Recanalization by Mechanical Embolus Disruption during Intra-Arterial Thrombolysis in the Carotid Territory
Takatoshi Sorimachia,
Yukihiko Fujiib,
Naoto Tsuchiyaa,
Takeo Nashimotoa,
Atsuko Haradaa,
Yasushi Itob and
Ryuichi Tanakab
a Department of Neurosurgery, Nishiogi-chuo Hospital, Tokyo, Japan
b the Department of Neurosurgery, Brain Research Institute, Niigata University, Japan
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FIG 1. Techniques of mechanical disruption. A, Microcatheter tip is advanced to the distal end of the embolus. Urokinase in 10 mL of normal or heparinized normal sodium chloride solution is manually injected into the embolus as forcefully as possible while the tip is slowly withdrawn into the proximal end of the embolus. B, Microcatheter tip is passed back and forth through the clot over a microguidewire several times. For an embolus at a bifurcation, the microcatheter is introduced into both distal arteries to disrupt clot entering them. C, Tip of a double-angled microguidewire is flexed into a J shape in the arterial lumen near the embolus and moved gently in the embolus along the vasculature several times. D, Rotation of a J-shaped guidewire tip in the embolus several times.
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FIG 2. Case 18. Right internal carotid angiograms, lateral view, before (A) and after (B) thrombolysis and local angiograms from a microcatheter (C and D).
A, Right ICA is occluded distal to the orifice of the posterior communicating artery (arrow).
B, ICA is recanalized. Distal M4 segment of the angular artery is persistently occluded by the fragmented embolus (arrowhead).
C, AP view from a microcatheter proximal to the embolus shows that the ICA is occluded (arrow) distal to the orifice of the posterior communicating artery (arrowheads).
D, AP view from a microcatheter in the distal end of the embolus shows no filling of contrast medium in the proximal MCA M1 segment (arrow). Findings indicate that the embolus extends from the distal ICA to the mid-M1 segment.
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FIG 3. Case 18. Mechanical disruption with a J-shaped microguidewire during thrombolytic therapy (A–C) and local angiograms from a microcatheter (D–F).
A and B, J-shaped tip (arrows) is moved from a position proximal to the embolus (A) to a distal position (B).
C, J-shaped tip (arrow) is rotated in the embolus.
D, AP view shows that the MCA M1 segment is occluded (arrow) just distal to the orifice of the anterior cerebral artery (arrowheads). Dislodgment of the embolus from the distal ICA to the mid-M1 segment is indicated.
E, AP view shows dislodgment of the embolus to the MCA M2 segment (arrow). The exact location of the embolus is difficult to identify on this view.
F, Lateral view shows fragmented emboli in the M2 segments of the parietal (arrow) and angular (arrowhead) arteries.
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FIG 4. Case 18. Local angiograms, lateral view, from a microcatheter.
A, Recanalization of the parietal artery.
B, Embolus in the M2 segment of the angular artery (arrow).
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