Angioplasty and Stenting of the Intracerebral Circulation

Abstract

A 44-yr-old, right-hand–dominant man was found by his spouse in the early morning in an unresponsive state. During urgent transfer to a hospital emergency room, he was described as being lethargic, vomiting, and occasionally nodding his head. His pupils were at 2 mm and dysconjugate gaze was noted. Questionable right-sided weakness was observed. The patient was immediately intubated and administered ventilatory support. A brain computerized tomography scan raised the question of a basilar artery thrombosis. A neurologic consultation concluded that his clinical situation was grave, likely to decline, and possibly develop into a “locked-in” state. Interventional neuroradiologic consultation was therefore immediately obtained. Angiography revealed that the patient had a complete basilar artery obstruction (Fig. 1), and therefore, a balloon angioplasty with thrombolysis (injection of urokinase) was performed with underlying stenosis noted. An 8-mm-long stainless steel coronary stent was then inserted into the basilar artery. Excellent restoration of blood flow was achieved (Fig. 2). This entire procedure was performed within 3 hrs of the patient’s initial arrival in the emergency room. He tolerated the procedure well, with no further decline in neurologic status. In fact, he began to rapidly improve such that 4 days after admission, he was weaned from the ventilator and able to be extubated. Nutritionally, he was supported with nasogastric tube feeds. A modified barium swallow revealed severe oropharyngeal dysphagia with aspiration and an inability to protect his airway. Hence, 14 days after his emergency admission, an upper endoscopy with percutaneous endoscopic gastrostomy was performed.Figure 1:: Preangioplasty view of the posterior circulation, with complete obstruction of the basilar artery.Figure 2:: Postangioplasty view showing thrombolysis and stenting with dramatic improvement of posterior circulation blood flow.Several days after this procedure, this patient was admitted to the acute hospital’s rehabilitation unit where he remained for approximately 3 wks. At admission, he was found to have just barely antigravity strength in his right upper and lower limbs, with poor dynamic balance and slurred speech. During his rehabilitation stay, he regained motor strength to near normal bilaterally and made significant gains in balance such that by the time of discharge from the rehabilitation unit, he was able to ambulate 600 feet using a rolling walker with only standby assistance. His swallowing ability continued to improve, and after 2 wks on the rehabilitation unit, he was started on a pureed diet, which was advanced to a mechanical soft diet with strict aspiration precautions. At follow-up outpatient examination several weeks later, this gentleman was now completely safe in ambulation, with no assistive device. He was also independent in all activities of daily living. He could safely climb the one flight of steps (using a hand rail) to his second-floor apartment. A repeat modified barium swallow revealed moderate pharyngeal dysphagia with a delay of swallowing and minimal penetration of thin liquids. It was recommended that he continue a mechanical soft diet with strict aspiration precautions. Although successful angioplasty of the basilar artery was first reported over two decades ago, angioplasty and stenting of the intracranial circulation does not at present have dedicated approval from the Food and Drug Administration, and therefore, this experimental procedure is performed for “humanitarian reasons.”1–4 Increasingly in recent years, flexible cardiac stents have been used postangioplasty in an attempt to reduce vessel recoil and re-stenosis. As there are no absolute indications for its performance, intracerebral angioplasty and stenting of the posterior circulation usually follows a reasoned judgment by the attending physicians that without this procedure the patient is likely to die or significantly deteriorate. On a nonacute basis, recurrent ischemic symptoms, despite medical treatment (e.g., antiplatelet or anticoagulant therapy), could also be considered an indication for this treatment.