J Cerebrovasc Endovasc Neurosurg.  2016 Sep;18(3):258-263. 10.7461/jcen.2016.18.3.258.

Emergent Double-barrel Bypass Shortly after Intravenous Administration of Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke

• Choi JH
• Park HS

• KMID: 2355651
• DOI: http://doi.org/10.7461/jcen.2016.18.3.258

Abstract

Although intravenous recombinant tissue plasminogen activator (IV rt-PA) is effective in many cases of acute ischemic stroke, the neurologic symptoms can worsen after IV rt-PA because of sustained vessel occlusion. For such cases, several reperfusion modalities are available, including intra-arterial thrombolysis (IAT), carotid endarterectomy, and superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Invasive procedures, such as major surgery, should be generally avoided within 24 hours after the administration of IV rt-PA. A 66-year-old man with no previous medical history developed left hemiparesis. A computed tomography scan revealed no acute lesion and he received IV rt-PA within 1.5 hours after symptom onset. Emergent magnetic resonance imaging showed significant diffusion-perfusion mismatch. He received IAT 2 hours after IV rt-PA administration, but IAT failed because of total occlusion of the cervical internal carotid artery. We initially planned to perform STA-MCA bypass the next morning because he had received IV rt-PA, but, 8 hours after IV rt-PA administration, his hemiparesis worsened from motor grade 3/4 to motor grade 1/2. Because of the large perfusion defect in both MCA divisions, double-barrel STA-MCA bypass was performed 10 hours after IV rt-PA administration. His symptoms rapidly improved after surgery and his modified Rankin Scale score 3 months later was grade 0. We suggest that emergent double-barrel bypass can be a viable option in patients who have perfusion defects of both MCA divisions in acute ischemic stroke after IV rt-PA administration.

Keyword

Acute stroke; Cerebral infarctions; STA-MCA bypass; Cerebral revascularization; Tissue plasminogen activator; Reperfusion

MeSH Terms

Administration, Intravenous*
Aged
Carotid Artery, Internal
Cerebral Arteries
Cerebral Infarction
Cerebral Revascularization
Endarterectomy, Carotid
Humans
Magnetic Resonance Imaging
Neurologic Manifestations
Paresis
Perfusion
Reperfusion
Stroke*
Tissue Plasminogen Activator*
Tissue Plasminogen Activator

Figure

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  Fig. 1 (A) The initial diffusion-weighted image (DWI) reveals small acute infarcts in the cortex, subcortex and corona radiata of the right hemisphere. (B) The magnetic resonance (MR) angiography shows occlusion of the right internal carotid artery (ICA) and middle cerebral artery (MCA). (C) The MR perfusion (T max map) reveals large perfusion defects in the right MCA whole territory. (D) Endovascular treatment was performed 2 hours after the administration of intravenous recombinant tissue plasminogen activator (IV rt-PA), but recanalization failed because of complete cervical ICA occlusion. (E) Eight hours after the administration of IV rt-PA, left side motor weakness of the patient worsened from motor grade 3/4 to motor grade 1/2, and the immediate follow-up DWI showed an increased cerebral infarction.

• 

  Fig. 2 (A) The diffusion-weighted image (DWI) on post-operative day 7 reveals a slight increase in cerebral infarction. (B) The postoperative 7-day magnetic resonance (MR) perfusion shows improved perfusion status, but some perfusion defects in the right internal border zone are still noted. However, his symptom rapidly improved after surgery. (C) The 1-year follow-up MR perfusion reveals more improved perfusion status. (D) The 1-year follow-up MR angiography demonstrates that the right superficial temporal artery is much thicker than its contralateral counterpart. At 3-month follow-up, the patient's mRS score was 0, and he remained well at his 1.5-year follow-up visit. mRS = modified Rankin scale.

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