Watershed subarachnoid hemorrhage after middle cerebral artery rescue stenting in patients with acute ischemic stroke

Francesco Diana,Giulia Frauenfelder,Maria Di Gregorio,Renato Saponiero,Daniele Giuseppe Romano

doi:10.1007/s00234-021-02692-0

Abstract

Cortical subarachnoid hemorrhage is an infrequent subtype of non-aneurysmal subarachnoid hemorrhage, rarely reported in watershed territories (wSAH) after carotid stenting. It has never been reported after treatment of middle cerebral artery stenosis (MCAS) that is increasingly used in selected patients, as rescue treatment of failed mechanical thrombectomy, due to recent advancements in endovascular interventions. We present a series of patients with MCAS that developed a wSAH after stenting.

Highlights

Cortical subarachnoid hemorrhage is an infrequent subtype of non-aneurysmal SAH localized in one or a small number of brain cortex sulcus, without spreading into the bas- CasesBetween January and November 2020 we performed 10 stenting in patients with AIS due to intracranial atherosclerotic disease: four patients with vertebra-basilar stenosis and six patients with middle cerebral artery stenosis (MCAS)
We present a series of cases developing a wSAH after intracranial stenting of MCAS
Collateral flow from the anterior cerebral artery (ACA) to MCA territories, which had been present at the time of occlusion, disappeared, but leptomeningeal arteries (LMAs) of watershed territories were still dilated

Summary

Introduction

Cortical subarachnoid hemorrhage (cSAH) is an infrequent subtype of non-aneurysmal SAH localized in one or a small number of brain cortex sulcus, without spreading into the bas-. Between January and November 2020 we performed 10 stenting in patients with AIS due to intracranial atherosclerotic disease: four patients with vertebra-basilar stenosis and six patients with MCAS. 2 female and 2 male with a mean age of 70 years (range, 53–85 years), developed a wSAH after treatment, all of them with MCAS. All patients had an ASPECT score > 6 and presented with a mean NIHSS of 9 (range, 5–16). At the CT-angiography (CTA), the MCA was occluded 2 patients, and sub-occluded in the others. MCA stenting was a rescue therapy in three cases and the first-line therapy in the other one (case 3)

F 79 No No

Discussion

Conclusion