J Cerebrovasc Endovasc Neurosurg.  2021 Mar;23(1):60-63. 10.7461/jcen.2021.E2020.05.001.

How to differentiate intracranial atherosclerotic disease or vasospasms after mechanical thrombectomy. Be patient or vasodilator is the secret?

• Pagiola I
• Amaral B
• Saito C
• Nalli D
• Carrete Junior H
• Frudit M

• KMID: 2514340
• DOI: http://doi.org/10.7461/jcen.2021.E2020.05.001

Abstract

Here we describe a successful mechanical thrombectomy (MT) for acute large vessel occlusion in stroke treatment with one passage (thrombolysis in cerebral infarction, TICI 3). Immediately after the withdrawing of the stent retriever, a narrowing of the middle cerebral artery was diagnosed. The rate of vasospasms during this procedure can be as higher as 41% (range from 6-41%). Here we describe our protocol when a narrowing of the artery is visualized after a stent retriever is withdrawn. A patient presented in our emergency room with National Institute of Health Stroke Scale (NIHSS) of 21, Alberta Stroke Program Early CT Score (ASPECTS) 8, computed tomography angiography revealed occlusion of the M1 segment and MT was indicated. One passage TICI Ⅲ was achieved. After that, the image showed a narrowing of the artery. We present one case of a spasm after stent retriever technique for MT, we injected vasodilator and the artery became normal in a few minutes differentiating between atheromatous stenosis and vasospasm. We present a technical note that can help to make the differentiation of vasospasm or atheromatous disease after MT with the stent retriever technique.

Keyword

Stroke, Vasospasms, Endovascular treatment, Ischemic stroke, Thrombectomy

Figure

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  Fig. 1. Noncontrast CT. (A) Hyperdense vessel sign on the left (black arrow). (B, C) Early ischemic changes (loss of grey-white matter differentiation). (D) Automated postprocessing of the CTP images (RAPID; iSchemaView, Menlo Park, CA, USA) with CBF <30% of 10 mL; Tmax >6 of 71 mL and mismatch volume: 61 mL. CT, computed tomography; CTP, computed tomography perfusion; CBF, cerebral blood flow.

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  Fig. 2. Left internal carotid artery DSA. (A) First angiographic acquisition confirmed the left M1 segment MCA occlusion (white arrow). (B) The deployment of a Stent retriever–Solitaire FR 4×40 (Ev3, Irvine, CA, USA) (black arrows). (C) First angiographic acquisition after Stent retriever withdrawn with a norrow lesion in the MCA (black arrowhead). (D) Angiographic acquisition after IA 6 mg of milrinone injection throw the balloon guide catheter (Cello 9 F-Ev3, Irvine, CA, USA) with resolution of the vasospasm (white arrowhead). DSA, digital subtraction angiography; MCA, middle cerebral artery.

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