Neurointervention.  2020 Mar;15(1):37-43. 10.5469/neuroint.2019.00241.

Transcarotid Mechanical Thrombectomy for Embolic Intracranial Large Vessel Occlusion after Endovascular Deconstructice Embolization for Carotid Blowout Syndrome

• Lu CJ
• Lin YH
• Lee CW

• KMID: 2502081
• DOI: http://doi.org/10.5469/neuroint.2019.00241

Abstract

Carotid blowout syndrome (CBS) is a fatal complication of head and neck cancer. Endovascular treatment, particularly deconstructive embolization, is effective for CBS, but it might result in thromboembolic events. We report the case of a 57-year-old man with underlying recurrent head and neck cancer who had CBS. The patient received endovascular embolization of the right internal, external, and common carotid arteries. Right internal carotid artery to middle cerebral artery embolic occlusion was noted immediately after the procedure, and left-sided weakness and facial palsy were found. Ipsilateral suprabulbar cervical internal carotid artery puncture was performed under fluoroscopic guidance, and rescue suction thrombectomy was successful. The patient had no significant neurological sequela. Transcarotid intraarterial thrombectomy is a reasonable method for managing postembolization large vessel occlusion, even in the neck, after irradiation.

Keyword

Intracranial embolism; Thrombectomy; Carotid artery injuries

Figure

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  Fig. 1. Preprocedural CTA. (A) CTA coronal view showing a 4-mm pseudoaneurysm (arrow) of the right inferior thyroid artery. (B) CTA sagittal view showing the encased right carotid bulb and proximal ICA with focal luminal narrowing (arrow). (C) Axial view of COW showing robust Acom (arrow) and proximal bilateral ACAs (arrowheads). (D, E) Axial and sagittal views of COW showing robust right Pcom (arrows). CTA, computed tomographic angiography; ICA, internal carotid artery; COW, circle of Willis; Acom, anterior communicating artery; ACAs, anterior cerebral arteries; Pcom, posterior communicating artery.

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  Fig. 2. Endovascular embolization of pseudoaneurysm of the right inferior thyroid artery and right carotid artery. (A) Frontal view of right subclavian artery angiography demonstrating a small pseudoaneurysm (arrow). (B) Postembolization of right inferior thyroid artery showing deployed coils and obliteration of the pseudoaneurysm. (C) Right CCA lateral angiography showing the ulceration (arrowhead) and focal narrowing (arrow) at the carotid bulb, compatible with vascular encasement and impending blowout. (D) Frontal fluoroscopic spot view after endovascular carotid trunk embolization revealing radiopaque coils in the ECA (arrow) and ICA (arrowhead) as well as a vascular plug in the CCA (black arrow). (E, F) Frontal and lateral views of left vertebral angiography showing a filling defect from the right ICA (arrows) to the proximal MCA (arrowheads). CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery; MCA, middle cerebral artery.

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  Fig. 3. Fluoroscopically guided direct puncture of the right ICA. (A, B) Frontal and lateral views of fluoroscopic spot views showing an imaginary direction of the ICA (dashed lines), using deployed coils as precise landmarks. The puncture needle (asterisks) was inserted toward the imaginary line. (C, D) Frontal and lateral views of right carotid angiography before embolization showed the course of the right ICA (dashed lines), which gave the imaginary guidance of ICA puncture. (E) The right neck puncture site showing the 6-French vascular sheath (white arrow), whose tip was just outside the carotid sheath, and the 5-French guiding sheath (black arrow) into the right ICA. ICA, internal carotid artery.

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  Fig. 4. Endovascular mechanical thrombectomy. (A, B) Frontal and lateral views of right ICA angiography showing progressive thrombosis in the right ICA and total occlusion of the MCA. The tip of the guiding catheter (white arrows) was placed in the upper cervical portion of the ICA, and the angiograms were obtained via the intermediate catheter at the distal petrous portion (black arrows). (C, D) Frontal and lateral views of right ICA angiography after suction thrombectomy showing TICI grade 3 reperfusion. ICA, internal carotid artery; MCA, middle cerebral artery; TICI, Thrombolysis in Cerebral Infarction.

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