Stroke secondary to ICAD with acute stenting using stent through balloon technique

The patient was taken for neurointervention under general anaesthesia. US-guided right radial 6Fr access. Benchmark catheter to left ICA. Sofia 5Fr and Solitaire Platinum 6 x 40 mm yielded no clot and ICAD was suspected.

The stenosis was angioplastied with a Scepter C 4 x 10 mm balloon with good response. Intravenous aspirin (500 mg) was administered and an Atlas 4 x 30 mm stent deployed via the Scepter C balloon. This achieved excellent luminal restoration, however, a note was made of early platelet aggregation at the mid to distal Atlas. This was initially treated with intravenous abciximab (10 mg), however, progressive platelet aggregation and stenosis were observed. A further intra-arterial dose of abciximab (5 mg) was delivered and platelet aggregation reversed.

The operation was terminated. A nasogastric tube was placed immediately under general anesthesia and the patient was loaded with 15 mg of Prasugrel.

The patient’s NIHSS reduced to 1 the next day. Post-op day 1 CTA demonstrated a broadly patent target vessel with no perfusion abnormality on CTP. Dual anti-platelet therapy was continued at Aspirin 100 mg and Prasugrel 5 mg daily. The patient was discharged to home with no residual symptoms on post-operative day 4.

Figure 1. Time to peak maps from initial CTP

Figure 2: Initial DSA demonstrating focal, smooth stenosis of the superior division proximal M2

Figure 3: Scepter C 4 x 10 mm angioplasty demonstrating focal waisting of the balloon

Figure 4: Atlas 4 x 30 mm deployed demonstrating excellent luminal restoration and distal flow.

Figure 5: Focal platelet aggregation at the mid to distal Atlas. This was successfully treated with Abciximab.

Figure 6: Post-operative day 1 CTP (time to peak) demonstrating no residual perfusion abnormality.