Endovascular Thrombectomy in young patient with a stroke – surgical procedure decompressive craniotomy

Rengaraj. G1, S. Fazal Ilahi2

1Physician Assistant, Kauvery Hospital, Cantonment, Trichy

2Consultant – Interventional Neurologist, Kauvery Hospital, Cantonment, Trichy

Case Presentation

A 35-years aged man with no significant past medical history presented to Emergency with weakness of right upper and lower limb, and loss of speech.

MRI Brain done outside had shown left MCA territory infarct, with M1 occlusion, and was referred here for further management. Nature of illness, need for intervention, prognosis and further management were explained to the family.

He was taken up for mechanical thrombectomy for left M1 occlusion and recanalization was achieved.

He was electively intubated prior to the procedure.. Cardiac evaluation was normal. Carotid and vertebral doppler showed mild atherosclerotic changes in bilateral carotid systems.

Repeat CT brain showed left MCA territory infarct with areas of reperfusion with increase in mass effect and minimal midline shift.

Further management

An urgent neurosurgical opinion was obtained. Left fronto temporo parietal decompressive craniotomy.,left anterior temporal lobectomy with cisternostomy were done.

Post op CT brain showed reduced mass effect. Hematologist’s opinion was sought for young stroke evaluation. Investigations were done to rule out APLA profile, which was normal.

In view of prolonged ventilation. Tracheostomy was advised, and was done. Medical gastroenterologist opinion  was sought for deranged LFT and managed with his advice.

Gradual weaning was done after the sensorium improved and shifted to neuro HDU. Swallow assessment showed poor gag reflex and a very weak cough. Aggressive physiotherapy was done. Patient was treated with antiedema measures, anti convulsants, single antiplatelet, DVT prophylaxis, PPI and other support measures. Repeat CT brain done on 29.05.24 showed reduced mass effect. Patient was sent to HAMSA rehabilitation for physiotherapy.

Indications for Mechanical Thrombectomy

  • Prestroke MRS score of 5
  • Occlusion of the MCA segment 1 (m1) large vessel occlusion
  • Young age
  • NIHSS score – ≥18
  • ASPECTS – ≥9
  • Treatment can be initiated (groin puncture) within 6 hours

Images illustrate

  • Maximum intensity projection from a time-of-flight MRA demonstrating an occlusion of the proximal right M1 segment
  • Diffusion weighted MRI demonstrating restricted diffusion within the Basal ganglia and anterior and posterior limb of the internal capsule.

Endovascular Intervention

Given the findings of the MRI, the patient was urgently transferred to the endovascular suite for intervention. He remained intubated and under general anesthesia while access was obtained in the right common femoral artery with an 8F sheath. A 100 cm-length, 5F JR3.5 angled Guidecath was navigated into the left internal carotid artery (ICA) over a 0. 035 inch Glidewire without difficulty given the history of aortic arch reconstruction.

An angiogram obtained from a left ICA injection confirmed the occluded proximal M1 segment. A Rebar 18 microcatheter was navigated through the guide catheter into the left ICA over a Synchro 14 micro-guidewire. The microguidewire was then carefully advanced through the M1 segment thrombus followed by the microcatheter over the guidewire and an angiogram was obtained through the microcatheter after the guidewire was withdrawn confirming the position of the catheter. A 4× 4mm Trevo XP ProVue Retriever stent was then deployed into the occluded M1 segment . After approximately 3 min, the stent retriever and microcatheter were withdrawn together as a unit through the 4F guide catheter in the ICA.

An angiogram obtained after the pass revealed that the M1 segment was still occluded and a thrombus fragment had migrated into the right middle cerebral artery

After the failed first pass of the stent retriever, a larger 4 × 40 mm Trevo XP ProVue Retriever stent was deployed into the right M1 segment using a Trevo Pro 18 micro catheter that was first passed through the M1 thrombus over a Synchro 14 microwire. After the deployment of the stent, the microcatheter was carefully withdrawn out of the groin over the stent pusher wire, leaving only the stent retriever and 5F guide catheter in place. Gentle aspiration was then applied to the guide catheter after 3 min while the stent retriever was carefully withdrawn from the M1 segment into the 5F catheter in the ICA. A subsequent angiogram showed partial recanalization of the M1 segment. This procedure was repeated for a third pass in the M1 segment. A 4 × 4mm stent retriever was once again deployed into the M1 clot and the microcatheter was withdrawn. Aspiration was applied to the 5F guide catheter as the stent was withdrawn, resulting in a TICI 2b recanalization of the left MCA territory.

The puncture to recanalization time for the procedure was 55 min and the time from symptom onset to full recanalization was 7 hr. The guide catheter and sheath were removed and pressure was held to the groin for 15 min.

Surgical Decompression for Malignant Cerebral Edema after Ischemic Stroke

The DC was life-saving in our patient with malignant MCA infarction. Most of the patients had surgery within 48 hr.

Ischemic stroke due to occlusion of the proximal middle cerebral artery (MCA), usually involves large portions of a hemisphere and may cause space-occupying cerebral edema, leading to rapid neurological deterioration and cerebral herniation. Nearly 35 years ago, Hacke et al coined the term “malignant” for acute and complete MCA territory infarction involving a space-occupying cerebral edema and subsequently a considerably rapid neurological deterioration and herniation. Malignant MCA infarction involves more than 50% of and often the entire MCA territory. In the early phase of malignant MCA infarction, cytotoxic edema develops followed by the development of vasogenic edema.

Approximately 1–10% of all MCA strokes can turn into malignant MCA infarction with a mortality risk of up to 80% within the first week. Acute brain swelling occurring within 48 hr results in elevated intracranial pressure or brain herniation, which in turn leads to the deterioration of consciousness or death usually within the first week. The clinical predictors of malignant transformation include high NIHSS score, young age, female gender, as well as history of hypertension, ischemic heart disease, and congestive heart failure. The radiological predictors of malignant transformation are >66% perfusion deficit, >50% involvement of MCA territory on initial CT scan, and combined involvement of internal carotid artery and MCA, among many others.

Control of ICP remains an important challenge in patients with severe post-stroke or post-traumatic brain edema. The medical management for raised ICP includes head-of-bed elevation, hyperventilation, osmotic therapy, and sedation. Although osmotic therapy has failed to improve treatment outcomes, it can be used to bridge the time until definitive surgical treatment can be performed. Systemic hypothermia in raised ICP due to malignant MCA infarction has been associated with multiple complications without any clear benefit on outcome.

Clinical Outcome

Admitted to the neuro intensive care unit. At that time, he was moving all of his extremities but was weaker on the right side. An MRI obtained on the following day did show an increased area of restricted diffusion deep to the insular cortex. He was placed on a heparin infusion as a bridge while warfarin was restarted with a goal INR of 2.0-2.5. The strength in his right arm and leg continued to improve throughout his hospitalization and was discharged home after a week. At a 30-day return outpatient clinical visit, he was walking normally with only a mild motor deficit in his right hand and a slight facial droop. His mRS at that time was 1-2.

Rengaraj. G
Physician Assistant

Dr. Fazal

Dr. S. Fazal Ilahi
Consultant Interventional Neurologist

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