Perfusion-computed tomography for simultaneous bilateral middle cerebral artery occlusion
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Perfusion-computed tomography for simultaneous bilateral middle cerebral artery occlusion Andrea Naldi 1,2 & Alessandra Di Liberto 1 & Enrica Duc 1 & Alessandro Rapellino 3 & Giacomo Paolo Vaudano 3,4 & Roberto Cavallo 1 & Andrea Boghi 4 Received: 26 September 2020 / Accepted: 16 November 2020 # Fondazione Società Italiana di Neurologia 2020
Abstract Bilateral simultaneous middle cerebral artery occlusion is a rare condition that may lead to severe neurological disability or death, thus requiring rapid intervention in order to restore vessels patency and brain perfusion. Perfusion-computed tomography is demonstrated to be a fundamental tool for selecting stroke patients candidate to mechanical thrombectomy, but its role for guiding the optimal strategy of endovascular treatment in concomitant multivessel cerebral occlusion has never been reported. We describe a case of bilateral middle cerebral artery occlusion in which perfusion-computed tomography was crucial both for addressing to endovascular procedure and planning the sequence treatment of mechanical thrombectomies. Keywords Perfusion-computed tomography . Middle cerebral artery occlusion . Bilateral . Mechanical thrombectomy
Introduction Bilateral simultaneous middle cerebral artery (MCA) occlusion is a rare condition that may present with sudden unconsciousness and lead to severe neurological disability or death [1]. Therefore, rapid interventions such as intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are required in order to restore vessel patency and brain perfusion, but they have to be performed within 4.5 and 6 h from symptom onset, respectively. However, the time window for endovascular procedure may be extended until 24 h since symptom onset when a mismatch between salvageable tissue (penumbra) and ischemic core is demonstrated by CT perfusion (CTP) imaging [2, 3]. Bilateral concomitant middle cerebral artery occlusion potentially requires a double endovascular treatment,
* Andrea Naldi [email protected] 1
Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
2
Department of Neuroscience “Rita Levi Montalcini”, University of Turin, Turin, Italy
3
Radiology Unit, San Giovanni Bosco Hospital, Turin, Italy
4
Neuroradiology Unit, San Giovanni Bosco Hospital, Turin, Italy
but the optimal strategy for the procedures is still unknown. We present a case of acute bilateral MCA occlusion in which CTP had a crucial role guiding the approach to MTs.
Case presentation An 84-year-old woman with a history of hypertension (modified Rankin Scale, mRS = 1) presented to our emergency department at 1:30 pm for unconsciousness. She was found unresponsive at 11 am and the last time seen in normal condition was at 2 am. Electrocardiography revealed an atrial fibrillation previously undiagnosed. Non-enhanced cranial CT demonstrated early ischemic signs on right basal ganglia and corona radiata and on left insula (Alberta stroke program early CT score [ASPECTS] = 7, bilaterally). CT angiography documented bilateral M1 o
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