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Nakamura K, Murata K, Kawakami T, Terakawa Y, Ikeda H, Sakaguchi M. Percutaneous transluminal angioplasty for stenosis of the posterior cerebral artery in progressive stroke. Case report. Neurol Med Chir (Tokyo) 2009; 49:351-3. [PMID: 19707000 DOI: 10.2176/nmc.49.351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 59-year-old male presented with repeated transient hemianopsia and hemiparesis on the left. Emergency magnetic resonance angiography showed stenosis of the right posterior cerebral artery (PCA). Endovascular recanalization with percutaneous transluminal angioplasty was performed immediately after the diagnosis. Patency of the PCA was successfully restored. The patient was discharged without neurological deficits. Progressive stroke in the PCA territory is rare. However, emergency endovascular recanalization is possible after prompt clinical diagnosis based on repeated diffusion-weighted magnetic resonance imaging and angiography after a 24-hour interval.
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Affiliation(s)
- Kazuhito Nakamura
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan.
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2
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Tsumoto T, Terada T, Tsuura M, Ryujin Y, Matsumoto H, Masuo O, Yamaga H, Itakura T. Endovascular therapy for acute thrombotic occlusion of the intracranial artery. Neuroradiology 2004; 46:453-8. [PMID: 15141329 DOI: 10.1007/s00234-004-1219-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2004] [Accepted: 03/09/2004] [Indexed: 11/24/2022]
Abstract
The goal of this study was to evaluate the efficacy of endovascular therapy for acute thrombotic occlusion. Six patients with acute thrombotic occlusion in the middle cerebral or basilar arteries underwent treatment with intra-arterial thrombolysis, followed by assessment of residual stenosis. If residual stenosis was greater than 70%, percutaneous transluminal angioplasty (PTA) was performed in the same session; otherwise, patients were anticoagulated, and PTA was performed several days later. Successful recanalization was achieved in five of six patients. One patient died of massive infarction, because of the failure of recanalization of the M1 segment. At discharge, modified Rankin scale distribution of the patients was: grade 0, one patient; grade 1, one patient; grade 2, two patients; grade 3, one patient; grade 6, one patient. Retreatment was required via PTA or stenting in two patients in which type C stenosis was present. In conclusion, endovascular therapy for acute thrombotic occlusion of an intracranial artery appears to be effective compared to conservative therapy. However, further refinement of the technique is required to prevent various complications, including vessel perforation, dissection, perforating artery occlusion and restenosis.
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Affiliation(s)
- Tomoyuki Tsumoto
- Department of Neurological Surgery, Wakayama Medical University, Wakayama, Japan.
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3
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Ezaki Y, Tsutsumi K, Onizuka M, Kawakubo J, Yagi N, Shibayama A, Toba T, Koga H, Miyazaki H. Retrospective analysis of neurological outcome after intra-arterial thrombolysis in basilar artery occlusion. ACTA ACUST UNITED AC 2003; 60:423-9; discussion 429-30. [PMID: 14572964 DOI: 10.1016/s0090-3019(03)00450-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Basilar artery occlusion usually has a very poor outcome and is associated with a high mortality rate. Local intra-arterial thrombolysis may improve the clinical outcome and reduce mortality in the treatment of acute basilar artery occlusion. We evaluated the possible variables affecting recanalization and clinical outcome in patients with basilar artery occlusions undergoing thrombolytic therapy. METHODS We analyzed retrospectively the clinical course and outcome of a series of 26 patients between 1998 and 2001. All patients who were examined within 24 hours after onset of symptoms underwent emergency cerebral angiography and subsequent intra-arterial thrombolysis. Three patients additionally received percutaneous transluminal angioplasty of underlying stenosis at the site of thrombosis. RESULTS Outcome was good in 9 patients (34.6%) and poor in 17 (65.4%). Recanalization could be achieved in 24 patients (92.3%) and was not affected by age, sex, site of occlusion, etiology, thrombolytic drugs, or time interval. Good outcome was associated with younger age, good initial clinical condition, and no evidence of brain stem infarction. There was no association between the interval (greater or less than 6 hours) from the onset of symptoms until the end of thrombolysis and survival. CONCLUSIONS We confirm that intra-arterial thrombolysis reduces mortality in basilar artery occlusion. Young patients (<75 years) without any infarct in brain stem before the start of treatment seem to be the ideal candidates for thrombolysis. Basilar artery thrombosis could and should be reopened, even late (after 6 hours) after symptom onset.
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Affiliation(s)
- Yasuyuki Ezaki
- Department of Neurosurgery, Sankokai Miyazaki Hospital, Nagasaki City, Japan
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4
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Kirton A, Wong JH, Mah J, Ross BC, Kennedy J, Bell K, Hill MD. Successful endovascular therapy for acute basilar thrombosis in an adolescent. Pediatrics 2003; 112:e248-51. [PMID: 12949321 DOI: 10.1542/peds.112.3.e248] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric stroke is an underrecognized, potentially treatable cause of childhood neurologic disease. Acute basilar artery thrombosis is a devastating disease rarely encountered in children. Acute interventions with both chemical and mechanical thrombolysis techniques can improve outcomes in adults with arterial thrombosis of the posterior cerebral circulation. We report a case of intervention with both intra-arterial alteplase (tissue plasminogen activator) and cerebral balloon angioplasty to treat a prolonged basilar artery occlusion secondary to idiopathic thrombosis in an adolescent. Despite the patient being clinically locked-in and intervention being delayed at least 20 hours from symptom onset, he obtained complete neurologic recovery. Issues of pediatric stroke, late therapeutic intervention, chemical thrombolysis, and cerebral angioplasty are discussed. This case highlights the underrecognition and subsequent delay in diagnosis of pediatric stroke and how acute intervention may cure otherwise catastrophic strokes in children.
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Affiliation(s)
- Adam Kirton
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Abstract
Basilar artery thrombosis is an infrequent but important neurological emergency requiring early diagnosis and treatment. Of particular relevance to emergency medicine is the recognition and consideration of the unusual signs that may be present in an often previously well patient. It is therefore crucial to expedite investigations, confirm the diagnosis and commence life-saving treatment through the early involvement of a number of disciplines including neurology, radiology and intensive care. This paper confirms the use of magnetic resonance imaging and angiography as the preferred investigative mode and microcatheter directed intra-arterial thrombolysis as the treatment strategy of choice.
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Affiliation(s)
- P G Richardson
- Emergency Department, Royal Brisbane Hospital, Brisbane Queensland, Australia.
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Terada T, Tsuura M, Matsumoto H, Masuo O, Hyotani G, Ryujin Y, Kamei I, Itakura T. Measurement of the intracranial arterial wedge pressure in cases of acute cerebral arterial occlusion to determine the indication of intraarterial thrombolytic therapy. Interv Neuroradiol 2000; 6 Suppl 1:213-5. [PMID: 20667251 DOI: 10.1177/15910199000060s135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2000] [Indexed: 11/15/2022] Open
Abstract
SUMMARY Wedge pressure of the occluded major cerebral artery (distal pressure beyond the occlusion) was measured to estimate the residual cerebral blood flow in thirteen patients with acute ischemic stroke. There existed the relationship that patients with higher wedge pressure tolerated longer ischemic insults than those with lower wedge pressure. Wedge pressure is measured with minimum time loss before starting thrombolytic therapy and may be a good indicator to estimate the brain tissue reversibility.
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Affiliation(s)
- T Terada
- Department of Neurological Surgery,Wakayama Medical College; Koyo Hospital, Wakayama Red Cross Hospital, Wakayama City, Japan
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7
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Nomura M, Hashimoto N, Nishi S, Akiyama Y. Percutaneous transluminal angioplasty for intracranial vertebral and/or basilar artery stenosis. Clin Radiol 1999; 54:521-7. [PMID: 10484219 DOI: 10.1016/s0009-9260(99)90849-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Despite the growing clinical use of percutaneous transluminal angioplasty (PTA) for atherosclerotic lesions, application of this technique for intracranial vertebral and/or basilar arteries is not common. In this report, we present our experience with PTA for intracranial vertebrobasilar systems and assess its usefulness. PATIENTS AND METHODS We report our experiences with PTA in six steno-occlusive lesions affecting intracranial vertebral and/or basilar arteries in five patients. One of the two patients with acute stroke had involvement of both the vertebral and basilar arteries, and the other had involvement of the dominant vertebral artery. In two of the other three patients, without acute stroke, the intracranial vertebral arteries were involved and in one the basilar artery was involved, but the symptoms were unresponsive to intensive medical therapy. PTA was performed for these lesions without complications and the clinical symptoms improved. During the procedure, we took care not to overdilate the lesions. RESULTS These lesions were treated by PTA without complications and the clinical symptoms improved. CONCLUSION The authors' experience suggests that PTA might be an effective therapy for stenoses of the intracranial vertebral and/or basilar arteries. In patients with acute stroke where there is not enough time for surgical treatment, emergency PTA is useful and improves the clinical symptoms. Further study is needed to confirm its long-term effectiveness for symptomatic stenosis of vertebrobasilar systems.
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Affiliation(s)
- M Nomura
- Department of Neurosurgery, National Cardiovascular Center, Osaka, Japan
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Jimenez C, Duong H, Olarte M, Pile-Spellman J. Recurrent abrupt occlusion after transluminal angioplasty for basilar artery stenosis: case report. Neurosurgery 1999; 44:210-5. [PMID: 9894984 DOI: 10.1097/00006123-199901000-00127] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE Angioplasty for basilar artery stenosis is often complicated by recurrent abrupt vessel closure. The clinical results can be catastrophic. In this case report, we assess the effects of intra-arterial papaverine (American Regent Laboratories Inc., Shirley, NJ) on rebound occlusion. CLINICAL PRESENTATION The patient presented with crescendo transient ischemic attacks from atherosclerotic narrowing of the midbasilar artery despite maximal medical treatment. INTERVENTION Angioplasty of the midbasilar artery was performed with serial balloon inflations. The patient was treated successfully with intra-arterial papaverine and achieved a nearly full recovery, with only mild dysarthria, by the time of the 7-month follow-up examination. CONCLUSION Using intra-arterial papaverine, we were able to reverse the effects of this potentially life-threatening complication of basilar artery angioplasty.
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Affiliation(s)
- C Jimenez
- Servicio de Neurocirugia, Hospital Universitario San Vincente de Paul, Medellín, Columbia
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Fessler RD, Wakhloo AK, Lanzino G, Qureshi AI, Guterman LR, Hopkins LN. Percutaneous transluminal angioplasty of intracranial artery stenosis: clinical results in 24 patients. Neurosurg Focus 1998; 5:e15. [PMID: 17112214 DOI: 10.3171/foc.1998.5.4.16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Circumscribed stenotic lesions of the intracranial arteries can cause cerebral ischemia by hemodynamic and/or thromboembolic mechanisms. Anticoagulation therapy, antiplatelet therapy, and bypass surgery are treatment strategies that have no direct impact on the underlying lesion. This study summarizes the experience of a single institution at which percutaneous transluminal angioplasty (PTA) of intracranial atherosclerotic stenoses was performed.
The authors performed a retrospective analysis of 24 consecutive patients. Their medical histories (cardiovascular risk factors, current clinical signs and symptoms and their duration, previous stroke[s], and medical treatment) were evaluated together with findings from previous imaging studies. The site and degree of the stenoses to be treated (target lesion) were identified with the use of ultrasound and angiography studies. Additional vascular stenoses were noted. Percutaneous transluminal angioplasty was performed using single-lumen balloon microcatheters with appropriate diameters. The results of PTA were correlated with angiographic and ultrasound findings and the clinical outcome.
Significant cardiovascular risk factors and clinical signs and symptoms related to the target lesion that persisted despite medical treatment were identified in all patients except one. The duration of symptoms varied from several days to 8 months. Previous stroke had occurred in four patients. The degree of stenosis was classified as “high grade” in 10 patients and as “subtotal” in 14. The target lesion (stenosis) was located in the anterior circulation in eight patients (four in the internal carotid and four in the middle cerebral arteries). Stenoses of posterior circulation vessels were treated in 16 patients (nine vertebral, six basilar, and one posterior cerebral arteries). Recanalization was rated “complete” in 15 patients and sufficient in six patients. In three patients residual stenosis remained. Complications were encountered in seven patients: two asymptomatic dissections, one transient vessel occlusion, one vessel occlusion with subsequent stroke, and three ischemic lesions likely due to thromboembolism, two of which caused only transient neurological symptoms.
Percutaneous balloon dilation proved effective in the treatment of intracranial atherosclerotic stenosis. There are, however, potential complications and experience with this procedure is only limited. Long-term results need to be determined. The authors conclude from their preliminary results that PTA may be an alternative to bypass surgery and conservative management and may be considered for patients in whom ischemic neurological symptoms persist despite medical treatment.
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Affiliation(s)
- R D Fessler
- Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
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Kinoshita Y, Terada T, Nakai E, Nakai K, Itakura T, Naka Y, Kido T, Kuwata T, Matumoto H, Moriwaki H. Intra-arterial Thrombolytic Therapy for Acute Vertebrobasilar Artery Occlusion. Interv Neuroradiol 1997; 3 Suppl 2:63-8. [PMID: 20678387 DOI: 10.1177/15910199970030s211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/1997] [Accepted: 09/18/1997] [Indexed: 11/17/2022] Open
Abstract
SUMMARY We report on the results of intra-arterial thrombolysis in 11 patients with vertebrobasilar artery occlusion treated within 6 hours after onset of symptoms. Urokinase (5 patients) or recombinant tissue plasminogen activator (t-PA) (6 patients) was injected through a microcatheter conducted to the thrombus. Eight patients showed recanalization of the thrombus. The outcome was excellent in 5 patients, good in 2 patients, and poor in one patient. Recanalization could not be achieved in 3 of the 11 procedures; all patients in whom recanalization failed died. There were no hemorrhagic complications after thrombolysis. Two patients with residual stenosis after thrombolysis underwent successful percutaneous transluminal angioplasty (PTA) to prevent reocclusion. Intra-arterial thrombolysis for vertebrobasilar artery occlusion is a safe and effective treatment if it is performed within 6 hours.
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Affiliation(s)
- Y Kinoshita
- Department of Neurological Surgery, Wakayama Medical College; Wakayama, Japan
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Terada T, Yokote H, Kinoshita Y, Tsuura M, Masuo O, Nakai K, Itakura T. Endovascular Treatment for Tandem Internal Carotid Stenosis. Development of a New Shunt Tube for PTA. Interv Neuroradiol 1997; 3 Suppl 2:208-11. [PMID: 20678421 DOI: 10.1177/15910199970030s245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/1997] [Accepted: 09/18/1997] [Indexed: 11/15/2022] Open
Abstract
SUMMARY Three patients with tandem internal carotid stenoses were treated in one operation including carotid endarterectomy (CEA) for the proximal stenosis and percutaneous transluminal angioplasty (PTA) for the distal stenosis. We devised a Y-shaped shunt tube which we used for CEA, while a PTA balloon catheter was introduced via the tube to perform PTA guided by portable digital subtraction angiography (DSA). No cerebrovascular events occurred during follow-up. Our approach avoids the risk of a second procedure while effectively treating tandem stenoses.
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Affiliation(s)
- T Terada
- Department of Neurological Surgery, Wakayama Medical College; Wakayama City, Japan
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Ohta H, Nakano S, Yano T, Ohnishi T, Miyahara D, Yokogami K, Goya T, Wakisaka S. Reperfusion therapy for acute vertebrobasilar occlusion. Interv Neuroradiol 1997; 3 Suppl 2:69-74. [PMID: 20678388 DOI: 10.1177/15910199970030s212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/1997] [Accepted: 09/18/1997] [Indexed: 11/15/2022] Open
Abstract
SUMMARY We reviewed retrospectively our experience in treating 10 patients with acute vertebrobasilar occlusion. Nine patients were treated with interventional reperfusion therapy and the remaining one patient with top of the basilar embolism was treated conservatively because of deep coma and decerebrate rigidity with severely reduced cerebral blood flow (CBF) in the brain stem. Among 9 patients with reperfusion therapy, 8 patients underwent intra-arterial thrombolytic therapy and the other one patient had direct percutaneous transluminal angioplasty (PTA). Eight patients had basilar artery occlusion, 1 patient treated with direct PTA had bilateral intracranial vertebral artery occlusion and the other patient had left posterior cerebral artery occlusion presumably preceding top of the basilar embolism. In 4 of 10 patients, residual CBF was evaluated by single photon emission computed tomograpy (SPECT). Successful recanalization with clinical improvement was achieved in 6 of 9 patients (66.7%) treated with reperfusion therapy. In patients with progression or fluctuation of incomplete brain stem syndrome, SPECT revealed preserved residual CBF and successful recanalization with clinical improvement was achieved by interventional reperfusion therapy. On the other hand, in patients with persistent deep coma and decerebrate rigidity, SPECT revealed marked reduction of residual CBF in the brain stem and recanalization could not improve clinical outcome. Preoperative SPECT may be useful to make a decision whether rep er fusion therapy should be performed or not in case of vertebrobasilar occlusion.
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Affiliation(s)
- H Ohta
- Department of Neurosurgery, Junwakai Memorial Hospital; Kamatsu, Miyazaki, Japan
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