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Intra-arterial thrombolysis of embolic middle cerebral artery using collateral pathways
Max K Kole1, David M Pelz, Donald H Lee
1Department of Clinical Neurological Sciences, University of Western Ontario, London Health Sciences Centre, University Campus, London, Ontario, Canada.
Insights
Prompt revascularization for carotid and middle cerebral artery occlusion is crucial. Intra-arterial thrombolysis via the posterior communicating artery offers a viable treatment option, improving outcomes for stroke patients.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Vascular Surgery
Background:
- Cervical internal carotid artery (ICA) occlusion with middle cerebral artery (MCA) embolic occlusion necessitates rapid revascularization to prevent severe stroke.
- Endovascular techniques for thrombolysis are improving clinical outcomes for major arterial occlusions.
- Identifying efficient pathways for thrombolysis to the occluded site is critical.
Observation:
- Two cases of acute stroke due to thrombotic cervical ICA occlusion and MCA embolic occlusion were treated.
- Catheter navigation through the posterior communicating artery (PCoA) was used for intra-arterial thrombolysis, bypassing the occluded ICA.
- No attempt was made to traverse the occluded internal carotid artery.
Findings:
- Near-complete flow restoration in one patient; minimal reopening in the other.
- Both patients experienced favorable clinical outcomes following the procedure.
- Successful recanalization achieved via collateral pathways.
Implications:
- Intra-arterial thrombolysis utilizing Circle of Willis collaterals, like the PCoA, is a potential therapeutic strategy.
- This approach circumvents risks associated with navigating occluded cervical ICA.
- Treatment via collaterals may expedite MCA reopening and improve stroke management.
Background And Purpose:
Cervical internal carotid artery (ICA) occlusion associated with middle cerebral artery (MCA) embolic occlusion requires prompt revascularization to prevent devastating stroke. With the advent of endovascular techniques for chemical and mechanical thrombolysis, the clinical outcome of patients with major arterial occlusions will improve. Finding the most expedient pathway to the site of end organ occlusion for thrombolysis is important.
Methods:
We present two cases of acute stroke secondary to thrombotic occlusion of the cervical ICA associated with MCA embolic occlusion treated with intra-arterial thrombolysis via catheter navigation through the posterior communicating artery to the site of MCA arterial occlusion. No attempt was made to transverse the occluded ICA.
Results:
Near complete restoration of flow was achieved in one patient and minimal vessel reopening was observed in the other patient. Both patients had good outcomes.
Conclusion:
Intra-arterial thrombolysis via Circle of Willis collaterals such as the posterior communicating artery for the treatment of acute thrombotic occlusion of the cervical internal carotid artery associated with embolic occlusion of the middle cerebral artery is a therapeutic option. This treatment option avoids the potential complications of navigating through an occluded proximal internal carotid artery and may expedite reopening of the MCA.
