Fig. 2 A, noncontrast head CT without identification of early Ischemic changes. B-D, CT head perfusion images demonstrate decreased cerebral blood flow (CBF), increased mean transit time (MTT), and relative preserved cerebral blood volume (CBV; arrows).

A 66-year-old woman presented to the ED with speech difficulty and left lower Extremity weakness. The patient had gone to bed the previous night and awoke with the symptoms. A noncontrast computed tomography (CT) was unremarkable. A CT head angiogram revealed focal narrowing of the distal right M1 middle cerebral arterial trunk. A CT perfusion examination revealed vulnerable brain tissue, decreased cerebral blood flow, increased mean transit time, and relative preserved cerebral blood volume within the right Middle cerebral artery (MCA) vascular territory relative to the contralateral side (Fig. 2A-D). The patient’s NIH stroke scale score progressed from 2 initially to 13. Heparin infusion was commenced with no improvement in symptoms.

Digital subtraction angiography of the right anterior circulation revealed abrupt truncation of the right M1 middle cerebral arterial trunk and delayed filling of right M2/M3 middle cerebral arterial branch vessels (Fig. 3A, B). Intra-arterial tissue plasminogen activator (2 mg) was administered. Digital subtraction angiography thereafter revealed critical focal distal narrowing of the right MCA. A 2.5 x 8-mm minivision balloon-mounted stent was

implanted across the stenosis. Complete recanalization of the right M1 MCA was achieved (Fig. 4A-C). The patient was transferred to skilled nursing care after 4 days with an NIH stroke scale of 4 and was discharged home after 11 days.

The natural history of symptomatic intracranial athero- sclerotic disease is dismal, with a median time of recurrent TIA, stroke, or death within 36 days and a failure rate of 50% for medical therapy [7]. The incidence of patients presenting emergently with acute profound progressive neurologic deficits consequent to critical intracranial steno-occlusive disease without prior TIA symptoms is not known. In this subset of patients, when refractory to emergent medical therapy, urgent mechanical vessel revascularization is the only option for brain tissue salvage.

Stent angioplasty for symptomatic atherosclerotic disease is primarily preventative against recurrence or anticipated Ischemic events and is performed electively [8,9]. Gupta et al

[10] reported on urgent revascularization of flow-limiting symptomatic intracranial atherosclerotic disease. In their study, stent implantation was not primarily performed and was used only after flow-limiting dissection or residual

Fig. 3 A, Digital subtraction angiography right internal carotid injection demonstrating critical stenosis of the right M1 MCA. B, Delayed opacification of distal right MCA vascularity.

Fig. 4 A, Digital subtraction angiography right internal carotid injection showing improvED flow within distal right MCA vascularity, with identification of a focal critical stenosis after intra-arterial tissue plasminogen activator (arrow). B, Balloon-mounted stent implantation at the site of critical narrowing (arrow). C, Complete revascularization of right M1 MCA trunk and distal branch vascularity.

narrowing after angioplasty was identified. Angioplasty alone is limited by the potential for acute occlusion consequent to vessel recoil and vessel dissection. Urgent primary stent angioplasty revascularization for acute clini- cally progressive intracranial atheromatous lesions has, to our knowledge, not been previously reported.

Consideration of acute atheromatous flow-limiting intra- cranial lesions as a diagnostic alternative to acute thrombotic/ embolic occlusion for a patient with acute neurologic deficits is critical in determining appropriate management. The differentiation is not always clinically apparent. Catheter angiography remains the criterion standard for more specific characterization of atheromatous lesions and for providing valuable information about flow characteristics to the affected vascular territory. Early recognition of an ather- osteno-occlusive lesion vs thrombotic/embolic occlusions may allow the waiving of tissue plasminogen activator administration and or utilization of the Merci device or other acute thrombectomy mechanical restoration techniques, in favor of acute stent angioplasty. At centers lacking a neurointerventionalist, early recognition of symptomatic intracranial atheromatous lesions may expedite appropriate early transfers to institutions that are capable of performing such procedures.

Further investigation and validity of stent implantation in the context of acute atheromatous intracranial disease is needed. The 2 cases presented, however, allude to potential benefit if used in the context of rapidly declining neurologic status.

Ajeet Gordhan MD

Bloomington radiology department of Neurointerventional radiology

St Joseph Medical Center Bloomington, IL 61704, USA

E-mail address: [email protected]

Rich Castillo MD Department of Emergency Medicine St Joseph Medical Center Bloomington, IL 61704, USA

William Reino MD Department of Neurology St Joseph Medical Center

Bloomington, IL 61704, USA

Jaydev Jani MD Department of Internal Medicine St Joseph Medical Center Bloomington, IL 61704, USA

doi:10.1016/j.ajem.2010.08.025

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