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Published on: October 20, 2017
[A case of cerebral cardioembolism successfully treated by Merci retriever despite a large ischemic change on
Junpei Kouge1, Takako Torii, Hideaki Nakagaki
1Department of Neurology, Saiseikai Fukuoka General Hospital, Japan.
Abstract:
A 63-year-old man with paroxysmal atrial fibrillation presented with aphasia (16:30) followed by right hemiplegia. The last known time that he was clinically well was 14:30. On admission (17:43), his baseline NIHSS score was 34. Head diffusion-weighted MR imaging (DWI) demonstrated large hyperintense signals throughout the left middle cerebral artery (MCA) territory. The left carotid angiogram (CAG) demonstrated occlusion of the left ICA 2 cm distal from the bifurcation. The right CAG showed a small branch laterally extending from the left anterior cerebral artery (ACA). Mechanical thrombectomy with a Merci retriever removed a large amount of thrombi after the first trial. The left ICA and MCA were recanalized to grade TICI 2b. The left hemiplegia was markedly improved, and he could walk independently. His NIHSS score was 11 at discharge. Revascularization therapy may improve a motor deficit in patients with possible penumbra of the precentral gyrus by collateral circulation from the ACA even if the ischemic lesion in the MCA territory is large on DWI.
Insights
Mechanical thrombectomy successfully restored blood flow in a stroke patient with a large left middle cerebral artery (MCA) clot. Prompt intervention significantly improved motor function, highlighting the effectiveness of revascularization therapy.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Vascular Neurology
Background:
- Stroke management requires rapid assessment and intervention.
- Large vessel occlusions (LVOs) in the middle cerebral artery (MCA) territory are associated with significant morbidity and mortality.
- Atrial fibrillation is a common risk factor for cardioembolic stroke.
Observation:
- A 63-year-old male with paroxysmal atrial fibrillation presented with acute aphasia and right hemiplegia.
- Diffusion-weighted MRI revealed extensive ischemic changes in the left MCA territory.
- Carotid angiography confirmed left internal carotid artery (ICA) occlusion.
Findings:
- Mechanical thrombectomy using a Merci retriever achieved recanalization of the left ICA and MCA to TICI grade 2b.
- The patient experienced marked improvement in left hemiplegia and regained independent ambulation.
- NIHSS score decreased from 34 on admission to 11 at discharge.
Implications:
- Mechanical thrombectomy is effective for LVOs in the MCA territory, even with large infarcts.
- Collateral circulation from the anterior cerebral artery (ACA) may preserve function in the precentral gyrus penumbra.
- Early revascularization therapy can significantly improve motor outcomes in acute ischemic stroke patients.
