Occlusion of all aortic arch great vessels: acute revascularization to perform endovascular stroke therapy.
BACKGROUND
We present a case of a patient with a left-sided stroke and occlusion of all aortic arch great vessels who was treated successfully with endovascular intervention followed by delayed cardiothoracic revascularization.


METHODS
A 46-year-old man presented with acute onset of dense right hemiparesis, facial droop, and aphasia with an initial National Institute of Health Stroke Score of 15. The patient was taken for emergent angiography after failing intravenous tissue plasminogen activator thrombolysis. Dedicated angiography of the aortic arch revealed occlusion of all great vessels, including the right brachiocephalic, left common carotid, and left subclavian artery. Delayed arterial filling of the right brachiocephalic and left subclavian artery by aberrant collaterals was seen. More distally, flow into the bilateral subclavian arteries, right common carotid artery, and left vertebral artery was appreciated. Serial balloon angioplasty of the left common carotid artery origin reconstituted flow. Subsequent selective angiogram of the left internal carotid artery revealed a proximal middle cerebral artery occlusion. Intra-arterial injection of tissue plasminogen activator followed by mechanical thrombectomy and intracranial stenting restored flow in the middle cerebral artery. Two months later the patient underwent aortic arch reconstruction with bifurcated graft to the brachiocephalic artery and left common carotid artery. At 1-year follow-up, the patient's examination revealed almost complete resolution of right hemiparesis with minimal hand weakness and mild expressive aphasia.


CONCLUSIONS
We report a rare case of occlusion of all aortic arch great vessels. Combined endovascular intervention and surgical revascularization resulted in an excellent durable outcome.
Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA.
Grzegorz
G
Brzezicki
Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA.
Theofilos
T
Machinis
Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA. Electronic address: jreavey-cantwell@mcvh-vcu.edu.
John
J
Reavey-Cantwell
D001013:Aorta, Thoracic / Q000473:pathology* / Q000601:surgery*; D001157:Arterial Occlusive Diseases / Q000473:pathology* / Q000601:surgery*; D002548:Cerebral Revascularization / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D020521:Stroke / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
Angioplasty; Aortic arch reconstruction; Arterial occlusive disease; Intracranial stenting; Mechanical thrombolysis; Stroke