Recanalization of Middle Cerebral Artery and Intracranial Aneurysm in the Same Ischemic Territory With Intravenous Administration of Recombinant Tissue Plasminogen Activator: Case Report

Mechanical Thrombectomy for Acute Stroke in Patients with Target and Unrelated Vessel AVMs and AVFs: A Case Series

BACKGROUND

Advances in acute and long-term poststroke care have resulted in improved survival and functional outcomes for patients who have suffered large vessel ischemic strokes. For years, tissue plasminogen activator was the mainstay of treatment for acute stroke. Its use was previously limited to patients without known comorbid intracranial vascular pathology because of concern for bleeding risk. More recently, however, the use of tissue plasminogen activator in select patients with vascular anomalies has increased and is now largely thought to be safe. With the safety and efficacy of mechanical thrombectomy now proven for large vessel occlusions (LVOs), similar investigation is needed to assess procedural safety in patients with concomitant arteriovenous (AV) malformations or fistulae.

METHODS

We reviewed patients treated for LVOs at our institution and those of our collaborators and identified 6 patients who were treated for LVO with either known or incidentally identified concomitant AV malformations or dural AV fistulae.

RESULTS

We present a case series of 6 patients with nonaneurysmal intracranial vascular lesions who underwent mechanical thrombectomy for LVO without complications related to these lesions.

CONCLUSIONS

Although limited by small size, our series adds to the literature evidence that mechanical thrombectomy for LVO can safely be performed with concomitant dural AV fistulae and AV malformations.

A Concealed Intracranial Aneurysm Detected after Recanalization of an Occluded Vessel: A Case Report and Literature Review

BACKGROUND

Based on the results of several randomized controlled trials, acute endovascular thrombectomy is strongly recommended for patients with acute ischemic stroke due to large artery occlusion (LAO). The incidence of an intracranial aneurysm has been reported to be approximately 5% in the general population. Therefore, the possibility of the coincidence of LAO and an intracranial aneurysm at the distal part of an occluded vessel should be considered.

SUMMARY

A 74-year-old female patient presented with the sudden onset of consciousness disturbance and left-sided weakness. Neuroimages demonstrated an acute infarction due to right middle cerebral artery occlusion. The occlusion was successfully treated, and an aneurysm was incidentally detected at the occluded artery. We reviewed the literature and identified 11 cases in 8 reports, which were similar to our case. Among the 11 cases, aneurysms ruptured during endovascular therapy in 2 cases. In the present report, we discussed the prediction of concealed aneurysms and avoidance of their rupture during endovascular intervention.

KEY MESSAGE

The presence of an aneurysm concealed behind an embolus should be carefully assessed on preoperative and intraoperative neuroimages. The important findings for suspecting such an aneurysm are a hyperdense nodular sign on preoperative computed tomography and unusual motion of the microwire during the endovascular intervention. Even if there is no finding indicative of an aneurysm, the catheter and thrombectomy devices should be more carefully advanced than usual, especially at the common sites of aneurysms, and the devices should be appropriately chosen.

Systemic thrombolysis in acute ischemic stroke patients with unruptured intracranial aneurysms

OBJECTIVE

We sought to determine the safety of IV thrombolysis (IVT) in acute ischemic stroke (AIS) patients harboring unruptured intracranial aneurysm (UIA) in a multicenter study and a comprehensive meta-analysis of available case series.

METHODS

We analyzed prospectively collected data from consecutive AIS patients treated with IVT during a 4-year period at 4 tertiary-care stroke centers. All patients routinely underwent CT or magnetic resonance angiography during hospitalization. The presence of UIA was documented on the basis of neuroradiology reports. Symptomatic intracranial hemorrhage (sICH) was defined as imaging evidence of ICH combined with an increase in NIH Stroke Scale score of ≥4 points. A systematic meta-analysis of case series reporting safety of IVT in AIS with concomitant UIA was conducted according to PRISMA recommendations.

RESULTS

Among 1,398 AIS patients treated with IVT, we identified 42 cases (3.0%) harboring a total of 48 UIAs. The rates of symptomatic and asymptomatic ICH were 2.4% (95% confidence interval [CI] by adjusted Wald method: 0%-12.6%) and 7.1% (95% CI: 1.8%-19.7%), respectively. A total of 5 case series met our inclusion criteria for meta-analysis, and the pooled rate of sICH among 120 IVT-treated AIS patients harboring UIA was 6.7% (95% CI: 3.1%-13.7%). In the overall analysis of 5 case-series studies, the risk ratio of sICH did not differ between AIS patients with and without UIA (risk ratio = 1.60; 95% CI: 0.54-4.77; p = 0.40) with no evidence of heterogeneity across included studies (I(2) = 22% and p = 0.27 for Cochran Q test).

CONCLUSIONS

Our prospectively collected multicenter data, coupled with the findings of the meta-analysis, indicate the potential safety of IVT in AIS patients with UIA.

Is acute reperfusion therapy safe in acute ischemic stroke patients who harbor unruptured intracranial aneurysm?

Background

Intracranial aneurysms are currently considered as contraindication for intravenous thrombolysis in acute ischemic stroke, very likely due to a possible increase in the risk of bleeding from aneurysm rupture; however, there is limited data available on whether intravenous thrombolysis is safe for acute ischemic stroke patients with pre-existing intracranial aneurysms.

Aims and/or hypothesis

To find out the safety of intravenous thrombolysis in acute ischemic stroke patients who harbor unruptured intracranial aneurysms.

Methods

We retrospectively reviewed the medical records and cerebrovascular images of all the patients treated with intravenous thrombolysis for acute ischemic stroke in our center from the beginning of 2006 till the end of April 2014. Those with unruptured intracranial aneurysm present on cerebrovascular images prior to acute reperfusion therapy were identified. Post-thrombolysis brain imaging was reviewed to evaluate for any intraparenchymal or subarachnoid hemorrhage related or unrelated to the aneurysm.

Results

A total of 637 patients received intravenous thrombolysis for acute ischemic stroke in our center during an 8.3-year period. Thirty-three (5.2%) were found to have at least one intracranial aneurysms. Twenty-three (70%) of those received only intravenous thrombolysis, and 10 patients received combination of intravenous and intra-arterial throm-bolysis. The size of the largest aneurysm was 10 mm in maximum diameter (range: 2-10 mm). The mean size of aneurysms was 4.8 mm. No symptomatic intracranial hemorrhage occurred among the 23 patients receiving only intravenous thrombolysis. Out of those who received a combination of intravenous and intra-arterial thrombolysis, one developed symptomatic intracranial hemorrhage in the location of acute infarct, distant to the aneurysm location.

Conclusion

Our findings suggest that neither intravenous thrombolysis nor combination of intravenous and intra-arterial thrombolysis increases the risk of aneurysmal hemorrhage in acute ischemic stroke patients who harbor unruptured intracranial aneurysms less than 10 mm in diameter. Their listing in exclusion criteria for intravenous throm-bolysis should be reconsidered to assure appropriate use of acute reperfusion therapy in this group of patients.