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Intra-arterial Thrombolysis of Acute Cerebral Vascular Occlusion During Endovascular Treatment of Adjacent Aneurysms at the Internal Carotid Artery

Zhi Chen, MD; Hongping Miao, MD; Gang Zhu, MD, PhD; Hua Feng, MD, PhD
JAMA Neurol. 2013;70(3):406-407. doi:10.1001/jamaneurol.2013.602.
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A 44-year-old man presented with sudden onset of severe headache, and acute subarachnoid hemorrhage was confirmed by computed tomographic scan. His clinical status was Hunt and Hess grade II on hospital admission. Angiogram revealed dual adjacent but separate aneurysms originating from the paraclinoid segment of the right internal carotid artery. Under general anesthesia and systemic heparinization, endovascular coiling of 2 aneurysms was successfully carried out (Figure 1). However, control angiogram right after the coiling and removal of the microcatheter revealed complete occlusion of the middle cerebral artery (Figure 2A). Then the microcatheter was quickly navigated to the thrombus, and clot fragmentation and intra-arterial thrombolysis (IAT) with urokinase were started (Figure 2B). Final control angiogram showed near complete recanalization of the middle cerebral artery after infusion of 650 000 IU of urokinase (Figure 2B). The patient did not develop any neurological deficit after embolization and an antiplatelet agent was administered orally. Follow-up computed tomographic scan revealed no infarction or intracranial hemorrhage.

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Figure 1. Coil embolization in a patient with dual adjacent aneurysms at the internal carotid artery. A, Three-dimensional digital subtraction angiogram showing 2 adjacent and separate aneurysms at the paraclinoid segment of the right carotid artery. B, Postoperative angiogram after coil embolization showing complete occlusion of the aneurysms. C, Nonsubtracted image showing the adjacence of the coil mass.

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Figure 2. Intra-arterial thrombolysis of acute cerebral vascular occlusion after the aneurysms' embolization. A, Repeated angiogram right after the embolization showing complete occlusion of the middle cerebral artery (arrow). B, Angiogram showing clot fragmentation by microwire and thrombus migration to distal M1 segment and M2 branches (arrows). C, Angiogram after thrombolysis showing near complete recanalization of the middle cerebral artery.

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