J Neurocrit Care.  2023 Jun;16(1):28-33. 10.18700/jnc.230011.

Delayed post-ischemic leukoencephalopathy in emergent large-vessel occlusive stroke after mechanical thrombectomy: case reports

• Ryu JC
• Lee D
• Kwon SU
• Chang JY

• KMID: 2543389
• DOI: http://doi.org/10.18700/jnc.230011

Abstract

Background
Delayed post-ischemic leukoencephalopathy (DPIL) is a rare complication after mechanical thrombectomy, with no well-established clinical characteristics and patho-mechanism. We explored the characteristics and possible mechanisms in three patients with DPIL.
Case Report
Based on the clinical manifestations and laboratory findings including magnetic-resonance imaging, magnetic resonance spectroscopy, electroencephalography, and lumbar puncture, DPIL was diagnosed in three patients. We administered antiplatelet agents and conservative treatment. Cardioembolism, successful recanalization using a balloon guiding catheter, and fluctuating or gradually worsening neurological symptoms in delayed phase between 13 and 70 days were common features of DPIL. Diffusion-weighted imaging and fluid-attenuated inversion recovery showed high-signal intensity in the affected subcortical white matter. Laboratory findings provided no evidence of an epileptic disorder, inflammatory demyelination, or tumorous conditions.
Conclusion
This report shows the characteristics and neuroradiologic images of DPIL. Among the various hypotheses, regional hypoxic-ischemic leukoencephalopathy and delayed reperfusion injury might be the patho-mechanism underlying DPIL.

Keyword

Delayed post-ischemic leukoencephalopathy; Mechanical thrombectomy; Large vessel occlusive stroke; Cardioembolic stroke

Figure

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  Fig. 1. Magnetic resonance imaging findings in case 1. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (A, B) on admission revealed no definite acute lesions. (C) DWI after mechanical thrombectomy showed some infarcts in the left corona radiata. On day 28, DWI (D) revealed high-signal intensities in the entire subcortex of left middle cerebral artery territory without signal changes on apparent diffusion coefficient (E). Fluid-attenuated inversion recovery (F) showed diffuse subcortical white matter lesions in the same territory.

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  Fig. 2. Magnetic resonance imaging findings in case 2. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (A, B) on admission revealed new infarcts in the left corona radiata and subcortical area. (C) Magnetic resonance perfusion showed severe diffusion-perfusion mismatch. (D) DWI on day 6 showed new infarcts after mechanical thrombectomy. (E, F) On day 30, DWI and fluid-attenuated inversion recovery demonstrated the presence of diffuse subcortical white matter lesions. (G) Magnetic resonance spectroscopy showed a mildly increased choline/N-acetyl aspartate ratio.

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  Fig. 3. Magnetic resonance imaging findings in case 3. (A, B) Diffusion-weighted imaging (DWI) and apparent diffusion coefficient on admission showed diffusion-restriction lesions in the left basal ganglia and corona radiata. (C) DWI after mechanical thrombectomy revealed new scattered infarcts in the left middle cerebral artery territory. On day 29, DWI and fluid-attenuated inversion recovery (D, F) demonstrated the presence of diffuse subcortical white matter lesions, without signal changes on apparent diffusion coefficient (E).

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