Improved cerebral perfusion after stenting of a petrous carotid stenosis: technical case report.
OBJECTIVE
Atherosclerotic occlusive disease of the intracranial vasculature is associated with increased risk of systemic vascular occlusive disease and stroke. Therapeutic options have included anticoagulation therapy, antiplatelet therapy, or, in a limited number of patients, extracranial-intracranial vascular bypass procedures. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after endovascular stenting of a severe petrous segment carotid stenosis.


METHODS
A 73-year-old man with severe coronary artery disease and unstable angina was referred for treatment of a 90% right petrous carotid artery stenosis before coronary artery bypass grafting. A brain single-photon emission computed tomographic scan using 99mTc-bicisate revealed diminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones.


METHODS
The patient underwent transfemoral placement of a 7-French introducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No changes were noted in lesion morphology after this infusion. A microguidewire was navigated across the lesion. Subsequent balloon angioplasty with a coronary artery balloon was performed twice, followed by placement of a 4- x 12-mm coronary stent.


CONCLUSIONS
Selective internal carotid artery angiography after stenting revealed markedly improved flow. A brain 99mTc-bicisate single-photon emission computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were noted; both were clinically silent. The patient had uncomplicated coronary artery bypass grafting 72 hours later. Five months postoperatively, he remains at home, living independently and with intact neurological function. Intracranial stenting for severe atherosclerotic stenosis is technically possible. However, its ultimate clinical role remains to be determined.
Fessler
R D
RD
Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 14209-1194, USA.
Lanzino
G
G
Guterman
L R
LR
Miletich
R S
RS
Lopes
D K
DK
Hopkins
L N
LN
D000368:Aged; D000789:Angina, Unstable; D000800:Angioplasty, Balloon; D001921:Brain / Q000098:blood supply / Q000000981:diagnostic imaging*; D017536:Carotid Artery, Common / Q000000981:diagnostic imaging; D016893:Carotid Stenosis / Q000601:surgery*; D002533:Cerebral Angiography; D002560:Cerebrovascular Circulation; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000601:surgery; D003545:Cysteine / Q000031:analogs & derivatives; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D015609:Organotechnetium Compounds; D019275:Radiopharmaceuticals; D015607:Stents; D015899:Tomography, Emission-Computed, Single-Photon; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D015609:Organotechnetium Compounds; D019275:Radiopharmaceuticals; D014568:Urokinase-Type Plasminogen Activator; C059659:technetium Tc 99m bicisate; D003545:Cysteine