Middle cerebral artery thrombolysis through the contralateral internal carotid artery--case report.
ABSTRACT A 63-year-old male presented with sudden onset of right hemiplegia and global aphasia. On admission he was stuporous. Computed tomography (CT) revealed no abnormalities except for right intraventricular meningioma found incidentally. Emergency angiography confirmed complete occlusion of the left internal carotid artery (ICA) and left M1 trunk whereas the left ICA bifurcation remained patent. The ipsilateral ICA was permanently occluded with two detachable balloons to prevent thrombus migration into the distal ICA and middle cerebral artery (MCA), followed by thrombolysis of the clot in the ipsilateral M1 through the contralateral ICA with urokinase (total dose 420,000 U) under systemic heparinization. Partial recanalization of the ipsilateral MCA was accomplished. The time interval from onset to recanalization was about 3 hours. Postoperative CT showed no hemorrhagic transformation. Slight right paresis and mild motor aphasia persisted 2 months later and he was transferred to a rehabilitation facility. Thrombolysis of the MCA embolism can be performed through the contralateral ICA in the presence of ipsilateral ICA occlusion.
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ABSTRACT: Tandem occlusion of the arteries at the extracranial and intracranial segments is a unique cause of ischemic stroke and is often associated with a poor prognosis. Although tandem occlusion is occasionally found during intra-arterial thrombolysis (IAT), as of yet no clear therapeutic strategy has been elucidated. After identifying distal intradural (DIL) and proximal extradural lesions (PEL) as well as the collateral state and clot burden, IAT was performed primarily targeting DIL by navigation of the microcatheter through the PEL or a collateral pathway. Among 147 consecutive patients who were treated with IAT for hyperacute ischemic stroke, 13 (11.4%) were identified to have tandem occlusion as the cause of stroke. Navigation of a microcatheter through occluded PEL (internal carotid artery/vertebral artery) or a collateral pathway (anterior communicating artery) to the DIL was successful in 9 patients. Of them, recanalization of the DIL could be achieved in 8 (89%). The overall recanalization rate among all patients with tandem occlusion was (62%, 8/13). A good functional outcome (modified Rankin score <or=2) at 3 months was noted in 6 patients (46.2%). Tandem occlusion may be successfully managed by strategic thrombolysis of the DIL as the primary therapeutic target for IAT. By this strategy, the ischemic brain could be effectively and rapidly perfused.Cerebrovascular Diseases 01/2008; 26(2):184-9. DOI:10.1159/000145326 · 3.70 Impact Factor
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ABSTRACT: This article is an account of a patient with nonconvulsive status epilepticus associated with an unusual EEG. The importance of recording speed in lateralizing the hemisphere of onset of epilepsy is emphasized, on the basis of one-way callosal traffic theory. From this vantage point, the following were deemed responsible for the currently divergent views on the lateralizing significance of various signs and symptoms in epilepsy: (1) the dichotomous nature of laterality of motor control, which is the same as that of seizure onset; (2) the probabilistic nature of the availability of the callosal channel for transfer of epileptiform discharges from the major to the minor hemisphere (i.e., the random variability of synaptic transfer); (3) the dynamic (varying) expanse of the epileptic region within the major hemisphere. Other data reviewed indicated that measuring the reaction time of two symmetrically located effectors is the most robust way of determining the laterality of the major hemisphere, with the side of shorter reaction time being opposite to the major hemisphere. Clinical presentations of seizures reflect the probabilistic involvement of different regions of the major hemisphere by the epileptic process and the spread of the epilepsy to the minor hemisphere via the callosum. Termination of seizure activity with diazepam was associated with simultaneous recovery of awareness and speech in this case.Epilepsy & Behavior 09/2006; 9(1):204-10. DOI:10.1016/j.yebeh.2006.05.005 · 2.06 Impact Factor