential therapeutic avenue for improving cerebral perfusion in select patients.
- Further research is needed to establish the definitive clinical role of intracranial stenting.
Objective And Importance:
Atherosclerotic occlusive disease of the intracranial vasculature is associated with increased risk of systemic vascular occlusive disease and stroke. Therapeutic options have included anticoagulation therapy, antiplatelet therapy, or, in a limited number of patients, extracranial-intracranial vascular bypass procedures. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after endovascular stenting of a severe petrous segment carotid stenosis.
Clinical Presentation:
A 73-year-old man with severe coronary artery disease and unstable angina was referred for treatment of a 90% right petrous carotid artery stenosis before coronary artery bypass grafting. A brain single-photon emission computed tomographic scan using 99mTc-bicisate revealed diminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones.
Technique:
The patient underwent transfemoral placement of a 7-French introducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No changes were noted in lesion morphology after this infusion. A microguidewire was navigated across the lesion. Subsequent balloon angioplasty with a coronary artery balloon was performed twice, followed by placement of a 4- x 12-mm coronary stent.
Conclusion:
Selective internal carotid artery angiography after stenting revealed markedly improved flow. A brain 99mTc-bicisate single-photon emission computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were noted; both were clinically silent. The patient had uncomplicated coronary artery bypass grafting 72 hours later. Five months postoperatively, he remains at home, living independently and with intact neurological function. Intracranial stenting for severe atherosclerotic stenosis is technically possible. However, its ultimate clinical role remains to be determined.