Case 1. A 72-year-old right-handed female with history of atrial fibrillation was referred to our center due to right-side weakness, difficulty speaking, and then stu- por for lasting of 3 h and 50 min. Brain CT ruled out intracranial hemorrhage (ICH).
W. Jiang (*) · Y.-Q. Zhang
Vascular Neurosurgery Department, New Era Stroke Care and Research Institute, The PLA Rocket Force General Hospital, Beijing, China
e-mail: [email protected]
36
The patient never took any anticoagulation or antiplatelet medication before. On neurological examination, she presented with decreased consciousness level, left deviation of eyes with normal pupillary response, aphasia and right hemiparesis, with National Institutes of Health Stroke Scale (NIHSS) of 18. Blood pressure (BP) was 149/78 mmHg. So, a decision of combined intravenous thrombolysis and mechanical thrombectomy was made. Intravenous r-tPA (0.9 mg/kg) was initiated at 4 h after the onset.
Catheter angiography at 4.5 h discovered a complete occlusion of left terminal internal carotid artery (ICA). Mechanical thrombectomy with the use of a 4 × 20 mm Solitaire™ AB device (Covidien, Irvine, California) was then performed. After a total of five passes of the device, with the first at 5 h and 10 min and the last at 6 h, the occlusion was completely recanalized (Fig. 3.1).
Her NIHSS remained 18 immediately after procedure. BP was 137/59 mmHg.
She received intravenous injection of nicardipine (a calcium channel blocker) 4.8 mg/h and esmolol (a beta receptor blocker) 60 mg/h in neurological intensive care unit, to maintain systolic BP between 110 and 120 mmHg. Edaravone (a free- radical scavenger) and rosuvastatin (a lipid-lowering agent) were also administered.
However, the patient’s status deteriorated at 9 h after the onset (i.e. 3 h after recana- lization), with sudden vomiting and slowness of pupillary light reflex. Emergent CT showed an early cerebral edema with sulci effacement in the left hemisphere, fol- lowed by intravenous infusion of 20% mannitol 250 ml. At 13 h after the onset, her oxygen saturation dropped to 80%, which was restored to 98% after mechanical ventilation. The patient presented with deep coma at 16 h after the onset (i.e. 10 h after recanalization), with bilateral pupil dilation to 4 mm and light reflex disappear- ance. The brain edema was more severe on repeated CT, with midline shift (Fig. 3.1).
Then, the patient got worse despite aggressive medical therapy, with central hyper- pyrexia on day 2, central diabetes insipidus on day 3, circulatory collapse on day 4.
The patient was deceased on day 5.
Case 2. A 60-year-old right-handed female with history of hypertension and cigarette smoking had episodes of left-sided weakness during the past 4 months despite aspirin treatment. Before 18 days on admission, she experienced a transient attack of difficulty finding words for about 10 min.
On admission, there was no abnormal finding on neurological examination.
Blood clotting tests showed prothrombin time (PT) 9.9 s, activated partial thrombo- plastin time (APTT) 35 s, thromboplastin time (TT) 14.6 s, international normalized ratio (INR) 0.89, fibrinogen (Fib) 2.68 g/l, and D-Dimer 0.1 mg/l. A severe stenosis at bifurcation of right MCA was detected on magnetic resonance angiography. The stenosis rate was 80% on catheter angiography. The patient was medicated with aspirin 300 mg and clopidogrel 75 mg daily for antiplatelet, atorvastatin 20 mg daily for lipid-lowering, and valsartan/hydrochlorothiazide tablet (80 mg/12.5 mg) daily for antihypertension. The dual-antiplatelet therapy was effective, as thromboelas- tography (TEG) test after 12 days showed inhibition rate of arachidonic acid (AA) and adenosine diphosphate showed (ADP) of 90% and 54%, respectively.
On the operation day morning, her BP was 130/80 mmHg. The patient was treated by an experienced neurointerventionalist under general anesthesia. After
W. Jiang and Y.-Q. Zhang
37
intravenous bolus of 3000 U heparin, the stenosis was dilated by slowly inflation of a 2.0 mm × 15 mm Gateway balloon catheter (Boston Scientific, Fremont, CA), fol- lowed by implantation of a 4.5 mm × 22 mm Enterprise self-expanding stent (Codman Neurovascular, Raynham, Massachusetts). The stenosis rate was reduced to 10% from 80%, with TICI 3 blood flow, and no evidence of vessel injuries. CT immediately after stenting showed no ICH (Fig. 3.2).
Upon leaving operating room at 14:00, the patient was neurologically normal with NIHSS of 0 and BP of 123/56 mmHg. Her BP was ordered to be controlled at
Fig. 3.1 A harmful emergent recanalization for acute ischemic stroke. This is a 72-year-old right- handed female with history of atrial fibrillation who had an acute occlusion of left terminal ICA verified by catheter angiography (a). The occlusion was timely revascularized by mechanical thrombectomy at 6 h of stroke onset (b). Despite aggressive management of cerebral ischemia- reperfusion injury, the patient’s status deteriorated with sudden vomiting and slowness of pupillary light reflex at 3 h after recanalization, and the CT showed an early brain edema with sulci efface- ment in the left hemisphere (c). The edema developed with midline shift 10 h after recanalization (d), and finally resulted in the death. The hemisphere swelling was more likely to be vasogenic than cytotoxic, as the occlusive artery did not result in large infarct after early recanalization; and the edema peak time occurred within 24 h
3 Cerebral Ischemic Reperfusion Injury (CIRI) Cases
38
the level of 100–110/60–70 mmHg, about 80% of the baseline BP. Dalteparin sodium (a low-molecular-weight heparin, LMWH) 5000 IU per 12 h was subcutaneously injected. Dual-antiplatelet, lipid-lowering and antihypertension agents were continued. Edaravone (a free-radical scavenger) 30 mg was intrave- nously infused twice daily.
However, the patient complained of headache and nausea at 5:00 the next morn- ing (i.e. 15 h post procedure), with no vomiting or neurological deficit. Her BP was 110–130/70–85 mmHg during the night. Emergent CT showed a hematoma of 3.9 × 3.7 cm in the right temporal lobe with a “fluid level” of the superior hypo- density area (blood plasma) and the inferior hyper-density area (blood cells).
Pseudoaneurysm, hyperperfusion syndrome with hemorrhage, and overdose of anti- thrombotic agents were highly suspected. Antiplatelet and anticoagulation therapy was discontinued at once, and her BP was controlled at the level of about 100/60 mmHg. The hematoma was found to get enlarged to 4.6 × 4.5 cm on the fol- low-up CT at 15:30 (i.e. 25.5 h post procedure). After ruling out the pseudoaneurysm
Fig. 3.2 A delayed ICH after elective stenting of intracranial stenosis. This is a 60-year-old right- handed female with episodes of left-sided weakness during the past 4 months despite aspirin ther- apy. A severe stenosis at bifurcation of right MCA was detected on magnetic resonance angiography (a and b). The stenosis rate was 80% on catheter angiography (c), and was reduced to 10% after stenting (d), with no ICH on CT immediately after stenting. However, the patient complained of headache and nausea at 15 h after stenting. A hematoma of 3.9 × 3.7 cm in the right temporal lobe was revealed by CT, with a “fluid level” of the superior hypo-density area (blood plasma) and the inferior hyper-density area (f). CT after 25.5 h of stenting showed enlargement (4.6 × 4.5 cm) of the hematoma (g), and then, the hematoma was completely evacuated surgically in the evening (h), with no difficulty in hemostasis. The hematoma was possibly related to procedure-related pseudoa- neurysm, excessive antithrombotic therapy and cerebral hyperperfusion syndrome (CHS). The pseudoaneurysm was ruled out after catheter angiography. The excessive antithrombotic therapy was not supported by blood clotting tests with normal results, and no difficulty in hemostasis dur- ing surgery. So the CHS was most probably associated with the ICH
W. Jiang and Y.-Q. Zhang
39
by emergent catheter angiography, the hematoma was surgically evacuated in the evening, with no difficulty in hemostasis (Fig. 3.2), followed by disappearance of the symptoms. Blood clotting tests after surgery showed normal results: PT 10.9 s, APTT 28.9 s, TT 14.1 s, INR 0.96, Fib 2.57 g/l, and D-Dimer 1.9 mg/l. The patient was given clopidogrel 75 mg/day again the next day to prevent in-stent thrombosis. She discharged with no sequela 2 weeks later.