INTERVENTIONAL NEURORADIOLOGY 24/7 Contact & Appointment€¦ · INTERVENTIONAL NEURORADIOLOGY 1.5...
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INTERVENTIONAL NEURORADIOLOGY 24/7 Contact & Appointment (310) 267-8761 or 8762 Patient with right sided weakness and aphasia DIVISION OF INTERVENTIONAL NEURORADIOLOGY Presents a patient case treated by the team members of the division and physicians and staff of the UCLA Comprehensive Stroke Center GARY DUCKWILER, MD Director and Professor FERNANDO VINUELA, MD Professor Emeritus REZA JAHAN, MD Professor SATOSHI TATESHIMA, MD, DMSc Associate Professor NESTOR GONZALEZ, MD Associate Professor VIKTOR SZEDER, MD, PhD Assistant Professor PATIENT PRESENTATION Figure 1: Non-contrast CT scan of the head (A) shows no bleeding and no significant hypodenstiy in the left hemisphere. CT angiogram study of the brain (B) shows left MCA occlusion (arrow). • 85 year old female with history of atrial fibrillation brought in by ambulance after being found sitting slumped in driver's seat of car for 1.5 hours. On evaluation, the patient had right sided weakness, mutism and visual disturbance. The NIHSS* was 17 on arrival in the emergency room. The patient is urgently taken to CT scanner for further evaluation. *National Institute of Health Stroke Scale EVALUATION AND IMAGING • Non-contrast head CT and CT angiogram (CTA) (Figure 1), CT perfusion (CTP) (Figure 2) show no significant hypodensity with MCA* proximal occlusion and with perfusion showing a large volume (58ml) of at risk tissue. *Middle Cerebral Artery INTERVENTION PERFORMED • Given the large volume of tissue at risk, intervention was deemed warranted. Angiogram of the left internal carotid artery (ICA) confirmed middle cerebral artery (MCA) occlusion (Figure 3). The Solitaire Flow Restoration device (Figure 4) was deployed in the left MCA for clot retrieval. Figure 2: CT perfusion study evaluated with automated software shows injured brain tissue volume of less than 1 ml with at risk tissue volume of 58 ml. (over) A B
Transcript of INTERVENTIONAL NEURORADIOLOGY 24/7 Contact & Appointment€¦ · INTERVENTIONAL NEURORADIOLOGY 1.5...
INTERVENTIONAL NEURORADIOLOGY
24/7Contact&Appointment(310)267-8761or8762
Patient with right sided weakness and aphasia
DIVISIONOFINTERVENTIONALNEURORADIOLOGY
Presentsapatientcasetreatedbytheteammembersofthedivision
andphysiciansandstaffoftheUCLAComprehensiveStrokeCenter
GARYDUCKWILER,MDDirectorandProfessor
FERNANDOVINUELA,MD
ProfessorEmeritus
REZAJAHAN,MDProfessor
SATOSHITATESHIMA,MD,DMSc
AssociateProfessor
NESTORGONZALEZ,MDAssociateProfessor
VIKTORSZEDER,MD,PhD
AssistantProfessor
PATIENTPRESENTATION
Figure1:Non-contrastCTscanofthehead(A)showsnobleedingandnosignificanthypodenstiyinthelefthemisphere.CTangiogramstudyofthebrain(B)showsleftMCAocclusion(arrow).
• 85yearoldfemalewithhistoryofatrialfibrillationbroughtinbyambulanceafterbeingfoundsittingslumpedindriver'sseatofcarfor1.5hours.Onevaluation,thepatienthadrightsidedweakness,mutismandvisualdisturbance.TheNIHSS*was17onarrivalintheemergencyroom.ThepatientisurgentlytakentoCTscannerforfurtherevaluation.
*NationalInstituteofHealthStrokeScale
EVALUATIONANDIMAGING
• Non-contrastheadCTandCTangiogram(CTA)(Figure1),CTperfusion(CTP)(Figure2)shownosignificanthypodensitywithMCA*proximalocclusionandwithperfusionshowingalargevolume(58ml)ofatrisktissue.
*MiddleCerebralArtery
INTERVENTIONPERFORMED
• Giventhelargevolumeoftissueatrisk,interventionwasdeemedwarranted.Angiogramoftheleftinternalcarotidartery(ICA)confirmedmiddlecerebralartery(MCA)occlusion(Figure3).TheSolitaireFlowRestorationdevice(Figure4)wasdeployedintheleftMCAforclotretrieval.
Figure2:CTperfusionstudyevaluatedwithautomatedsoftwareshowsinjuredbraintissuevolumeoflessthan1mlwithatrisktissuevolumeof58ml.
(over)
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B
INTERVENTIONAL NEURORADIOLOGY
24/7Contact&Appointment(310)267-8761or8762
ProceduresprovidedbyDINRforadultandpediatricpatients
AcuteIschemicStroke
AcuteThrombectomy/ThrombolysisExtra/IntracranialAngioplasty/Stenting
BrainHemorrhage,Aneurysm/AVM/fistulae
AneurysmcoilingStent/balloonassistedaneurysmcoilingFlowdiverterstentdeviceembolization
AVM/DuralfistulaeembolizationVenousSinusThrombectomy/Thrombolysis
Directtranscutaneousembolization
ChronicOcclusiveCerebrovascularDiseaseExtra/IntracranialAngioplasty/Stenting
VenousSinusAngioplasty/Stenting
Head/neck/orbittumors&vascularmalformations,epistaxis
EndovascularembolizationDirectpercutaneousembolization
DivisionofInterventionalNeuroradiologyDavidGeffenSchoolofMedicineatUCLARonaldReaganUCLAMedicalCenter757WestwoodPlaza,Suite2129LosAngeles,CA90095-7437http://radiology.ucla.edu/site.cfm?id=217
DivisionofInterventionalNeuroradiology–ALeaderinNeurovascularCareandResearch• InventedtheMerciretriever–the1stendovascular
deviceforacutestroketherapy• InventedGDCandMatrixcoils–theleadingtoolfor
aneurysmtreatmentaroundtheworld• DevelopedOnyxliquidembolicmaterial–theleading
therapyforbrainvascularmalformations
Figure3:Anteroposteriorviewofleftinternalcarotidarteryangiogram(A)showsocclusionoftheleftproximalMCA(arrow).FollowingdeploymentoftheSolitaireFlowRestorationdevice,clotisretrievedandpostretrievalangiogram(B)showscompleterecanalizationoftheMCA.
PATIENTOUTCOME
• NeurologicexaminationthefollowingdaywasbacktobaselinewiththeNIHSS=0.Thepatientwasdischargedhomeafter4daysofhospitalization.
INTERVENTIONPERFORMED(CONTINUED)
• PostretrievalangiogramoftheleftICAshowscompleterecanalizationoftheMCAvessels(Figure3B).Thetimeintervalfromarrivalintheemergencyroomtorecanalizationwas100min.
Figure4:SolitaireFlowRestorationDevice.
BA
DISCUSSION
In2015,fiverandomizedtrialsshowedefficacyofendovascularthrombectomyoverstandardmedicalcareinpatientswithacuteischemicstrokecausedbyocclusionofarteriesoftheproximalanteriorcirculation.Furthermore,pooledanalysisofthefivetrialsshowedthatendovascularthrombectomymorethandoublestheoddsofanindependentoutcomecomparedwithbestmedicaltherapyaloneinthispatientpopulation.TheAmericanHeartAssociationguidelinesnowrecommendendovasculartherapyforselectedpatientswithacuteischemicstroke*.Timetotreatmentiscriticalandasisoftensaid“timeisbrain.”Multiplestudieshaveshownacorrelationbetweenearlyrecanalizationandfunctionalindependence.Establishingtargettimeintervalsisparamountasitcanleadtoimprovedoutcomesinischemicstrokepatientsasitalreadyhasinpatientsundergoingpercutaneouscoronaryinterventionaftermyocardialinfarction.Currentsocietalrecommendationsarepatientarrivalathospitaltorecanalizationtimelessthan90minutes**.*Stroke.2015;46:3020-3035PublishedonlinebeforeprintJune29,2015,**JNeurointervSurg.2015Aug31.pii:neurintsurg-2015-011984.doi:10.1136/neurintsurg-2015-011984.[Epubaheadofprint]
