Stent retriever thrombectomy with aneurysm in target vessel: Technical note

Intracranial aneurysms in patients with acute ischemic stroke prevalence and influence on mechanical thrombectomy over 14 years in a tertiary-care center

INTRODUCTION

The prevalence of intracranial aneurysms (IA) in patients with acute ischemic stroke (AIS) requiring mechanical thrombectomy (MT) is unclear.

OBJECTIVE

To describe the prevalence of IA in patients with AIS and their influence on MT.

MATERIALS & METHODS

This is a retrospective cohort study on all patients admitted with a diagnosis of AIS from January 2008 to March 2022 at a tertiary academic center. The records were reviewed for demographic, clinical, imaging, and outcomes data. Only patients who had CTA at admission were included in this analysis.

RESULTS

Among 2265 patients admitted with AIS, this diagnosis was confirmed in 2113 patients (93.3 %). We included 1111 patients (52.6 %) who had head CTA and 321 (28.9 %) who underwent MT. The observed prevalence of aneurysms on CTA was 4.5 % (50/1111 patients), and 8 (16 %) had multiple aneurysms. MT was performed in 7 patients harboring IAs: 6 ipsilateral (5 proximal and 1 distal to the occlusion)and 1 contralateral aneurysm.. The patient with a contralateral aneurysm had a TICI 2B score In patients with ipsilateral aneurysms, TICI 2B or 3 was achieved in 3 cases (50 %), which is significantly lower than historical control of MT (91.6 %) without IA (p = 0.01). No aneurysms ruptured during MT. The aneurysm noted distal to the occlusion was mycotic.

CONCLUSION

In this analysis, the observed prevalence of IA in patients with AIS was 4.5%. Ipsilateral aneurysms (proximal or distal to the occlusion site) deserve particular attention, given the potential risk of rupture during MT. Aneurysms located distal to the occlusion were mycotic and the rate of recanization in patients with ipsilateral aneurysms was low compared to historical controls. Further studies are needed to improve the outcomes in patients with IA requiring MT.

Intra-aneurysmatic thrombectomy in a distal anterior cerebral artery aneurysm

Thrombectomy procedures following intra-aneurysmatic lesions are extremely rare, and few cases have been reported. This article describes a microsurgical intra-aneurysmatic thrombectomy (MIaT) for a distal anterior cerebral artery (DACA) aneurysm. We present the case of a 48-year-old female that was admitted to the emergency room, showing neurologic deterioration with focal deficits. A computed tomography angiography (CTA) scan revealed an aneurysm located in the distal segment of the left anterior cerebral artery. During the surgical procedure, after clipping, a wellformed clot was visualized through the aneurysm's wall obstructing the left DACA flow. We proceeded to open the aneurysm's dome to remove the thrombus and clip the aneurysm neck, re-establishing the flow of the left DACA. Intra-aneurysmatic thrombosis can occur as a complication during clipping, obstructing the distal flow of vital arteries and causing fatal results in the patient's postoperative status. MIaT is a good technique for restoring the flow of the affected vessel and allows a secure aneurysm clipping after thrombus removal.

Endovascular thrombectomy in the setting of occult cerebral artery aneurysm: Reducing the risk of iatrogenic rupture

Cerebral artery aneurysms are present in up to 10% of ischemic stroke patients, often within or adjacent to the occluded vessel. In some cases, the approach to intervention may need to be modified based on the size and location of the aneurysm. We describe a 99-year-old female with a known history of cerebral aneurysm who underwent successfully mechanical thrombectomy of a right middle cerebral artery thrombus; an 8-mm aneurysm involving the right M1 bifurcation was identified only on post-procedural digital subtraction angiography. In addition, we discuss strategies to reduce the risk of iatrogenic aneurysm rupture in the setting of endovascular thrombectomy.

Ruptured hidden intracranial aneurysm during mechanical thrombectomy: A case report

Background:

Acute ischemic stroke (AIS) patients have a higher prevalence of cerebral aneurysm than a healthy reference population. However, it was recently reported that cases of an unknown hidden aneurysm in AIS patients with large-vessel occlusion are rare. We report a rare case of subarachnoid hemorrhage (SAH) during mechanical thrombectomy (MT) using a stent retriever for AIS.

Case Description:

A 46-year-old patient with the right internal carotid artery terminal occlusion presented with the left-sided hemiparesis, hemispatial neglect, and dysarthria and underwent MT. Initial thrombectomy using a stent retriever and reperfusion catheter was unsuccessful. Angiography just before the second attempt showed SAH. Fortunately, we achieved recanalization of the thrombolysis in cerebral infarction 2b and hemostasis by lowering the blood pressure followed by coil embolization of the ruptured aneurysm. Only a few cases of ruptured aneurysms have been reported during MT using a stent retriever. Stent withdrawal is suspected to cause aneurysm rupture in cases with an unknown hidden middle cerebral artery bifurcation aneurysm.

Conclusion:

Preinterventional detection of a hidden aneurysm is difficult. Therefore, surgeons must always consider the possibility of a hidden aneurysm rupture in vessels distal to the occlusion site and make adequate preparations for the prompt treatment of ruptured aneurysms after MT.

Mechanical Thrombectomy for Acute Cerebral Large Vessel Occlusions Involving a Cerebral Aneurysm in the Target Vessel

Objective

Mechanical thrombectomy (MT) for acute cerebral large vessel occlusion (LVO), which involves a cerebral aneurysm in the target vessel, indicates a risk of rupture of the aneurysm. Safety of the MT for LVO involving cerebral aneurysm was examined.

Methods

In all, 240 consecutive patients with LVO were treated with MT between January 2018 and December 2019. Angiographic images and clinical records of patients with LVO involving cerebral aneurysm in the target vessel were retrospectively analyzed.

Results

Cerebral aneurysms were involved in seven patients (2.9%) in the target vessels. Aspiration thrombectomy was first considered; however, five of seven lesions were difficult to manage with aspiration thrombectomy alone. The stent retriever (SR) was combined with aspiration catheter for elongated vessel lesions and distal lesions. In all lesions, good recanalization was achieved without aneurysmal rupture.

Conclusion

Aneurysms were identified in 2.9% of LVO in this study. Good recanalization was performed in all cases, and no cerebral aneurysmal rupture was observed during the perioperative period, and the procedure was relatively safe. Further case accumulation is needed for MT device selection and procedures for LVO involving cerebral aneurysm.

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 Direct Aspiration First Pass Technique for Mechanical Thrombectomy in the Setting of a Suspected Cerebral Aneurysm

There is little guidance in the literature on which thrombectomy technique is preferred in patients with acute ischemic stroke and concomitant aneurysms. Here, we present the case of a 58-year-old female with an acute ischemic stroke requiring emergent thrombectomy that was complicated by the presence of multiple, nonruptured intracranial aneurysms. Imaging confirmed an occlusion of the right middle cerebral artery and multiple nonruptured intracranial aneurysms. The patient was administered intravenous recombinant tissue plasminogen activator and the thrombus was aspirated via a direct aspiration first pass technique (ADAPT). Her symptoms improved significantly postoperatively with a consequent National Institutes of Health Stroke Scale (NIHSS) score of 0. The purpose of this case report is to give an overview and compare various techniques that can help guide the physician for safe, early revascularization while reducing recanalization time in patients having an ischemic stroke who also harbor intracranial aneurysms.