Clinical Case Report
Presentation
64 year old Male patient with history of nasopharyngeal cancer (NPC) treated with radiotherapy 12 years ago.
Recurrent tumor was identified during follow up.
During biopsy performed under general anesthesia, profuse bleeding occurred at the early stages of the procedure and could not be controlled with local surgical intervention.
DSA confirmed carotid blow-out and associated left MCA upper trunc occlusion.
Prof Dr. Osman KIZILKILIC
Istanbul University, Cerrahpasa Medical School Radiology Department, Neuroradiology Division
Dr. Bora KORKMAZER
Istanbul University, Cerrahpasa Medical School Radiology Department, Neuroradiology Division
PRE-PROCEDURE Angio images
Left ICA images showed the carotid blow-out and the bleeding site
Right ICA and Basilar DSA images showing insufficient collateral flow to left ICA territory. As a result, occlusion of Left-ICA was ruled out as a treatment option and the decision to graft the bleeding lesion was taken.
See below angio images from injections into the right ICA and into the Basilar artery to check collateral flow:
Step 1: STENT GRAFTING OF THE CAROTID BLOW OUT
A stent graft was positioned across the lesion in order to stop the bleeding and reconstruct the torn carotid segment.
Angio images (DSA) before stent-graft placement:
Angio images (DSA) post stent-graft placement:
– Confirmed reconstruction of the parent artery and stopped bleeding
– Showed occlusion of upper MCA with a perfusion defect
Step 2: THROMBECTOMY OF THE MCA
A 5 Fr distal access catheter (DAC) was driven past the initial carotid lesion, going through the stent graft.
A 21” ID microcatheter was then driven past the occlusion and microcatheter injection was performed to visualize distal circulation.
Thrombectomy was performed using the NeVa 4 x 20 mm
NeVa was retrieved into the 5 Fr DAC
See below images to observe NeVa placement, with the proximal Drop Zone positioned right on the suspected position of the clot:
Click below to watch the procedure:
Before-After the Recanalization:
Post-op CT
Post-Op CT images show absence of ICH.
24 h control MR FLAIR images
24 h control MR FLAIR images show no infarction in the brain parenchyma.
Procedural Statistics
The total procedure including stent grafting of the carotid blow out took 32 minutes.
The thrombectomy procedure, from post-stent graft DSA to recanalization took 10 minutes.
Clinical Outcome
24 hour NIHSS of the patient was 0:
neurologically intact without any motor deficit.
At VESALIO, we feel blessed to be part of the stroke field where together with these dedicated stroke teams, we can make an incredible impact on people’s lives.
Thank you Istanbul Cerrahpasa stroke team: Prof Kizilkilic, Dr Korkmazer, Yunus Demir and all the lab technicians and nurses as well as the anesthesiology team supporting this case.
