Author + information
Patient initials or identifier number
A 84 years old man
Relevant clinical history and physical exam
This 84-year-old man had hypertension, CAD, old CVA, bilateral carotid stenosis s/p PTAS to right ICA in 2010. PTAS to left ICA-CCA performed on 2016/7/28. After the procedure, he transferred to neurology ICU for embolic stroke. IV t-PA and Clopidogrel were given. Aspirin was held due to hemorrhagic transformation. However, sudden onset conscious change (GCS: E1V1M4) and right hemiparesis were noted on 2016/7/31 (NIHSS 27).
Relevant test results prior to catheterization
Brain CT angiography showed s/p stent placement at left CCA-ICA and right ICA. Long segmented total occlusion from the stenotic site of the left CCA-ICA stenting to the left posterior cavernous ICA. Ill-defined hypodensities at the left occipital lobe and high fronto-parietal lobes with mass effect. Perfusion CT revealed prolonged MTT, decreased CBF and CBV at the left cerebral hemisphere.
Relevant catheterization findings
left CCA: Distal heavily calcified with 70% stenosis
left ICA: 80% stenosis
left ECA: 90% stenosis
PTA to distal left ICA with “Abbott XACT Carotid Stent System 9-7 mm x 40 mm”
PTA to proximal left ICA-CCA with “Abbott XACT Carotid Stent System 10-8 mm * 40 mm” (overlapping)
Post-dilatation to the stents with Boston Sterling 6 x 20 mm up to 10A 5 seconds.
2016/7/31 angiogram: left ICA subacute stent thrombosis
We engaged Neruon Max 088 to left CCA, wiring finecross Micro Catheter and Sion then Ultimate 3 to distal ICA. Performed thrombosuction with ELIMINATE to left ICA, many black thrombi was retrieved. Shifted Ultimate 3 to Sion Blue with extension wire, and then gave intracranial NTG 500 mcg. Tip injection with Fine cross, thrombus dislodge at MCA M2 branch was noted. Gave IC NTG 200 mcg and heparin 2000 U. Inserted ST01 + Marksman catheter and passed GW4 to M2 branch. Deployed ev3 Solitaire FR 4 x 20 mm for 120 seconds for mechanical thrombectomy. Some black thrombi were removed. The Solitaire FR 4 x 20 mm for deployed again, but no thrombus was retrieved. Checked distal cerebral flow via ST 01, and no thrombus detected from distal cervical ICA to M2. Checked proximal flow from Neruon Max 088, TICI 3 flow was achieved (4 hours and 32 minutes), with residual ICA instent lesion. Wiring Boston Filter wire to distal ICA, then remove ST 01. Deploy “Boston Carotid Wall 10 x 24 mm” to proximal ICA ISR lesion. Post dilatation with Boston Sterling 6 x 20 mm up to 12A5″. The final ICA and intracranial flow were good.
On the next day, the Verify Now-P2Y12 assay revealed clopidogrel resistance (0% platelet inhibition). Aspirin and Cilostazol given thereafter. Following brain perfusion CT revealed recent infarcts at the left occipital lobe and high fronto-parietal lobes. There were some neurologic sequelae including poor consciousness (E4V2M4), bilateral vocal cord palsy and right hemiparesis. Fortunately, the patient discharged one month later.