Presentation
Sudden malaise and slurred speech.
Patient Data
Non-contrast CT:
No evidence of intracranial bleed or infarct.
Hyperdense intracranial left vertebral artery (V4).
CT angiogram:
Short filling defect in right V4 at level of occipital condyle.
Filling defect in left V4 immediately distal to origin of PICA, extending into proximal basilar artery.
Not clear as to where the distal basilar artery receives its supply from, as the PComs are hypoplastic.
Non-stenosing atherosclerosis at origin of internal carotid arteries (ICA).
In light of no visible infarct on NCCT and filling defects in the vertebrobasilar system, the patient was given a tissue plasminogen activator (tPA), after which he rapidly fell into a coma. A repeat NCCT head (not shown) was done, which showed no intracranial bleed. He was then rushed to the angiography suite.
Under general anesthesia, the was punctured and an 8F sheath was put in place. After diagnostic catheterization of both internal carotid arteries and left vertebral artery was performed (not shown), a long 6F sheath was passed into the upper cervical left vertebral artery.
A single thrombectomy trial was performed, using the Solumbra technique 1 (i.e. stent retriever and proximal suction). Satisfactory canalization was achieved (TICI 3); however, there remained severe residual stenosis. Balloon angioplasty performed.
Control angiography done at 10, 20, and 30 minutes after completion - satisfactory flow, no restenosis. It was thus decided not to insert a stent.
Case Discussion
While at the hospital for an unrelated matter, started feeling bad and slurring his words. History of type 2 diabetes, obesity, 60 pack years of smoking, and CABG for IHD. Neurologic examination at the ED: NIHSS 3-4. ECG: atrial fibrillation, chronicity unknown.
Non-contrast CT (NCCT) head showed no visible brain infarct. CT angiography showed a filling defect in V4 segment of the right vertebral artery and a filing defect spanning the distal left V4-proximal basilar artery. After receiving a tissue plasminogen activator (tPA) for thrombolysis, the patient rapidly fell into a deep coma with flaccidity. Intubated and ventilated. Stat repeat NCCT head showed no intracranial bleed or infarct.
He was rushed to the angiography suite, where mechanical thrombectomy was performed on the vertebrobasilar thrombus (see details above, under Angiography), followed by balloon angioplasty.
He recovered well and rapidly and was released from the hospital 4 days after thrombectomy.
Unable to process the form. Check for errors and try again.