Endovascular recanalization for chronic symptomatic middle cerebral artery total occlusion
A 43-year-old male smoker with hypertension and hyperlipidemia presented with a 2-month history of recurrent transient ischemic attacks (TIA) of left-sided weakness. Brain MRI showed unremarkable right MCA territory. Angiogram demonstrated total occlusion of the right MCA M1 segment with Thrombolysis in Cerebral Ischemia (TICI) grade 0 (). Pial collaterals extending from the right anterior cerebral artery (ACA) () and posterior cerebral artery to the right MCA territory were evident. The risks and benefits of conservative medical treatment, extracranial to intracranial bypass and endovascular therapy were discussed with the patient and his families. In light of his recurrent symptoms despite medical therapy with antiplatelet agents, endovascular recanalization of the right MCA was planned. Under general anesthesia, the lesion was traversed with a coaxial assembly of Agility soft microguidewire (Cordis Endovascular, Miami Lakes, Florida, USA) and Prowler 14 microcatheter (Cordis Endovascular, Miami Lakes, Florida, USA) (). The microguidewire was then withdrawn, the patency of the lumen distal to the lesion confirmed through the microcatheter () and a Transcend microguidewire (Boston Scientific, Fremont, California, USA) was exchanged. The diameter of the proximal segment of the right MCA adjacent to the lesion was approximately 2.5 mm and lesion length was 6 mm by visual estimation, compared with the 6 French guide catheter (Boston Scientific, Natick, Massachusetts, USA). After withdrawing the microcatheter, a 2.5×8 mm Apollo balloon expandable stent (MicroPort Medical, Shanghai, China) was advanced over the microguidewire and deployed at the lesion. Subsequent angiogram demonstrated resolution of the occlusion and good antegrade perfusion to the right MCA territory (TICI grade 3) (). Postoperatively, blood pressure was maintained at 100–120/60–80 mm Hg to minimize the risk of reperfusion injury. The patient displayed no periprocedural neurological complications verified independently by a neurologist. At his 29-month follow-up, the patient remained asymptomatic on treatment with antiplatelet agent and risk factor control.\nA 66-year-old male smoker with diabetes mellitus and hypertension presented with a 2-month history of TIA of left-sided weakness, similar to case No 1. Brain MRI showed multiple small infarctions in the right MCA territory. Angiogram demonstrated total occlusion of the right MCA M1 segment with TICI grade 0, and 70% stenosis of the right ACA ostium (). Pial collaterals extending from the right ACA () and posterior cerebral artery contributed to the supply of the right MCA territory. Under general anesthesia, the lesion was traversed with an assembly of Agility soft microguidewire and Prowler 14 microcatheter, which was then exchanged with a Transcend microguidewire. The diameter of the C7 segment of the right internal carotid artery adjacent to the lesion was visually estimated to be 3 mm and lesion length 8 mm. The occlusion was predilated with a Maverick 2×9 mm balloon angioplasty (Boston Scientific, Natick, Massachusetts, USA) (), followed by deployment of a 2.5×9 mm Wingspan stent (Boston Scientific, Natick, Massachusetts, USA) covering the entire lesion site (). Subsequent angiogram demonstrated complete recanalization of the right MCA with good antegrade perfusion to the right MCA territory (TICI grade 3) (). No perioperative complications were observed. Twelve months later, there was recurrence of TIA of left-sided weakness while on medical treatment. After discussing with the patient and his relatives, repeat endovascular treatment was planned. An 80% in-stent restenosis () demonstrated on angiogram was successfully treated with Maverick 2×9mm balloon angioplasty without complications (). At his next 12-month follow-up, the patient remained asymptomatic on medical treatment.