Stentriever Angioplasty (Stent-plasty) for Post-embolectomy Segmental Middle Cerebral Artery Vasospasm

Vasospasm after stent retriever thrombectomy is common. It is usually treated conservatively and has a good prognosis. In cases of moderate or severe vasospasm, interventionalists rely on chemical and balloon angioplasty. Recent experience has shown the potential value of stent retriever when used as an angioplasty device for the endovascular treatment of cerebral vasospasm. A 76-year-old man with a history of arterial hypertension, hyperlipidemia, ischemic heart disease, and peripheral vascular disease was admitted for right hemispheric ischemic stroke with a baseline National Institutes of Health Stroke Scale (NIHSS) score of 16. He was last seen well 2 h prior to admission. The Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast cranial CT was 9. CT angiography (CTA) showed a cut-off in the M1 segment of the right middle cerebral artery (MCA) and poor collaterals. The patient received intravenous thrombolysis and was transferred to the neuroangiography suite for endovascular intervention. Under general anesthesia, the patient underwent single-pass endovascular revascularization of the right MCA using a pRESET 6/30 stent retriever (WallabyPhenox). Stent retriever embolectomy resulted in severe vasospasm of the M1 segment. Microcatheterization of the proximal M1 segment and intra-arterial infusion of diluted nimodipine were only partially effective. Microcatheterization of the distal M1 segment allowed deployment of the same pRESET stent retriever used for thrombectomy. The second deployment of this device resulted in a rapid angioplasty effect observed by fluoroscopy. Post-procedure CT showed development of an ischemic stroke in right MCA territory with mild hemorrhagic transformation (HI1) and an ASPECTS of 8. At discharge after 12 days, the patient had an excellent clinical outcome (NIHSS 3, modified Rankin Scale [mRS] 1). On follow-up CT, day 26, the hemorrhage had been reabsorbed. This case relates to previous observations on the use of stent retrievers to treat vasospasm associated with subarachnoid hemorrhage and severe vasospasm caused by the stent retrievers after mechanical thrombectomy. This chapter presents and discusses the rationale and advantages of this endovascular option.