Stent-mediated wedging of a calcific embolus to recanalize an occluded middle cerebral artery: technical case report

Calcific cerebral emboli are rare yet pose a difficult therapeutic challenge because of their lack of response to thrombolytic therapy and their propensity for fragmentation.

A 75-year-old woman developed aphasia and hemiparesis after cardiac catheterization from a near-occlusive calcific embolus to the left middle cerebral artery origin. The calcific embolus was shown to be hemodynamically limiting by computed tomographic perfusion and diffusion-weighted magnetic resonance imaging.

The patient was treated medically for 6 days with anticoagulation, antiplatelet, and hypertensive therapies but continued to deteriorate. A decision was made to attempt retrieval of the calcific embolus. Conventional intracranial mechanical clot and coil retrieval systems were used initially but were unsuccessful and caused migration of the calcific embolus, leading to complete occlusion of the left middle cerebral artery origin. At this point, the decision was made to wedge the calcific embolus against the vessel wall. A balloon-mounted coronary stent was used to achieve this successfully, resulting in recanalization of the middle cerebral artery trunk and flow restoration.

Symptomatic calcific emboli, which are poorly responsive to pharmacological therapy and difficult to recover using conventional retrieval systems, may be treated by immobilization against the vessel wall using a balloon-mounted stent.