39 Hemorrhagic Transformation after Endovascular Stroke Therapy
39.1 Case Description
39.1.1 Clinical Presentation
A 79-year-old male presented with acute onset of language disturbance and right hemiparesis 75 minutes post–stroke onset. His past medical history revealed hypertension and hyperlipidemia, with a baseline modified Rankin scale (mRS) score of 1. Examination in the emergency department confirmed complete left middle cerebral artery (MCA) syndrome with a National Institutes of Health Stroke Scale (NIHSS) score of 23. Emergent noncontrast CT (NCCT) at 90 minutes post–stroke onset revealed hyperattenuating left M1 MCA and ASPECTS score of 8. Following bolus intravenous thrombolysis at 94 minutes post onset of symptoms, endovascular treatment is contemplated.
39.1.2 Imaging Workup and Investigations
NCCT at 90 minutes post–stroke onset reveals hyperattenuating left M1 MCA (Fig. 39.1a) and ASPECTS score of 8.
CTA of the head confirms proximal left M1 MCA occlusion with good collaterals (Fig. 39.1b).
CTA of the neck reveals focal noncalcified thrombus at the left internal carotid artery (ICA) origin (FigFig. 39.1c).
Fig. 39.1 NCCT (a) and subsequent CTA axial and sagittal maximum intensity projection (b,c) demonstrate a dense left MCA, M1 occlusion, and noncalcified thrombus at the ICA origin.
39.1.3 Diagnosis
Acute proximal left MCA occlusion, presumed large artery-to-artery embolism from thrombus at the left ICA origin.
39.1.4 Treatment
Initial Management
Intravenous thrombolysis was administered after initial NCCT, 94 minutes after stroke onset.
A decision is made to proceed to emergent endovascular treatment, based on time from onset, presence of large vessel occlusion, and favorable ASPECTS score.
For collateral augmentation, a 500-mL normal saline fluid bolus is administered, and systolic blood pressure (SBP) maintained at 150 to 180 mm Hg en route to the neuroangiography suite.
39.1.5 Endovascular Treatment
Material
7-Fr-long (90-cm) sheath for access (micropuncture kit; 6F dilator; 7F KSAW-7.0–38–90-RB-SHTL-FLEX- HC sheath).
125-cm Davis catheter (Cook Medical Inc) and 0.038 Glidewire (Terumo).
Abbott Vascular XACT stent 9–7 mm × 40 mm.
Penumbra 5 Max ACE catheter.
Velocity 0.025 microcatheter.
Synchro-2 standard microwire 200 cm.
Synchro-2 standard microwire 300 cm.
Solitaire 4 mm × 40 mm stentriever.
Technique
The endovascular procedure was carried out under local anesthesia and conscious sedation administered by the anesthesia team.
SBP was maintained at 150 to 180 mm Hg to maximize collateral support, while the intracranial occlusion remained present, but not exceeding the recommended upper limit post–intravenous tissue plasminogen activator (IV-tPA) administration.
The 7-Fr-long sheath was advanced into the left common carotid artery (CCA) over the 125-cm Davis catheter.
Since the appearances on the CTA of the neck suggested soft thrombus, a decision was made to trap the cervical ICA thrombus with a stent. In light of the documented intracranial occlusion, a distal protection device was not used.
A Velocity microcatheter was used to carefully navigate an exchange length Synchro 2 standard microwire across the narrowed left ICA origin, aiming to avoid displacing the thrombus.
The microcatheter was removed, and the 9 to 7 mm × 40 mm XACT stent was navigated across the thrombus site over the exchange length 0.014 microwire. The XACT stent was successfully deployed with full expansion. However, postdeployment angiography demonstrated that a portion of the cervical ICA thrombus had migrated distally to cause a complete ICA terminus occlusion.
The stent system was removed, and a Penumbra 5 Max ACE catheter was used to attempt primary aspiration of the ICA terminus thrombus, but without success.
Subsequently, a triaxial system of the Penumbra 5 Max ACE, the Velocity microcatheter, and 200 cm Synchro 2 standard microwire were navigated across the thrombus into the M2 left MCA, microwire was removed, and a 4 × 40 mm Solitaire stentriever used to recanalize both the left MCA and ICA. Two passes were required, and TICI 2b reperfusion was achieved (Fig. 39.2a).
Subsequent angiogram revealed active contrast pooling in the lenticulostriate territory (Fig. 39.2b). Since active bleeding was suspected, the procedure was immediately terminated and SBP reduced to less than 140 mm Hg.
Time from groin puncture to TICI 2b reperfusion was 51 minutes; time from initial stentriever deployment to TICI 2b reperfusion was 21 minutes.
Fig. 39.2 Catheter angiographic images (a,b) demonstrate active contrast extravasation in the lenticulostriate territory after recanalization. Subsequent NCCT (c) demonstrates a large left basal ganglia hematoma with intraventricular extension. Note the denser areas within the hematoma on CT reflecting extravasated contrast.
39.1.6 Postprocedure Care
There was no immediate intra- or postprocedural neurological deterioration; emergent intubation was not required.
Emergent repeat NCCT confirmed large basal ganglia hemorrhage (Fig. 39.2c), with denser contrast pooling in the posterior margin of the hematoma, which was compatible with the angiographic findings.
A meeting with the family was held and the options of intubation, external ventricular drainage, and aggressive medical management were balanced against the option of transitioning to hospice care. Given the patient’s age, significant clinical deficit, and imaging findings, a high disability and mortality rate was expected. Based on the patient’s previously stated wishes, a decision was made for supportive hospice care.
39.1.7 Outcome
Comfort care measures were instituted, and the patient died 24 hours later.
39.2 Companion Case
39.2.1 Case
Hemorrhagic transformation 27 hours after mechanical thrombectomy.
39.2.2 Clinical Presentation
A 58-year-old female presents with a left MCA occlusion and a NIHSS score of 14 3 hours after the beginning of stroke symptoms. Emergent NCCT reveals early ischemic changes in the left lentiform nucleus with an ASPECTS score of 9. The patient received IV-rtPA and was taken to the angiography suite for endovascular treatment.
39.2.3 Imaging Workup and Investigations
NCCT (Fig. 39.3) and CTA demonstrate hypoattenuation of the left lentiform nucleus, an ASPECTS score of 9, and a left M1 occlusion.
39.2.4 Diagnosis
Acute proximal left MCA occlusion.
39.2.5 Treatment
Initial Management
Intravenous thrombolysis.
Patient is transferred to the angiography suite for mechanical thrombectomy.
39.2.6 Endovascular Treatment
Material
Solitaire 4 mm × 40 mm stentriever.
Technique
The endovascular procedure was carried out under local anesthesia and conscious sedation administered by the anesthesia team.
No intraprocedural heparin was administered.
Initial catheter angiogram confirmed the left proximal M1 occlusion (Fig. 39.4a).
The Solitaire device was deployed across the M1 thrombus with immediate reperfusion.
3 passes performed with final TICI 2B reperfusion (Fig. 39.4b).
Time from groin puncture to TICI 2B reperfusion: 40 minutes.
On table NIHSS score following reperfusion: 4.
Xper CT demonstrated hyperattenuation in the caudate head and the lentiform nucleus, keeping with contrast staining, but there was no evidence of hemorrhage (Fig. 39.4c).
Fig. 39.4 Catheter angiogram demonstrates left proximal M1 occlusion (a) with TICI 2B reperfusion postthrombectomy (b). Xper CT (c) demonstrates hyperattenuation in the caudate head and the lentiform nucleus in keeping with contrast staining, but no evidence of hemorrhage. Note that the staining in the lentiform nucleus corresponds to the area of infarction seen on the pretreatment NCCT (Fig. 39.3).
39.2.7 Postprocedure Care
Prophylactic heparin and aspirin commenced the next day.
27 hours after the end of the procedure, the patient experienced sudden clinical deterioration. Emergent repeat NCCT demonstrated large basal ganglia hemorrhage (Fig. 39.5) with intraventricular extension.
Fig. 39.5 NCCT demonstrates a large left basal ganglia hematoma with intraventricular extension.
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