Improved cerebral perfusion after stenting of a petrous carotid stenosis: Technical case report

Richard D. Fessler, Giuseppe Lanzino, Lee R. Guterman, Robert S. Miletich, Demetrius K. Lopes, L. Nelson Hopkins

Research output: Contribution to journalArticle

21 Citations (Scopus)

Abstract

OBJECTIVE AND IMPORTANCE: Atherosclerotic occlusive disease of the intracranial vasculature is associated with increased risk of systemic vascular occlusive disease and stroke. Therapeutic options have included anticoagulation therapy, antiplatelet therapy, or, in a limited number of patients, extracranial-intracranial vascular bypass procedures. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after endovascular stenting of a severe petrous segment carotid stenosis. CLINICAL PRESENTATION: A 73-year-old man with severe coronary artery disease and unstable angina was referred for treatment of a 90% right petrous carotid artery stenosis before coronary artery bypass grafting. A brain single-photon emission computed tomographic scan using (99m)Tc-bicisate revealed diminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones. TECHNIQUE: The patient underwent transfemoral placement of a 7-French introducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No changes were noted in lesion morphology after this infusion. A microguidewire was navigated across the lesion. Subsequent balloon angioplasty with a coronary artery balloon was performed twice, followed by placement of a 4- x 12-mm coronary stent. CONCLUSION: Selective internal carotid artery angiography after stenting revealed markedly improved flow. A brain (99m)Tc-bicisate single-photon emission computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were noted; both were clinically silent. The patient had uncomplicated coronary artery bypass grafting 72 hours later. Five months postoperatively, he remains at home, living independently and with intact neurological function. Intracranial stenting for severe atherosclerotic stenosis is technically possible. However, its ultimate clinical role remains to be determined.

Original languageEnglish (US)
Pages (from-to)638-642
Number of pages5
JournalNeurosurgery
Volume45
Issue number3
DOIs
StatePublished - 1999
Externally publishedYes

Fingerprint

Carotid Stenosis
Internal Carotid Artery
Perfusion
Photons
Coronary Artery Bypass
Stents
Stroke
Balloon Angioplasty
Unstable Angina
Urokinase-Type Plasminogen Activator
Brain
Therapeutics
Vascular Diseases
Infarction
Blood Vessels
Coronary Artery Disease
Coronary Vessels
Angiography
Pathologic Constriction
Catheters

Keywords

  • Atherosclerosis
  • Coronary artery bypass graft
  • Single-photon emission computed to-mography
  • Stent
  • Stroke

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Fessler, R. D., Lanzino, G., Guterman, L. R., Miletich, R. S., Lopes, D. K., & Hopkins, L. N. (1999). Improved cerebral perfusion after stenting of a petrous carotid stenosis: Technical case report. Neurosurgery, 45(3), 638-642. https://doi.org/10.1097/00006123-199909000-00041

Improved cerebral perfusion after stenting of a petrous carotid stenosis : Technical case report. / Fessler, Richard D.; Lanzino, Giuseppe; Guterman, Lee R.; Miletich, Robert S.; Lopes, Demetrius K.; Hopkins, L. Nelson.

In: Neurosurgery, Vol. 45, No. 3, 1999, p. 638-642.

Research output: Contribution to journalArticle

Fessler, RD, Lanzino, G, Guterman, LR, Miletich, RS, Lopes, DK & Hopkins, LN 1999, 'Improved cerebral perfusion after stenting of a petrous carotid stenosis: Technical case report', Neurosurgery, vol. 45, no. 3, pp. 638-642. https://doi.org/10.1097/00006123-199909000-00041
Fessler, Richard D. ; Lanzino, Giuseppe ; Guterman, Lee R. ; Miletich, Robert S. ; Lopes, Demetrius K. ; Hopkins, L. Nelson. / Improved cerebral perfusion after stenting of a petrous carotid stenosis : Technical case report. In: Neurosurgery. 1999 ; Vol. 45, No. 3. pp. 638-642.
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abstract = "OBJECTIVE AND IMPORTANCE: Atherosclerotic occlusive disease of the intracranial vasculature is associated with increased risk of systemic vascular occlusive disease and stroke. Therapeutic options have included anticoagulation therapy, antiplatelet therapy, or, in a limited number of patients, extracranial-intracranial vascular bypass procedures. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after endovascular stenting of a severe petrous segment carotid stenosis. CLINICAL PRESENTATION: A 73-year-old man with severe coronary artery disease and unstable angina was referred for treatment of a 90{\%} right petrous carotid artery stenosis before coronary artery bypass grafting. A brain single-photon emission computed tomographic scan using (99m)Tc-bicisate revealed diminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones. TECHNIQUE: The patient underwent transfemoral placement of a 7-French introducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No changes were noted in lesion morphology after this infusion. A microguidewire was navigated across the lesion. Subsequent balloon angioplasty with a coronary artery balloon was performed twice, followed by placement of a 4- x 12-mm coronary stent. CONCLUSION: Selective internal carotid artery angiography after stenting revealed markedly improved flow. A brain (99m)Tc-bicisate single-photon emission computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were noted; both were clinically silent. The patient had uncomplicated coronary artery bypass grafting 72 hours later. Five months postoperatively, he remains at home, living independently and with intact neurological function. Intracranial stenting for severe atherosclerotic stenosis is technically possible. However, its ultimate clinical role remains to be determined.",
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