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Advanced Neurology Delayed occlusion after mechanical thrombectomy

in the right hemisphere. Given the high risk of ischemic the use of any device, and it should be noted that delayed
17
stroke in this area, we decided to proceed with an EC-IC vascular stenosis and occlusion may still occur even with
bypass surgery after a thorough discussion with the the ADAPT method used, similar to our case. Vascular
patient. This case was considered symptomatic MCA stenosis after MT has been documented not only in cases
occlusion due to the initial event. The superiority of EC-IC with pre-existing stenotic lesions but also in cardioembolic
bypass surgery over medical treatment for occlusion or stroke cases where apparent vascular stenosis is not
severe stenosis of intracranial arteries has not yet been evident. Therefore, diligent observation is warranted.
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established. However, it has been reported that patients
4,7
with decreased cerebrovascular reactivity to acetazolamide 4. Conclusion
are at high risk of recurrent ischemic stroke. 8-10 In the JET We encountered a case where MT was performed for MCA
study, a randomized controlled trial conducted in Japan, occlusion. Following the procedure, reocclusion occurred
surgical treatment significantly reduced the recurrence in the chronic phase. The patient underwent an EC-IC
rate of ischemic stroke compared to medical treatment in bypass surgery and resumed work without experiencing
cases where quantitative cerebral blood flow evaluation ischemic episodes. After MT, especially in cases with
showed decreased cerebral blood flow at rest and reduced residual stenosis, it is important to consider the potential
cerebrovascular reactivity with an acetazolamide challenge for delayed stenosis or occlusion.
in the MCA territory. Based on these findings, we
11
determined that surgery was appropriate and performed Acknowledgments
the EC-IC bypass surgery.
None.
There is ongoing debate about the treatment of ICAS.
The SAMMPRIS trial compared aggressive medical Funding
management alone to aggressive medical management None.
combined with transluminal angioplasty and stenting for
severe stenotic lesions of 70% or more, favoring aggressive Conflict of interest
medical therapy alone. The VISSIT trial compared medical
5
therapy alone with balloon-mounted stent placement for The authors declare that they have no competing interests.
lesions of 70% or more, showing a higher risk of stroke Author contributions
or transient ischemic attack (TIA) within 12 months in
the stent group compared to medical therapy alone. In Conceptualization: Hideki Kanamaru
12
addition, the CASSIS trial compared medical therapy Investigation: Hideki Kanamaru
alone with medical therapy plus stent placement for non- Writing – original draft: Hideki Kanamaru
penetrating branch territory or non-disabling stroke cases Writing – review & editing: Yoshinari Nakatsuka, Fumio
with TIA but found no significant difference between Asakura, Hiroto Murata
the groups. A systematic review encompassing these
13
randomized controlled trials concluded that, currently, Ethics approval and consent to participate
angioplasty or stent placement for symptomatic ICAS does This study was approved by the Institutional Review Board
not show superiority over medical therapy alone. In our (Approval Number: 2023-074). The patient consented to
14
case, although the lesion was symptomatic and severe, the participate, and written consent was obtained.
patient did not undergo stent placement due to the lack of
stenosis progression or recurrent ischemic episodes after Consent for publication
MT in the acute phase. However, if stenosis progression Written consent was obtained.
had been detected, stent placement could have been
considered as a treatment option. ICAS following MT that Availability of data
employs previous-generation devices has been reported to
occur in 8.8% of cases with more than 50% stenosis on MRI Authors can provide data upon an appropriate request.
3 months later. Intracranial artery dissection may also be References
15
considered as a possible cause of progressive restenosis
or occlusion. In a case series of spontaneous intracranial 1. GBD 2019 Stroke Collaborators. Global, regional, and
artery dissection, stenting was associated with the best national burden of stroke and its risk factors, 1990-2019:
rate of recanalization. This pathology is also possible in A systematic analysis for the Global Burden of Disease Study
16
our case as a cause of delayed occlusion. In vitro studies 2019. Lancet Neurol. 2021;20(10):795-820.
have shown that endothelial cell damage can result from doi: 10.1016/s1474-4422(21)00252-0

Volume 3 Issue 3 (2024) 4 doi: 10.36922/an.3332