Purpose: We report two cases of acute ischemic stroke patients treated by additional thrombectomy using a basket-shaped microsnare (Soutenir) after infusion of intravenous recombinant tissue plasminogen activator (rtPA). Successful recanalization and good prognosis were achieved in both cases. Case 1: A 67-year-old man presented with left hemiplegia and agnosia. After completion of the intravenous rtPA infusion, he continued to show severe neurological deficit. Angiography revealed occlusion of the posterior trunk and a branch of the anterior trunk of the right middle cerebral artery (MCA). The two occluded arteries were successfully recanalized by removing the clot with Soutenir, resulting in neurological improvement. Case 2: A 49-year-old man presented with right hemiplegia and aphasia. After completion of the intravenous rtPA infusion, he continued to show severe neurological deficit. Angiography revealed occlusion of the left MCA at the proximal M1 segment. The occluded artery was successfully recanalized by removing the clot in the manner described above, resulting in neurological improvement. Conclusion: To our knowledge, this is the first report describing patients treated by additional thrombectomy using a Soutenir after failed intravenous infusion of rtPA. This procedure is a therapeutic option for selected acute ischemic stroke patients who are unresponsive to intravenous rtPA.
Objective: There have been few reports on the association of large or giant aneurysms with congenital absence or hypoplasia of the internal carotid artery (ICA). We present a case of a giant anterior communicating artery aneurysm associated with hypoplasia of the unilateral ICA with secondary occlusion. Case presentation: A 62-year-old man was diagnosed with a giant anterior communicating artery aneurysm (10×12×28 mm) associated with hypoplasia of the unilateral ICA. A left common carotid angiogram revealed occlusion of the cervical portion of the left ICA. A right internal carotid arteriogram showed the aneurysm. Both the left anterior cerebral artery and left middle cerebral artery were filled from the right ICA via the anterior communicating artery. Due to the complicated morphology and calcified wall of the aneurysm, we performed endovascular treatment using a combination of 18- and 10-series microcatheters to make separate coil frames in the aneurysmal sac. Twenty-seven Guglielmi detachable coils with a total length of 419cm were placed in the aneurysm, which resulted in satisfactory occlusion. The patient was discharged without complications, and there was no evidence of aneurysmal recurrence for three years. Conclusion: Large or giant aneurysms associated with congenital absence or hypoplasia of the ICA are rare. In their treatment them, it is important to avoid a decrease in collateral blood flow. The endovascular procedure is a reasonable therapeutic option.
Objective: Unraveled coils can be removed during cerebral aneurysm embolization. However, if the unraveled coil is engaged with other indwelling coils, its retrieval is sometimes difficult. We report 2 patients in whom unraveled coils were irretrievable, and were left in the vascular lumen between the aneurysm and the puncture site, rather than being forcibly retrieved. Methods: We stretched the unraveled coil as much as possible in the parent artery, and withdrew the catheters. The unraveled coil remained in the vascular lumen between the aneurysm and the puncture site. The tail of the unraveled coil was cut and, making a small incision at the puncture site, the remaining part was buried with ligation in the subcutaneous tissue. Systemic heparinization and antiplatelet therapy were performed after the procedure. Results: Neither patient experienced complications attributable to the unraveled coil in the vascular lumen. Coil compaction occurred in one patient who underwent further coil embolization. The residual unraveled coil was not affected by the procedure and remained stable in the vascular lumen. Conclusion: We consider that leaving the unraveled coils in the vascular lumen is an acceptable alternative to forcible retrieval.