Buying Time for Recanalization in Acute Stroke: Arterial Blood Infusion Beyond the Occluding Clot as a Neuroprotective Strategy

Abstract

Acute ischemic stroke treatment is meant to induce early reperfusion before ischemic lesion becomes definitive; unfortunately, in many cases, recanalization occurs too late. We present a case in which oxygenated blood was perfused through the occluding clot during intra-arterial (IA) thrombolysis to anticipate reperfusion. A 63-year-old woman was admitted 1 hour after acute left-sided hemiplegia National Institutes of Health Stroke Scale (NIHSS 18). Transcranial Doppler (TCD) showed proximal right middle cerebral artery (MCA) occlusion. Systemic thrombolysis failed to recanalize MCA, so IA rescue was initiated. During the procedure, TCD recorded flow in MCA. A microcatheter was passed through the clot and 20 mL of oxygenated blood was injected over 2 minutes beyond occlusion. During blood perfusion, TCD detected nonpulsating flow in distal M2 branches. Then, tissue plasminogen activator (t-PA) was injected directly intrathrombus; mechanic fragmentation was also attempted. No recanalization was observed, however, neurological status partially improved. The process was repeated until 6 hours after symptom onset. Only partial Thrombolysis in Cerebral Ischemia (TICI-2a) recanalization was achieved, but physical examination revealed substantial improvement: NIHSS score of 11. Repeated TCD showed partial recanalization (9 hours) and complete recanalization (12 hours). At 24 hours, NIHSS score was 1. Momentary reperfusion of ischemic penumbra with oxygenated blood is feasible and may allow to "buy time" until definitive reperfusion is achieved.