Stroke in Evolution Due to Critical
MCA Stenosis
Mohammed A. Almekhlafi and Mayank Goyal
Case
An 82-year-old man presented with a right MCA
clinical syndrome that started almost 24 h prior to
his presentation. CT angiogram showed a near
complete occlusive narrowing of the distal right
M1. An acute MRI brain showed critical hypo-
perfusion of the right MCA territory with mini-
mal core on DWI (Fig. 88.1). He was referred for
delayed reperfusion therapy.
Issue
This patient had symptoms onset beyond the con-
ventional treatment window. However, he had
evidence of clinical–radiographic mismatch
(severe clinical deficit not explained by the DWI
lesion). This was more in favor of atherosclerotic
narrowing with unstable plaque vs. a nonocclu-
sive thrombus. In such circumstances, the tissue
window is more relevant than the time window.
M. A. Almekhlafi (*)
Department of Neurology, Faculty of Medicine,
King Abdulaziz University, Jeddah, Saudi Arabia
e-mail: malmekhlafi@kau.edu.sa
M. Goyal
Department of Radiology, Seaman Family MR
Research Centre, Foothills Medical Centre,
Calgary, AB, Canada
e-mail: mgoyal@ucalgary.ca
© The Author(s) 2019
V. Gupta et al. (eds.), 100 Interesting Case Studies in Neurointervention: Tips and Tricks,
https://doi.org/10.1007/978-981-13-1346-2_88
88
Management
He was loaded with ASA and clopidogrel in
anticipation of possible stenting. The angio-
graphic runs showed near complete occlusion of
the distal right M1-MCA with very slow filling of
both M2 branches (Fig.  88.2). The area of nar-
rowing was believed to represent an atheroscle-
rotic critical stenosis, and permanent stent
detachment was decided.
Under road map guidance, a Prowler select
plus microcatheter was advanced over a
Transcend Platinum wire across the stenotic seg-
ment into an M2 branch. A check run through the
microcatheter confirmed the appropriate landing
zone for the stent. From there, a 3  ×  30  mm
Solitaire stent was deployed from the proximal
M2 branch to the proximal right M1-MCA. This
immediately resulted in significant improvement
of the right hemispheric flow (Fig.  88.3). The
stent was successfully detached after that. Check
angiogram showed good anterograde flow intra-
cranially with no distal emboli. The patient had
significant clinical improvement.
375
376 M. A. Almekhlafi and M. Goyal

Fig. 88.1  Acute diffusion-weighted MRI showing small areas of scattered cortical restricted diffusion and in the deep
white matter

Fig. 88.2  Initial angiographic run showing tapering and Fig. 88.3  Final angiographic run showing restoration of
narrowing of the right distal middle cerebral artery with normal flow through the stent (circle) and the MCA
slow flow in the M2 branches as can be seen in the delayed branches
M2 filling relative to the ACA
88  Stroke in Evolution Due to Critical MCA Stenosis
Tips and Tricks
1. A tissue-based paradigm can be used to extend
the treatment window in carefully selected
patients.
2. Pre-planning the procedure to use detachable
stent is important when atherosclerotic nar-
rowing is suspected as the underlying
mechanism.
377
Suggested Reading
Ansari S, et al. Intracranial stents for treatment of acute
ischemic stroke: evolution and current status. World
Neurosurg. 2011;76(6 Suppl):S24–34.
Xavier AR, et al. Safety and efficacy of intracranial stent-
ing for acute ischemic stroke beyond 8 h of symptom
onset. J Neurointerv Surg. 2012;4(2):94–100.