Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 59, Num. 3, 2011, pp. 401-404

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 401-404

Topic of the Issue: Case Report

Endovascular treatment for acute ischemic stroke using solitaire stent: Temporary endovascular bypass, a novel technique

Vikram Huded, KN Rajesh, S Netravathi, Rajesh Iyer

Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Bangalore, India

Correspondence Address: Vikram Huded, Department of Neurology, Narayana Hrudayalaya Institute of Neurosciences, Narayana Health City, Bangalore, India drvikramhuded@gmail.com

Date of Submission: 30-Jul-2010
Date of Decision: 31-Aug-2010
Date of Acceptance: 17-Jan-2011

Code Number: ni11117

PMID: 21743170

DOI: 10.4103/0028-3886.82750

Abstract

Keywords: Acute stroke, rtPA, solitaire

Introduction

Early restoration of flow to perfuse salvageable brain tissue has been shown to significantly reduce the morbidity and mortality of ischemic stroke. The recanalization rate of patients with carotid T occlusion even with intravenous (IV) thrombolysis is 10%; ^[1],[2] and with intraarterial (IA) thrombolysis, 33%. ^[3] Use of mechanical devices in acute stroke has shown promise in patients with large-vessel occlusion. The Merci mechanical clot retriever (Concentric Medical, Mountain View, California) and the Penumbra device (Penumbra, Inc., Alameda, California) are thrombectomy devices that have increased the ability to recanalize acute thromboembolic occlusion in patients with ischemic stroke. ^[4],[5] Self-expanding intracranial stents are being used for early restoration in large-vessel occlusive disease. The Solitaire revascularization device (ev3, Inc., Irvine, California) is a recoverable self-expanding thrombectomy device that can also be used as a temporary endovascular bypass. We report a patient in whom Solitaire Aneurysm Bridging (AB) stent was used as a temporary bypass procedure to recanalize carotid T occlusion patient.

Case Report

A 30-year-old woman, a known patient of rheumatic heart disease -mitral stenosis, presented with left-sided weakness of 3½ hours' duration. On examination, she was dysarthric, had right-sided gaze deviation and left-sided hemiplegia. National Institutes of Health Stroke Scale (NIHSS) score was 18. Cardiac examination revealed mitral stenosis with atrial fibrillation. Computed tomography (CT) brain scan with CT-angiogram of cerebral vasculature showed right carotid T occlusion without no signs of early infarct [Figure - 1]. She was taken for intra-arterial thrombolysis. Under general anesthesia, 6F guiding catheter was negotiated into the right internal carotid artery. She received 3000 U of heparin bolus. Angiogram showed carotid T occlusion [Figure - 2]. Microcatheter was then navigated into the thrombus distally into the middle cerebral artery (MCA) bifurcation. Using a microcatheter, recombinant tissue plasminogen activator (rtPA, 20 mg) was infused in a small dose in the distal internal carotid artery (ICA) and M1 segment of MCA. As recanalization could not be achieved, Solitaire self-expandable stent (4 × 20) was deployed into the terminal ICA and M1 segment; and with partial withdrawal into the rebar microcatheter, with aspiration on guiding catheter, the stent was retrieved. A part of the clot could be retrieved with the stent [Figure - 3]. Angiogram showed recanalization of distal ICA with opacification of A1 segment. Again solitaire was deployed in the right M1 segment [Figure - 4]. Angiogram showed recanalization of MCA with filling defects within the stent Ten milligrams of rtPA was injected slowly from the guiding catheter, and the Solitaire stent was retrieved. Post-thrombolysis angiogram showed complete recanalization [Figure - 5]. The total duration of the procedure was 90 minutes. Following the procedure, the patient was sedated and ventilated for 12 hours. The post-extubation clinical examination showed complete recovery. CT brain plain done 24 hours after the procedure did not show any reperfusion hemorrhag [Figure - 6].

Discussion

Management of acute ischemic stroke has always been a formidable challenge. Various treatment strategies available today lead to higher rates of recanalization. Mechanical revascularization with devices such as the Merci and Penumbra has improved recanalization rates to 70% to 80%, which is relatively superior to the 66% recanalization rate in the Prolyse in Acute Cerebral Thromboembolism (PROACT) II trial. ^[6] With the use of mechanical thrombectomy devise, recanalization rate has improved further but not 100%. This has prompted interest in stenting in patients with acute ischemic stroke. In a study by Caspar Brekenfeld et al., ^[7] tweleve patients were treated with intracranial stents (self-expandable stents) for acute ischemic stroke. Occlusions were located in the posterior vertebrobasilar circulation in six patients and in the anterior circulation in six patients. Stent placement was feasible with all the procedures and resulted in partial or complete recanalization (TIMI 2/3) in 92% of the patients. The main problems with self-expanding stents are the need for long-term antiplatelet therapy after stent placement and increase in the possibility of hemorrhage. The other issue with self-expandable stent is the high rate of recurrent stenosis, 25% to 29.7%. ^[8],[9] The Solitaire revascularization device (ev3, Inc., Irvine, California) is a retrievable self-expanding thrombectomy device. This can be used as a temporary endovascular bypass and clot retriever in acute stroke patients. Moreover, it can be electrolytically detached like a coil in case permanent stent placement is necessary, such as in the setting of an atherothrombotic lesion.

In a study by Castaño et al., ^[10] the recanalization rate with Solitaire was 90%, and sixteen patients showed immediate restoration of flow after stent deployment. No significant procedure-related events occurred. Symptomatic intracranial hemorrhage occured in 2 (10%) patients, and 45% of patients showed good functional outcome at 3 months (modified Rankin Scale score ≤2). In a study, Seifert et al. ^[11] have used Solitaire AB combined with local intra-arterial thrombolysis in the 'bridging technique' in four patients of acute ischemic stroke in the anterior and posterior circulation. They directly achieved after stenting an effective revascularization with reduced recanalization time. Stenting was found to be technically successful without complications in all the patients. In our patient, we used Solitaire because there was no recanalization even after using intra-arterial rtPA. We had to deploy the stent twice to reestablish the flow. After the first deployment and retrieval, a chunk of thrombus came out with the stent; and after the second deployment into M1, there was complete recanalization. So Solitaire stent is one of the modalities that can be used for flow restoration in acute ischemic stroke. SOLITAIRE™ FR with the Intention for Thrombectomy (SWIFT) study is in progress, the results of which may determine the efficacy of Solitaire compared to Merci device.

A retrievable, self-expanding stent, viz., "the Solitaire revascularization device," represents a novel interventional treatment option for acute stroke. The advantage of this device is flexibility; eliminating the need for aggressive antiplatelet therapy; avoiding risk of in-stent stenosis; and achieving faster recanalization. Further data are needed to assess the safety and efficacy of this device.

References

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