Fatal Hemorrhage Complicating Intracranial Stenting After Failed Thrombectomy for Intracranial Atherosclerotic Stenosis in a Patient with Moderate Stroke: Risk Factors for Hemorrhagic Transformation, Red Flags, and Lessons Learned

Most large vessel occlusions (LVOs) are secondary to emboli of cardiac or cervical artery origin. Current stent retrieval and aspiration thrombectomy techniques are highly effective in removing these emboli in most cases. However, these techniques are less effective in LVOs with underlying intracranial atherosclerosis. Technical difficulties and significant intra- and postprocedural reocclusion rates have been reported for intracranial atherothrombotic occlusions, and salvage treatment with intra-arterial thrombolysis, balloon angioplasty, or stenting may be required for successful long-term revascularization. A 56-year-old woman with an unremarkable medical history and no history of vascular risk factors who was a nursing assistant at our medical center presented with slower motor responses, apathy, depression, impairment of complex movement such as preparing and delivering food to patients, and an inability to concentrate starting 3 days before her admission. In addition, she experienced transient left facial weakness followed by speech changes 2 days before admission. On the day of admission, she was sent to the emergency department (ED) by her coworkers after developing left facial and left brachial paresis. Over the next hour, she developed right gaze deviation, speech alterations, and left hemiparesis. Her admission National Institutes of Health Stroke Scale (NIHSS) score of 4 increased to 12–14. The Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast cranial CT was reported by a senior radiologist as 7. In contrast, “Rapid AI” reported an ASPECTS of 10 despite a clear hypodense area in the right frontal subcortical region. CT perfusion imaging (CTP) showed a right hemispheric perfusion deficit, consistent with the patient’s neurological examination findings of right gaze deviation and left hemiparesis. The volume of the area where cerebral blood flow (CBF) was reduced to <30% of expected levels was 0 ml, and the volume of the area with a time to peak concentration (Tmax) >6 s was 133 ml, with a mismatch ratio defined as infinite. CT angiography (CTA) demonstrated occlusion of the distal internal carotid artery (ICA). The patient did not receive intravenous thrombolysis and was transferred from the emergency department to the neuroangio suite for endovascular intervention. An 8F introducer sheath was placed in the right femoral artery under general anesthesia. Angiograms of the right ICA showed occlusion of the ICA beyond the origin of the ophthalmic artery (OA). There was atherosclerotic infiltration in the cavernous ICA, and at the proximal end of the occlusion, a jagged extension threatened the ostium of the OA. Of note, the OA supplied a single anterior ethmoidal-anterior meningeal arcade that contributed to the anterior pial supply, a compensatory duro-pial synangiosis mechanism usually seen in longstanding ischemic conditions. The patient underwent stentriever-assisted mechanical thrombectomy with only a modest result, so balloon angioplasty and repeat thrombectomy maneuvers were performed. Aspirin and ticagrelor were administered via nasogastric tube. Finally, the patient required intracranial stenting. At the end of the procedure, the artery was widely recanalized and antegrade intracranial circulation was restored. The patient opened her eyes 1 h after the procedure, while still under the effects of light sedation and intubated. Her pupils were normal and she moved her four limbs vigorously without paresis. Sedation was deepened. Three hours later, she developed right-sided anisocoria and then bilateral pupil dilation. Urgent head CT showed a large parenchymal hemorrhage. The patient was taken to surgery for urgent hemorrhage evacuation and decompressive craniectomy, but the outcome was fatal. The management of large vessel occlusions caused by underlying atherosclerotic stenosis is technically challenging, often requiring prolonged procedures with bailout maneuvers and techniques, and may present unique complications such as re-occlusion and hemorrhagic complications. This chapter focuses on hemorrhagic complications associated with revascularization of acute atherothrombotic occlusions.