Angioplasty and Stenting for the Internal Carotid or Middle Cerebral Artery Occlusion in

a Subacute Stroke Stage in Deteriorating Patients with

the Internal Border Zone Infarcts

Iwata T, Mori T, Tajiri H, Uesugi T, Nakazaki MDepartment of Stroke Treatment

Shonan Kamakura General Hospital Stroke Center, Kamakura City, 　 Japan

Background• Neurological symptoms of some patients with the

internal carotid artery (ICA) or the middle cerebral artery (MCA) occlusion are mild at onset but deteriorate day by day.

• Several days after the onset, the internal border zone (IBZ) infarcts occurs.

• However, it is not established how to treat them in a subacute stroke stage and how to improve their clinical outcome.

Purpose

The internal border zone (IBZ) means an arterial border zone differentiated from the cortical border zone(CBZ). The purpose of our retrospective study is to investigate whether or not angioplasty and/or stenting for the ICA or MCA occlusion in a subacute stroke stage can improve clinical outcome in severely disabled patients due to the internal border zone (IBZ) infarcts.

IBZ(A) and CBZ(B) infarcts

Contour map of frequency of affected sites in the IBZ (A) and CBZ (B) infarcts. The location of the IBZ can vary along the lateral ventricle, whereas the CBZ is distributed more heterogeneously as wedged areas that extend from the frontal and occipital horn of the lateral ventricle or within the paramedian white matter at the supraventricular level.

Seok Woo Yong, et.al. Stroke. 2006;37:841-846

　 Patients (1)• Acute ischemic stroke patients• Period: Jan 2004 to Dec 2008• Onset-to arrival tine: within 72 hours• Emergency MRA showed the ICA or MCA occlusion • DWIs showed no extensive infarcts in the ICA or MCA

territory.• No cerebral hemorrhage on CT scans

Patients (2)

• Their neurological symptoms were mild at onset and modified Rankin Scale (mRS) was 2 or less then.

• They deteriorated day by day despite dual antiplatelets.• Modified RS (mRS) was 4 or more on the 7th day. • CT scans or MR images on the 7th day demonstrated the

internal border zone (IBZ) infarcts.

Groups of the patients

group E: patients who gave written informed consent and underwent

angioplasty and/or stenting for the ICA or MCA occlusion from 7 to 14 days after the stroke onset

group C: patients who did not.

Evaluation• Patients’ baseline features• NIHSS on admission• NIHSS on the 7th day• NIHSS on discharge• Hospitalization periods• mRS on discharge • mRS at 3 months

Compared between two groups.

Results (1)　　 　 Group E Group C p Value

　　　　　　　　　　　　　 (n=6) (n=11) • Age, median,• (IR) [years] 71.5 (64-75) 82 (72-86) NS• Male sex , • no., (%) 4 (66.7%) 7 (63.6%) NS• Hypertension ,• no.(%) 6 (100.0%) 10 (90.9%) NS• Hyperlipidemia, • no.(%) 4 (66.7%) 6 (54.5%) NS • Diabetes mellitus,• no.(%) 　 4 (66.7%) 6 (54.5%) NS• MCA occlusion,• no., (%) 4 (66.7%) 8 (72.7%) NS

Results (2)Group E Group C p Value

(n=6) 　 (n=11)

NIHSS on admission,median, (IR) 6.5 (5.25-11.5) 6 (4-9.5) NSNIHSS on the 7th day, median, (IR) 13 (12-16.25) 12 (10-13.5) NSNIHSS on discharge,median, (IR) 7 (6.25-10.75) 13 (11-18.5) NSmRS on dischargemedian, (IR) 4.5 (4-5) 5 (4-5) NSHospitalizationperiod [days], (IR) 11 (11-11) 12 (9-13) NS

mRS at 3 month (m) 2.5 (2-3.75) 4(4-5.5) 0.0127**

Case(the MCA Occlusion)

A 63-year-old woman was admitted to our institution, since her right-sided hemiparesis deteriorated over 60 hours.

CT and MRI on admission (3rd day)

CT T2WI DWI

63-yo-female

MRI and MRA on admissionMRA

PWI (time-intensity curve)

Left MCA territory

Treatment and clinical course

She took dual antiplatelets agents. However, her neurological symptoms deteriorated day by day.

Diagnostic left carotid angiography (6th day)

Total occlusionof the Left MCA

A-P view Lateral view

Left MCA occlusion

Estimated length of the occlusion

Probable peripheral branch of the MCA opacified via collateral circulation

M1

CT scans (8th day)The NIHSS score rose up to 30.

CT scans showed the IBZ infarcts.

Balloon Angioplasty for the Left MCA Occlusion (9th day)

Gateway 2.0mm×12mm

Synchro-14S 300cm

Total occlusionof the Left MCA

AP view

Successful balloon angioplasty (9th day)

Lateral viewAnteroposterior view

Clinical outcome of the patient

• NIHSS on the 3rd day: 23• NIHSS on the 7th day: 30• NIHSS on the 11th day: 18• Hospitalization periods: 11 days• mRS on discharge: 5

• mRS at 3 months: 3

ConclusionAngioplasty and stenting for the ICA or

MCA occlusion, even more than 7 days after the stroke onset, may be feasible and effective in improving their 3-month clinical outcome in severely disabled patients due to the internal border zone infarcts .