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Mechanical recanalization for acute bilateral cerebral artery occlusion – literature overview with a case

Miran Jeromel
Miran Jeromel
, 
Zoran V Milosevic
Zoran V Milosevic
 and 
Janja Pretnar Oblak
Janja Pretnar Oblak
   | Mar 26, 2020
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Article Category: Review
Published Online: Mar 26, 2020
Page range: 144 - 148
Received: Jan 19, 2020
Accepted: Mar 05, 2020
DOI: https://doi.org/10.2478/raon-2020-0017
© 2020 Miran Jeromel, Zoran V Milosevic, Janja Pretnar Oblak, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Figure 1

Initial imaging workup upon arrival at the general hospital. CT angiography (CTA) shows right M1 occlusion (arrow).
Initial imaging workup upon arrival at the general hospital. CT angiography (CTA) shows right M1 occlusion (arrow).

Figure 2

(A) Control images taken in the general hospital after clinical deterioration during intravenous thrombolysis and before the transfer to the tertiary institution. There were still no signs of ischaemic brain damage in the right cerebral hemisphere but there were subtle signs of stroke in the left middle cerebral artery (MCA) territory (white line delineates loss of cortical grey matter – white matter differentiation in the frontoparietal lobe with sulcal effacement). (B) Control images taken in the general hospital after clinical deterioration during intravenous thrombolysis and before the transfer. CT angiography (CTA) showed persistent right M1 occlusion (black arrow) but also left carotid “T” occlusion (white arrow). (C) Control images taken in the general hospital after clinical deterioration during intravenous thrombolysis and before the transfer. CT perfusion imaging (CTP) showed a penumbra in the right MCA territory (black circle) and irreversible brain damage in the left MCA territory (white circle).
(A) Control images taken in the general hospital after clinical deterioration during intravenous thrombolysis and before the transfer to the tertiary institution. There were still no signs of ischaemic brain damage in the right cerebral hemisphere but there were subtle signs of stroke in the left middle cerebral artery (MCA) territory (white line delineates loss of cortical grey matter – white matter differentiation in the frontoparietal lobe with sulcal effacement). (B) Control images taken in the general hospital after clinical deterioration during intravenous thrombolysis and before the transfer. CT angiography (CTA) showed persistent right M1 occlusion (black arrow) but also left carotid “T” occlusion (white arrow). (C) Control images taken in the general hospital after clinical deterioration during intravenous thrombolysis and before the transfer. CT perfusion imaging (CTP) showed a penumbra in the right MCA territory (black circle) and irreversible brain damage in the left MCA territory (white circle).

Figure 3

(A) Digital subtraction angiography (DSA) at the beginning of mechanical recanalization. Right internal carotid contrast injection confirming right M1 occlusion. (B) DSA at the beginning of mechanical recanalization. Left side contrast injection showing complete spontaneous recanalization of the carotid “T” occlusion with thrombembolar distal migration (occlusion of the proximal M2 segment of the major MCA branch) (arrow).
(A) Digital subtraction angiography (DSA) at the beginning of mechanical recanalization. Right internal carotid contrast injection confirming right M1 occlusion. (B) DSA at the beginning of mechanical recanalization. Left side contrast injection showing complete spontaneous recanalization of the carotid “T” occlusion with thrombembolar distal migration (occlusion of the proximal M2 segment of the major MCA branch) (arrow).

Figure 4

(A) Digital subtraction angiography (DSA) after mechanical recanalization. Right M1 mechanical recanalization (aspiration device) led to complete flow restoration. (B) MR diffusion weighted imaging (DWI) scan taken 6 days after mechanical recanalization: complete salvage of the affected right middle cerebral artery (MCA) brain parenchyma (recanalization at 7 hours after stroke onset). In contrast, subsequent persistent left M2 occlusion without collateral flow resulted in significant stroke within 3 hours after stroke onset.
(A) Digital subtraction angiography (DSA) after mechanical recanalization. Right M1 mechanical recanalization (aspiration device) led to complete flow restoration. (B) MR diffusion weighted imaging (DWI) scan taken 6 days after mechanical recanalization: complete salvage of the affected right middle cerebral artery (MCA) brain parenchyma (recanalization at 7 hours after stroke onset). In contrast, subsequent persistent left M2 occlusion without collateral flow resulted in significant stroke within 3 hours after stroke onset.

Comparing 6 reported cases of mechanical thrombectomy in acute bilateral ICA and/or MCA occlusions

Author, (Year),Sex/ageSite of occlusionMechanicalClinical
referenceClinical presentation(years)ICAMCAthrombectomy (technique)outcome
Dietrich et al. (2014)5left hemiparesis, progressing to comaM/72-+ (M1)aspiration+stent- retrieverminor deficit
Pop et al. (2014)6impaired consciousnessF/78++ (M2)stent-retrieverno deficit
Pop et al.(2014)6right sided weaknessF/66++ (M1)stent-retrieversevere deficit
Braksick et al. (2018)7comaF/76-+ (M1)- (no data)coma
Larrew (2019) et al. 8coma- (no data) / middle age++ -aspirationfatal
Storey et al. 2019)9hemiparesis / hemiplegiaF/64++ (M1,M2)aspiration+stent-retrieverminor deficit
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