PMC4896173_01
84-year-old man with stroke. CT scan shows hyperdense basilar artery due to thrombosis (arrow).
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The basilar artery did appear hyperdense (Figure 1).
84-year-old man with stroke. Arrow indicates area of delayed time to peak color-coded red involving the pons.
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CT perfusion study was hampered by patient motion but did demonstrate delayed time to peak in the posterior cerebral artery territory (Figure 2).
84-year-old man with stroke. Arrows outline proximal and distal ends of the basilar artery clot.
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CT angiogram demonstrated a 1.7 cm segment of unopacified basilar artery indicating the presence of thrombus (Figure 3).
84-year-old man with stroke. (A) Diagnostic catheter angiogram. Arrow indicates proximal aspect of basilar artery clot as seen on left vertebral artery injection from catheter angiogram. Obstruction by clot is complete. (B) After intra-arterial TPA, there is partial recanalization of the basilar artery disclosing an underlying critical stenosis of the basilar artery (long arrow) and residual thrombus (arrowhead). The tip of the microcatheter is labeled with the short arrow.. 84-year-old man with stroke. (C) Re-thrombosis of the basilar artery after repeat angiography 5 minutes later. (D) Re-establishment of flow after balloon angioplasty and an additional 2 mg of TPA into the clot.. 84-year-old man with stroke. (E) AP and (F) lateral view after angioplasty with significant residual stenosis. (G) AP and lateral (H) views after placement of a Wingspan stent. Arrows indicate position of proximal and distal stent markers.
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At 3 hours and 45 minutes post onset, diagnostic catheter angiogram confirmed the presence of a basilar thrombosis (Figure 4A). After receiving 4 mg of TPA (2 mg into the clot and 2 mg distal to the clot) the basilar artery was completely recanalized with no evidence of distal embolization (Figure 4B). Within 5 minutes, the basilar artery spontaneously rethrombosed (Figure 4C). TPA was infused into the clot and balloon angioplasty with a 2.5 x 15 mm semi-compliant balloon (Gateway Balloon, Boston Scientific Corporation, Natick, MA) was performed. This resulted in complete persistent recanalization of the basilar artery at 5 hours and 49 minutes after his initial stroke symptoms (Figure 4D). However, there was felt to be a residual 80% stenosis of the basilar artery (Figures 4E and F). The final angiogram demonstrated approximately 30% residual stenosis (Figure 4 G and H).
84-year-old man with stroke. Post-thrombolysis MRI. Small diffusion defects right thalamus (A) and pons (B)
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Magnetic resonance imaging (MRI) demonstrated small areas of diffusion restriction in the mid-pons and medial right thalamus (Figure 5).