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Published in July 13, 2023
Angioplasty and Stenting of an MCA Stenosis
Xiaolong Zhang

Case Review


History


• 68-year-old female 

• CC: left limb weakness for 1 year which worsened over the past 1 month. 
• The patient suffered from sudden onset of left limb deficiency, unconsciousness and right gaze on March 29, 2020. CTA confirmed a right MCA occlusion and CT revealed a right basilar ganglia region infarction. Thrombolysis could not be performed outside the therapeutic window, while endovascular therapy is not indicated for a large-area infarction. On May 9, 2021, the symptoms aggravated with slurred speech. Balloon angioplasty was performed in local hospital. However, the symptoms persisted.
• Medical history：Inferior vena cava filter was performed on April 8, 2020. Balloon angioplasty was performed in May 2021. Two seizures occurred, when the patient failed to take sodium valproate.
• Medication: rivaroxaban 20mg qd; clopidogrel 75mg qd; atorvastatin 20mg qn.
• PE: muscle strength of left upper limb 0, left lower limb III, along with slurred speech.



Figure 1. CT taken on 2021/05/10 shows right frontal and temporal lobe chronic infarctions. No evidence of right MCA calcification.



Figure 2. The right MCA severe stenosis was dilated by balloon.But one-month follow up CTA shows severe re-stenosis of the right MCA. 



Figure 3 GIF. Multiple arteriosclerotic stenosis of bilateral PCAs. Pial collateral compensation from right PCA are noted. 


Figure 4. A small carotid-ophthalmic aneurysm was found incidentally. 


1

Strategy


• The symptoms were caused by severe right MCA stenosis. Although balloon angioplasty was performed, CTA revealed re-stenosis occurred. Furthermore, the symptoms persisted and worsened, therefore stenting has become necessary.

• Post-operative blood spanssure control can avoid hyperperfusion syndrome or hemorrhage of the chronic infarction area.
• The small ophthalmic aneurysm only needs follow up due to its low rupture risk.

2

Operation



Figure 5. A proper working projection was selected to avoid any skeletal artifact and reveal the right MCA clearly. 



Video 1. General heparinization. Gateway 1.5*15mm balloon was navigated to the stenotic segment guided by Floppy-300 microwire. The vessels shifted when the microcatheter crossed the MCA. 



Figure 6 GIF. The stenosis was dilated by balloon under 7 ATM for 60s. Nimodipine 1ml was administrated after balloon angioplasty. 



Video 2. Wingspan 2.5*15mm was deployed covering the stenosis. 



Video 3. The delivery system became entangled with the distal end of the stent requiring repeated  adjustment of the microwire. 



Figure 7 GIF. Angiography shows the revascularization of the stenosis. 



Figure 8. The watershed line migrated after the operation indicating increased flow in the right MCA territory. 



Figure 9. However, compared to the span-angioplasty angiography, the inferior trunk occlusion is noted in the post-angioplasty angiography, which could be due to plaque dislogement after stenting. 



Figure 10 GIF. Pial collateral compensation to the region of occluded inferior MCA branch is noted. 



Figure 11. The territory of the occluded MCA branch decreased after operation. 



Figure 12. Posterior circulation compensates the region of the occluded MCA branch. 


Figure 13 GIF. Dyna CT showed no hemorrhage. Nimodipine 1ml and Tirofiban 6ml were given via the guiding catheter. 

3

Post-operation



Figure 14. Three-day post-operative MRI DWI shows no acute infarction. 


4

Summary


• CTP is unnecessary for the large area chronic infarction; while endovascular therapy spansents a high risk of hemorrhage. After balloon angioplasty was performed, CTA revealed re-stenosis. Furthermore, the symptoms continued and worsened, therefore stenting is necessary.

• Post-operative blood spanssure control can avoid hyper-perfusion or hemorrhage.
• The small ophthalmic aneurysm only requires follow up due to its low rupture risk.
• The vessels shifted when the microcatheter crossed the MCA, indicating the vessels were fragile.
• The delivery system of the wingspan stent became entangled with the distal end of the stent  requiring repeated adjustment of the microwire.
• The occluded MCA branch was compensated by the pia artery of the posterior cerebral artery. No acute infarction was found in the MR.
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