Mechanical Thrombectomy for Acute Ischemic Stroke in a Patient with Concomitant Spontaneous Intracerebral Hemorrhage

Mechanical Thrombectomy for Acute Ischemic Stroke in a Patient with Concomitant Spontaneous Intracerebral Hemorrhage

ARTICLE IN PRESS Case Studies Mechanical Thrombectomy for Acute Ischemic Stroke in a Patient with Concomitant Spontaneous Intracerebral Hemorrhage S...

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Case Studies

Mechanical Thrombectomy for Acute Ischemic Stroke in a Patient with Concomitant Spontaneous Intracerebral Hemorrhage Stefano Forlivesi,

MD,

Paolo Bovi,

MD,

and Manuel Cappellari,

MD

Data from randomized clinical trials and current guidelines suggest that patients with anterior circulation occlusion with contraindications to intravenous thrombolysis may benefit from direct mechanical thrombectomy. Nevertheless, no data are available on the efficacy and safety of direct mechanical thrombectomy in patients with concomitant spontaneous intracerebral hemorrhage. We report the case of a 51-year-old woman with a spontaneous intracerebral hemorrhage in the right parietal and occipital lobes, who experienced, 7 days later, an occlusion of the proximal left middle cerebral artery. Direct mechanical thrombectomy was performed, with complete recanalization of the left middle cerebral artery and good clinical outcome. To our knowledge, this is the first case report of direct mechanical thrombectomy for acute ischemic stroke in the setting of concomitant spontaneous intracerebral hemorrhage in a different vascular territory. Key Words: Intracerebral hemorrhage—ischemic stroke—mechanical thrombectomy—large vessel occlusion. © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Case Illustration

From the Stroke Unit, Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy. Received December 28, 2016; revision received March 23, 2017; accepted April 21, 2017. Conflict of interest: The authors declare that they have no conflict of interest. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article. Address correspondence to Stefano Forlivesi, MD, Azienda Ospedaliera Universitaria Integrata Verona, Piazzale Aristide Stefani 1, 37126 Verona, Italy. E-mail: [email protected] 1052-3057/$ - see front matter © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.04.024

A 51-year-old woman was admitted to the emergency department for acute onset of headache, left-side weakness, and visual disturbances. Non-contrast brain computed tomography (CT) scan showed a large intracerebral hemorrhage (ICH) in the right parietal and occipital lobes (Fig 1, A). The patient was taking warfarin for a mechanical prosthetic mitral valve, and international normalized ratio value was 5.86. Oral anticoagulation was suspended, but no specific reversal agents were administered, considering the high risk of thrombotic complications due to the mechanical prosthetic valve. Lowdose low-molecular-weight heparin was started to prevent deep vein thrombosis. After 7 days, the patient experienced a sudden onset of aphasia and right hemiplegia (National Institutes of Health Stroke Scale score of 19). Non-contrast CT scan showed no change in the size of the known ICH, and a hyperdense left middle cerebral artery (MCA). CT angiography confirmed an occlusion of the M1 segment of the left MCA, with good collateral circulation (Fig 1, B). Because ICH is an absolute

Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2017: pp ■■–■■

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ARTICLE IN PRESS S. FORLIVESI ET AL.

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Figure 1. (A) Axial non-contrast CT scan shows an intracranial hemorrhage in the right parietal and occipital lobes (asterisk). (B) Left middle cerebral artery occlusion on CT angiography (arrow, axial reformatted maximum intensity projection image). (C) Angiogram of the left internal carotid artery shows proximal occlusion of the left middle cerebral artery (arrow). (D) Angiogram of the left internal carotid artery shows complete recanalization of the left middle cerebral artery after mechanical thrombectomy. (E) Follow-up non-contrast CT scan excludes ischemic lesions in the left middle cerebral artery territory. Abbreviation: CT, computed tomography.

contraindication to intravenous thrombolysis (IVT),1 the patient was transferred to the angiography suite to undergo direct mechanical thrombectomy (MT). The procedure was performed under conscious sedation. An 8-F sheath was placed in the right common femoral artery. A 6-F Neuron MAX catheter (Penumbra, Inc, Alameda, CA) was placed in the left common carotid artery, and a 5MAX distal aspiration catheter (Penumbra, Inc) was placed in the supraclinoid internal carotid artery. Thrombus aspiration was performed with complete recanalization of the left MCA (Fig 1, C,D) and concomitant resolution of the symptoms. Neurological examination at the end of the procedure showed only a mild left hemiparesis with homonymous hemianopia owing to the right ICH. Followup CT scan performed 24 hours after MT did not detect any ischemic lesion in the left MCA territory (Fig 1, E).

Discussion We report the case of a patient who experienced an acute ischemic stroke several days after the suspension of oral

anticoagulation therapy for a spontaneous ICH. The stroke is to be considered as cardioembolic in nature, because the patient had a high-risk source of cardioembolism (mechanical prosthetic valve).2 Acute MCA occlusion was treated with direct MT owing to the presence of ICH, which is an absolute contraindication to IVT.1 Oral anticoagulation therapy with warfarin (international normalized ratio goal: 2.5-3.5) should be restarted as soon as possible after hematoma reabsorption. Data from randomized clinical trials and current guidelines suggest that patients with anterior circulation occlusion who have contraindications to IVT may benefit from direct MT.3,4 Nevertheless, no data are available on the efficacy and safety of direct MT in patients with ICH. To our knowledge, this is the first case report of direct MT for acute ischemic stroke in the setting of concomitant spontaneous ICH in a different vascular territory.

References 1. Toni D, Mangiafico S, Agostoni E, et al. Intravenous thrombolysis and intra-arterial interventions in acute

ARTICLE IN PRESS MECHANICAL THROMBECTOMY FOR ACUTE ISCHEMIC STROKE ischemic stroke: Italian Stroke Organisation (ISO)-SPREAD guidelines. Int J Stroke 2015;10:1119-1129. 2. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35-41. 3. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke:

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a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723-1731. 4. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association Focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2015;46:3020-3035.