INTERVENTIONAL NEURORADIOLOGY
24/7Contact&Appointment(310)267-8761or8762
Patient with right sided weakness and aphasia
DIVISIONOFINTERVENTIONALNEURORADIOLOGY
Presentsapatientcasetreatedbytheteammembersofthedivision
andphysiciansandstaffoftheUCLAComprehensiveStrokeCenter
GARYDUCKWILER,MDDirectorandProfessor
FERNANDOVINUELA,MD
ProfessorEmeritus
REZAJAHAN,MDProfessor
SATOSHITATESHIMA,MD,DMSc
AssociateProfessor
NESTORGONZALEZ,MDAssociateProfessor
VIKTORSZEDER,MD,PhD
AssistantProfessor
PATIENTPRESENTATION
Figure1:Non-contrastCTscanofthehead(A)showsnobleedingandnosignificanthypodenstiyinthelefthemisphere.CTangiogramstudyofthebrain(B)showsleftMCAocclusion(arrow).
• 85yearoldfemalewithhistoryofatrialfibrillationbroughtinbyambulanceafterbeingfoundsittingslumpedindriver'sseatofcarfor1.5hours.Onevaluation,thepatienthadrightsidedweakness,mutismandvisualdisturbance.TheNIHSS*was17onarrivalintheemergencyroom.ThepatientisurgentlytakentoCTscannerforfurtherevaluation.
*NationalInstituteofHealthStrokeScale
EVALUATIONANDIMAGING
• Non-contrastheadCTandCTangiogram(CTA)(Figure1),CTperfusion(CTP)(Figure2)shownosignificanthypodensitywithMCA*proximalocclusionandwithperfusionshowingalargevolume(58ml)ofatrisktissue.
*MiddleCerebralArtery
INTERVENTIONPERFORMED
• Giventhelargevolumeoftissueatrisk,interventionwasdeemedwarranted.Angiogramoftheleftinternalcarotidartery(ICA)confirmedmiddlecerebralartery(MCA)occlusion(Figure3).TheSolitaireFlowRestorationdevice(Figure4)wasdeployedintheleftMCAforclotretrieval.
Figure2:CTperfusionstudyevaluatedwithautomatedsoftwareshowsinjuredbraintissuevolumeoflessthan1mlwithatrisktissuevolumeof58ml.
(over)
A
B
INTERVENTIONAL NEURORADIOLOGY
24/7Contact&Appointment(310)267-8761or8762
ProceduresprovidedbyDINRforadultandpediatricpatients
AcuteIschemicStroke
AcuteThrombectomy/ThrombolysisExtra/IntracranialAngioplasty/Stenting
BrainHemorrhage,Aneurysm/AVM/fistulae
AneurysmcoilingStent/balloonassistedaneurysmcoilingFlowdiverterstentdeviceembolization
AVM/DuralfistulaeembolizationVenousSinusThrombectomy/Thrombolysis
Directtranscutaneousembolization
ChronicOcclusiveCerebrovascularDiseaseExtra/IntracranialAngioplasty/Stenting
VenousSinusAngioplasty/Stenting
Head/neck/orbittumors&vascularmalformations,epistaxis
EndovascularembolizationDirectpercutaneousembolization
DivisionofInterventionalNeuroradiologyDavidGeffenSchoolofMedicineatUCLARonaldReaganUCLAMedicalCenter757WestwoodPlaza,Suite2129LosAngeles,CA90095-7437http://radiology.ucla.edu/site.cfm?id=217
DivisionofInterventionalNeuroradiology–ALeaderinNeurovascularCareandResearch• InventedtheMerciretriever–the1stendovascular
deviceforacutestroketherapy• InventedGDCandMatrixcoils–theleadingtoolfor
aneurysmtreatmentaroundtheworld• DevelopedOnyxliquidembolicmaterial–theleading
therapyforbrainvascularmalformations
Figure3:Anteroposteriorviewofleftinternalcarotidarteryangiogram(A)showsocclusionoftheleftproximalMCA(arrow).FollowingdeploymentoftheSolitaireFlowRestorationdevice,clotisretrievedandpostretrievalangiogram(B)showscompleterecanalizationoftheMCA.
PATIENTOUTCOME
• NeurologicexaminationthefollowingdaywasbacktobaselinewiththeNIHSS=0.Thepatientwasdischargedhomeafter4daysofhospitalization.
INTERVENTIONPERFORMED(CONTINUED)
• PostretrievalangiogramoftheleftICAshowscompleterecanalizationoftheMCAvessels(Figure3B).Thetimeintervalfromarrivalintheemergencyroomtorecanalizationwas100min.
Figure4:SolitaireFlowRestorationDevice.
BA
DISCUSSION
In2015,fiverandomizedtrialsshowedefficacyofendovascularthrombectomyoverstandardmedicalcareinpatientswithacuteischemicstrokecausedbyocclusionofarteriesoftheproximalanteriorcirculation.Furthermore,pooledanalysisofthefivetrialsshowedthatendovascularthrombectomymorethandoublestheoddsofanindependentoutcomecomparedwithbestmedicaltherapyaloneinthispatientpopulation.TheAmericanHeartAssociationguidelinesnowrecommendendovasculartherapyforselectedpatientswithacuteischemicstroke*.Timetotreatmentiscriticalandasisoftensaid“timeisbrain.”Multiplestudieshaveshownacorrelationbetweenearlyrecanalizationandfunctionalindependence.Establishingtargettimeintervalsisparamountasitcanleadtoimprovedoutcomesinischemicstrokepatientsasitalreadyhasinpatientsundergoingpercutaneouscoronaryinterventionaftermyocardialinfarction.Currentsocietalrecommendationsarepatientarrivalathospitaltorecanalizationtimelessthan90minutes**.*Stroke.2015;46:3020-3035PublishedonlinebeforeprintJune29,2015,**JNeurointervSurg.2015Aug31.pii:neurintsurg-2015-011984.doi:10.1136/neurintsurg-2015-011984.[Epubaheadofprint]
