J Korean Neurosurg Soc.  2020 Nov;63(6):717-722. 10.3340/jkns.2020.0053.

Endovascular Approach in Patients with Acute Complete Occlusion Due to Middle Cerebral Artery Dissection

• Park KH
• Kwak HS
• Park JS

• KMID: 2508601
• DOI: http://doi.org/10.3340/jkns.2020.0053

Abstract

Objective
: Dissection of the middle cerebral artery (MCA) is less common than dissection of vessels in the vertebrobasilar system or carotid artery. Acute complete occlusion related to MCA dissection is extremely rare. We report an endovascular approach in patients with acute complete occlusion due to MCA dissection.
Methods
: We reviewed retrospectively the endovascular procedure and clinical results for acute-stroke patients who underwent recanalization from October 2014 through December 2018. Initial imaging findings and the endovascular procedure were analyzed for patients with acute complete occlusion due to MCA dissection.
Results
: We undertook first-line aspiration thrombectomy using a Penumbra catheter in 294 patients with acute occlusion of the M1 segment. Of these patients, seven were confirmed to have acute complete occlusion due to MCA dissection. All patients had angiographic findings of an intimal flap at the proximal occlusion site of the MCA. One patient complained of severe headache during microcatheter passage through the occluded lesion and died due to massive bleeding caused by rupture of the false lumen. The remaining patients underwent initial contact aspiration thrombectomy without microcatheter passage. After aspiration thrombectomy, six patients had delayed flow through the MCA. One patient underwent stenting of the MCA because of progressive symptoms.
Conclusion
: An intimal flap at the proximal portion of an occluded MCA can suggest the possibility of MCA dissection. Contrast aspiration thrombectomy without microcatheter passage can reduce the risk of false lumen rupture in cases of MCA dissection.

Keyword

Stroke; Middle cerebral artery; Dissection; Thrombectomy

Figure

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  Fig. 1. A 48-year-old woman with complete occlusion of left M1. A : Left internal carotid angiogram showing complete obstruction of the left middle cerebral artery with focal intimal flap (arrow). B : Left internal carotid angiogram using microcather after patient reported severe headache during catheter passage through the obstructive lesion shows extension of the false lumen (arrows) and contrast stagnation (open arrow). C : Noncontrast computed tomography scan after interventional procedure showing massive subarachnoid hemorrhage with contrast extravasation caused by middle cerebral artery rupture.

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  Fig. 2. A : Middle cerebral dissection. B : False lumen location of microcatheter. C : Re-entry of false lumen into the middle cerebral artery. D : Rupture of middle cerebral artery due to microcatheter in the false lumen.

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  Fig. 3. A 45-year-old man with complete occlusion of left M1. A : Left internal carotid angiogram showing complete obstruction of the left middle cerebral artery with focal intimal flap (arrow). B : Left internal carotid angiogram after initial contrast aspiration thrombectomy using a Penumbra catheter showing a double lumen and intimal flap (arrows). The patient was discharged without neurological complications.

Reference

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