Posterior-to-anterior circulation access using the Penumbra Stroke System for mechanical thrombectomy of a right middle cerebral artery thrombus

Ferdinand Hui, Sandra Narayanan, C. Michael Cawley

Research output: Contribution to journalArticle

Abstract

Background: Mechanical thrombectomy devices rely on the ability of an operator to directly access a thrombus with the device. The authors demonstrate the first reported posterior-to-anterior circulation approach using the Penumbra Stroke System (Penumbra, Inc, Alameda, CA) for thrombectomy in acute stroke. Case Description: A 53-year-old man presented 5 hours and 15 minutes after onset of left homonymous hemianopia, left facial droop, left upper extremity plegia, and left lower extremity paresis (NIHSS = 15). Computed tomography of the head revealed hyperdense material in the right M1 to M2 segments without loss of gray-white differentiation in the right cerebral hemisphere. Cerebral angiography at 6 hours and 50 minutes revealed occlusion of the right ICA at its origin. Injection of the left vertebral artery demonstrated clot in the right M1 segment with no anterograde flow. An Excelsior 1018 (Boston Scientific, Natick, MA) microcatheter was used to access the right PCOM and subsequently the right ICA and right MCA. A joint decision was made with the stroke neurology service to bury the microcatheter within the right MCA clot and administer 13 mg of tPA. A triaxial system using the Penumbra 041 catheter, Excelsior SL-10 microcatheter, and Synchro2 (Boston Scientific) guidewire was used to traverse the left vertebral and basilar arteries, the right PCOM, and the right ICA to the thrombosed right M1 segment. Aspiration using the Penumbra 41 catheter and 41 Separator was performed, resulting in a TIMI-2 result with minimal residual superior right M2 thrombus. Conclusion: In patients with proximal vascular occlusion, mechanical thrombectomy with relatively stiff thrombectomy systems can be achieved through collateral pathways in the circle of Willis. Although the diameter mismatch between the Penumbra 41 catheter and a microguidewire may make sharp turns challenging, the use of an SL-10 microcatheter as a functional obturator may afford access.

Original languageEnglish (US)
Pages (from-to)17-21
Number of pages5
JournalWorld Neurosurgery
Volume73
Issue number1
DOIs
StatePublished - Jan 2010
Externally publishedYes

Fingerprint

Intracranial Thrombosis
Thrombectomy
Middle Cerebral Artery
Stroke
Thrombosis
Catheters
Vertebral Artery
Circle of Willis
Hemianopsia
Equipment and Supplies
Cerebral Angiography
Basilar Artery
Cerebrum
Paresis
Neurology
Upper Extremity
Paralysis
Blood Vessels
Head
Tomography

Keywords

  • Penumbra device
  • Posterior-to-anterior circulation stroke
  • Thrombectomy
  • Thrombolysis
  • TPA

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Posterior-to-anterior circulation access using the Penumbra Stroke System for mechanical thrombectomy of a right middle cerebral artery thrombus. / Hui, Ferdinand; Narayanan, Sandra; Cawley, C. Michael.

In: World Neurosurgery, Vol. 73, No. 1, 01.2010, p. 17-21.

Research output: Contribution to journalArticle

@article{30d17ac1296d4398aff9de87e01e696d,
title = "Posterior-to-anterior circulation access using the Penumbra Stroke System for mechanical thrombectomy of a right middle cerebral artery thrombus",
abstract = "Background: Mechanical thrombectomy devices rely on the ability of an operator to directly access a thrombus with the device. The authors demonstrate the first reported posterior-to-anterior circulation approach using the Penumbra Stroke System (Penumbra, Inc, Alameda, CA) for thrombectomy in acute stroke. Case Description: A 53-year-old man presented 5 hours and 15 minutes after onset of left homonymous hemianopia, left facial droop, left upper extremity plegia, and left lower extremity paresis (NIHSS = 15). Computed tomography of the head revealed hyperdense material in the right M1 to M2 segments without loss of gray-white differentiation in the right cerebral hemisphere. Cerebral angiography at 6 hours and 50 minutes revealed occlusion of the right ICA at its origin. Injection of the left vertebral artery demonstrated clot in the right M1 segment with no anterograde flow. An Excelsior 1018 (Boston Scientific, Natick, MA) microcatheter was used to access the right PCOM and subsequently the right ICA and right MCA. A joint decision was made with the stroke neurology service to bury the microcatheter within the right MCA clot and administer 13 mg of tPA. A triaxial system using the Penumbra 041 catheter, Excelsior SL-10 microcatheter, and Synchro2 (Boston Scientific) guidewire was used to traverse the left vertebral and basilar arteries, the right PCOM, and the right ICA to the thrombosed right M1 segment. Aspiration using the Penumbra 41 catheter and 41 Separator was performed, resulting in a TIMI-2 result with minimal residual superior right M2 thrombus. Conclusion: In patients with proximal vascular occlusion, mechanical thrombectomy with relatively stiff thrombectomy systems can be achieved through collateral pathways in the circle of Willis. Although the diameter mismatch between the Penumbra 41 catheter and a microguidewire may make sharp turns challenging, the use of an SL-10 microcatheter as a functional obturator may afford access.",
keywords = "Penumbra device, Posterior-to-anterior circulation stroke, Thrombectomy, Thrombolysis, TPA",
author = "Ferdinand Hui and Sandra Narayanan and Cawley, {C. Michael}",
year = "2010",
month = "1",
doi = "10.1016/j.surneu.2009.05.020",
language = "English (US)",
volume = "73",
pages = "17--21",
journal = "World Neurosurgery",
issn = "1878-8750",
publisher = "Elsevier Inc.",
number = "1",

}

TY - JOUR

T1 - Posterior-to-anterior circulation access using the Penumbra Stroke System for mechanical thrombectomy of a right middle cerebral artery thrombus

AU - Hui, Ferdinand

AU - Narayanan, Sandra

AU - Cawley, C. Michael

PY - 2010/1

Y1 - 2010/1

N2 - Background: Mechanical thrombectomy devices rely on the ability of an operator to directly access a thrombus with the device. The authors demonstrate the first reported posterior-to-anterior circulation approach using the Penumbra Stroke System (Penumbra, Inc, Alameda, CA) for thrombectomy in acute stroke. Case Description: A 53-year-old man presented 5 hours and 15 minutes after onset of left homonymous hemianopia, left facial droop, left upper extremity plegia, and left lower extremity paresis (NIHSS = 15). Computed tomography of the head revealed hyperdense material in the right M1 to M2 segments without loss of gray-white differentiation in the right cerebral hemisphere. Cerebral angiography at 6 hours and 50 minutes revealed occlusion of the right ICA at its origin. Injection of the left vertebral artery demonstrated clot in the right M1 segment with no anterograde flow. An Excelsior 1018 (Boston Scientific, Natick, MA) microcatheter was used to access the right PCOM and subsequently the right ICA and right MCA. A joint decision was made with the stroke neurology service to bury the microcatheter within the right MCA clot and administer 13 mg of tPA. A triaxial system using the Penumbra 041 catheter, Excelsior SL-10 microcatheter, and Synchro2 (Boston Scientific) guidewire was used to traverse the left vertebral and basilar arteries, the right PCOM, and the right ICA to the thrombosed right M1 segment. Aspiration using the Penumbra 41 catheter and 41 Separator was performed, resulting in a TIMI-2 result with minimal residual superior right M2 thrombus. Conclusion: In patients with proximal vascular occlusion, mechanical thrombectomy with relatively stiff thrombectomy systems can be achieved through collateral pathways in the circle of Willis. Although the diameter mismatch between the Penumbra 41 catheter and a microguidewire may make sharp turns challenging, the use of an SL-10 microcatheter as a functional obturator may afford access.

AB - Background: Mechanical thrombectomy devices rely on the ability of an operator to directly access a thrombus with the device. The authors demonstrate the first reported posterior-to-anterior circulation approach using the Penumbra Stroke System (Penumbra, Inc, Alameda, CA) for thrombectomy in acute stroke. Case Description: A 53-year-old man presented 5 hours and 15 minutes after onset of left homonymous hemianopia, left facial droop, left upper extremity plegia, and left lower extremity paresis (NIHSS = 15). Computed tomography of the head revealed hyperdense material in the right M1 to M2 segments without loss of gray-white differentiation in the right cerebral hemisphere. Cerebral angiography at 6 hours and 50 minutes revealed occlusion of the right ICA at its origin. Injection of the left vertebral artery demonstrated clot in the right M1 segment with no anterograde flow. An Excelsior 1018 (Boston Scientific, Natick, MA) microcatheter was used to access the right PCOM and subsequently the right ICA and right MCA. A joint decision was made with the stroke neurology service to bury the microcatheter within the right MCA clot and administer 13 mg of tPA. A triaxial system using the Penumbra 041 catheter, Excelsior SL-10 microcatheter, and Synchro2 (Boston Scientific) guidewire was used to traverse the left vertebral and basilar arteries, the right PCOM, and the right ICA to the thrombosed right M1 segment. Aspiration using the Penumbra 41 catheter and 41 Separator was performed, resulting in a TIMI-2 result with minimal residual superior right M2 thrombus. Conclusion: In patients with proximal vascular occlusion, mechanical thrombectomy with relatively stiff thrombectomy systems can be achieved through collateral pathways in the circle of Willis. Although the diameter mismatch between the Penumbra 41 catheter and a microguidewire may make sharp turns challenging, the use of an SL-10 microcatheter as a functional obturator may afford access.

KW - Penumbra device

KW - Posterior-to-anterior circulation stroke

KW - Thrombectomy

KW - Thrombolysis

KW - TPA

UR - http://www.scopus.com/inward/record.url?scp=77953264215&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=77953264215&partnerID=8YFLogxK

U2 - 10.1016/j.surneu.2009.05.020

DO - 10.1016/j.surneu.2009.05.020

M3 - Article

VL - 73

SP - 17

EP - 21

JO - World Neurosurgery

JF - World Neurosurgery

SN - 1878-8750

IS - 1

ER -