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Abstract
A 55 year-old male with a history of substance use disorder presented after syncope and fall. The patient was obtunded on arrival and promptly intubated, which was complicated by a drop in systolic blood pressure from 261mmHg to 83mmHg. Exam subsequently revealed global aphasia. On MRI, he was found to have acute bilateral ACA/MCA and MCA/PCA borderzone strokes and bilateral chronic cavitations in a watershed distribution. MRA head & neck revealed complete occlusions of the bilateral ICAs from the level of the bifurcations.
DSA was pursued to better characterize the chronicity of the lesions, which re-demonstrated bilateral ICA occlusions, with significant collateralization from the leptomeningeal branches of both PCAs. On the left side, microcatheter injection demonstrated some patency in the cervical and petrous L ICA with an extensive clot burden, suggesting acute on chronic occlusion. Aspiration thrombectomy was therefore pursued on the left, with a copious amount of clot removed throughout the ICA (figure 1A, B). Angioplasty was performed on a persistent narrowing in the cavernous segment, favored to reflect underlying atherosclerosis. Following balloon deflation, angiogram demonstrated possible plaque dissection; therefore, Cangrelor gtt was initiated and a balloon-mounted Onyx Resolute Zotarolimus-eluting stent was placed.
Post-intervention exam initially remained stable. However, the following day, new RUE flaccidity was noted, and CTA confirmed re-occlusion of the L ICA. The patient was taken back for repeat aspiration thrombectomy of the cervical and petrous ICA and additional stenting of the distal cavernous segment with a second Onyx Resolute stent. The patient’s RUE strength improved without further progression of symptoms, though he remained aphasic. He was kept on a Cangrelor gtt, with the addition of a temporary heparin gtt for residual sub-occlusive thrombus, followed by transition to ticagrelor and aspirin.
Drug-eluting stents have a long history of use in coronary procedures and have begun to gain favor in cases of ICAD. Recent trials demonstrated safety and efficacy of Zotarolimus-eluting stents, as well as lower rates of in-stent thrombosis using Sirolimus-eluting stents when compared to bare metal stents. In our patient, we suspected acute thrombosis superimposed on chronic atherosclerosis. Therefore, he was taken for aspiration thrombectomy, and in the setting of underlying ICAD, balloon-mounted drug-eluting stents were placed. The limitation of using balloon-mounted stents is the inability to conform to a lesion in a curvature. In this case, two stents were used to cover the long lesion within the clinoid and cavernous segments with technical success.
Disclosures A. Molaie: None. C. Beaman: None. J. Morales: None. M. Nour: None. S. Tateshima: None.