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Local intraarterial fibrinolytic therapy for embolic stroke associated with vascular anomalies--two case reports
Abstract:
Two cases of embolic stroke associated with vascular anomalies were treated by intraarterial fibrinolytic therapy. A 78-year-old male had embolic stroke associated with fenestration of the middle cerebral artery (MCA). The embolus lodged in the terminal portion of the right internal carotid artery (ICA) and in the M2 portion of the right MCA. The fenestration was not detected before local fibrinolytic therapy, but was identified by postinterventional angiography. An 82-year-old female had a left-sided persistent primitive trigeminal artery (PPTA), and the embolus lodged in the terminal portion of the left ICA. Left internal carotid angiography also showed rich collateral circulation via the abundant leptomeningeal anastomosis. The PPTA involved the left ICA, so the anomalous anatomy had to be considered in performing local thrombolysis. However, the rich collateral circulation allowed recanalization of the occluded ICA without inducing bleeding. Dissolution of persistently adherent emboli must be performed with great care because of the possibility of such rare vascular anomalies.
Insights
Intraarterial fibrinolytic therapy for embolic stroke can be complicated by rare vascular anomalies like middle cerebral artery fenestration and persistent primitive trigeminal artery. Careful consideration of anomalous anatomy is crucial for safe and effective treatment.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Radiology
Background:
- Embolic stroke presents a significant clinical challenge, often requiring urgent intervention.
- Intraarterial fibrinolytic therapy is a key treatment modality for acute ischemic stroke.
- Undiagnosed vascular anomalies can complicate endovascular procedures.
Observation:
- Two patients with embolic stroke associated with rare vascular anomalies underwent intraarterial fibrinolytic therapy.
- Case 1: Embolic stroke in a 78-year-old male with a fenestration of the middle cerebral artery (MCA), initially undetected.
- Case 2: Embolic stroke in an 82-year-old female with a persistent primitive trigeminal artery (PPTA) involving the internal carotid artery (ICA), demonstrating rich collateral circulation.
Findings:
- The fenestration of the MCA was identified post-treatment via angiography.
- The PPTA required careful consideration during local thrombolysis due to its involvement with the ICA.
- Rich collateral circulation in the second case facilitated recanalization without complications.
Implications:
- Dissolving emboli in patients with potential vascular anomalies necessitates meticulous pre-procedural evaluation and careful technique.
- Awareness of rare vascular anomalies is critical for interventionalists performing stroke treatment.
- This highlights the importance of advanced imaging in identifying and managing complex stroke cases.