Case Report Bilateral Mechanical Thrombectomies for Simultaneous MCA Occlusions Christopher Storey, Jonathon Lebovitz, Ahmad Sweid, Stavropoula Tjoumakaris, Reid Gooch, Robert H. Rosenwasser, Pascal Jabbour Key words - Bilateral MCA Stroke - Endovascular treatment - Ischemic Stroke - Mechanical Thrombectomy Abbreviations and Acronyms CT: Computed tomography ICA: Internal carotid artery MCA: Middle cerebral artery TICI: Thrombolysis in cerebral infarction - BACKGROUND: Bilateral hemispheric dysfunction is devastating to consciousness. We present a unique case of a patient who developed bilateral middle cerebral artery infarcts with significant neurological improvement post bilateral thrombolysis in cerebral infarction (TICI) 3 thrombectomies. - CASE DESCRIPTION: The patient is a 64-year-old woman who presented 3 Journal homepage: www.journals.elsevier.com/worldneurosurgery hours after her husband was awakened and found her with left hemiplegia. She had a history of atrial fibrillation and had her apixaban held for 5 days before the coronary angiogram that she received the day before arrival. Upon presentation, she was antigravity on the right side and withdrawing on the left side. Computed tomography angiogram showed a right M1 occlusion and an left M2 occlusion. Computed tomography perfusion revealed a mismatch with large penumbra, and she was taken for mechanical thrombectomy. Mechanical thrombectomy was performed using a combination of stent retriever and aspiration catheter with a TICI 3 revascularization. By the following morning, the patient was full strength on the right and antigravity on the left with a left facial droop. The patient recovered her speech and was fully oriented before leaving for rehabilitation on postoperative day 3. Available online: www.sciencedirect.com - CONCLUSIONS: The transient hypercoagulable state that was created with 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved. the withdrawal of apixaban likely increased our patient’s risk of stroke. The literature supports continuing oral anticoagulants for endovascular procedures. The devastating consequences of thromboembolic events, whether stroke or pulmonary embolism, can be catastrophic, but luckily, mechanical thrombectomy provides the means to minimize the morbidity and mortality from bilateral infarctions. Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA To whom correspondence should be addressed: Pascal Jabbour, M.D. [E-mail: pascal.jabbour@jefferson.edu] Citation: World Neurosurg. (2019) 132:165-168. https://doi.org/10.1016/j.wneu.2019.08.236 INTRODUCTION Bilateral hemispheric dysfunction is devastating to consciousness. There are few reported cases of bilateral middle cerebral artery (MCA) occlusions, but most either occurred chronically or at separate times. We present a unique case of a patient who developed bilateral MCA infarcts with significant neurological improvement post bilateral thrombolysis in cerebral infarction (TICI) 3 thrombectomies. CASE REPORT The patient is a 64-year-old woman who presented 3 hours after her husband was awakened and found her with left hemiplegia. She had a history of atrial fibrillation and had her apixaban held for 5 days before the coronary angiogram that she received the day before arrival. She resumed her apixaban the evening before she arrived. At the outside hospital, she presented with a Glasgow Coma Scale score of 5 and was intubated but improved to following commands on the right side on arrival at our institution. She was antigravity on the right side and withdrawing on the left side. Computed tomography (CT) angiography showed a right M1 occlusion and an left M2 occlusion (Figure 1A). CT perfusion showed a mismatch with large penumbra, and she was taken for mechanical thrombectomy (Figure 1B, C). We chose to start with the right M1 occlusion (Figure 2A) due to the larger territory at risk and the worse associate neurological exam. The left femoral artery was accessed with an 8F sheath. A 90-cm Neuronmax (Penumbra, Alameda, CA) and a React 71 (Medtronic, Fridley, MN) were used for distal right internal carotid artery (ICA) access. Marksman (Medtronic) microcatheter WORLD NEUROSURGERY 132: 165-168, DECEMBER 2019 and Synchro 2 (Stryker, Kalamazoo, MI) wire were used to access the distal MCA. An Embotrap device (Cerenovus, Miami, FL) was deployed across the clot (Figure 2B). The Embotrap device was retrieved under aspiration of the React 71 catheter, which was advanced over the Embotrap during retrieval into the distal M1. The React 71 catheter was withdrawn under aspiration until flow was noted. After back bleeding, digital subtraction angiography showed TICI 3 revascularization (Figure 2C). We then proceeded to the left ICA with the same setup where digital subtraction angiography verified the L M2 thrombus (Figure 3A). Using the same technique as before, an Embotrap was deployed with good distal filling on digital subtraction angiography (Figure 3B). Using the same www.journals.elsevier.com/world-neurosurgery 165 CASE REPORT CHRISTOPHER STOREY ET AL. SIMULTANEOUS BILATERAL MCA OCCLUSIONS Figure 1. Computed tomography (CT) angiography/perfusion showing bilateral middle cerebral artery occlusion with a large penumbra. (A) Coronal CT angiography reconstruction showing a right M1 occlusion retrieval technique as above, a TICI 3 revascularization was achieved (Figure 3C). The patient was extubated later that day, and by the following morning, she was full strength on the right and antigravity on the left with a left facial droop. Her apixaban was restarted on postoperative day 1 after magnetic resonance imaging showed a right basal ganglia infarct and small left-sided infarcts (Figure 4). The infarcts correlated with the areas with completed infarct noted on the CT perfusion (Figure 1C). She also recovered her speech and was fully oriented before leaving for rehabilitation on postoperative day 3. DISCUSSION There are only a few reported cases of patients presenting with bilateral MCA occlusions. One case was a young man with severe neurocysticercosis who presented with acute right hemiparesis.1 The left MCA had occluded acutely, but the right MCA likely occluded over time, as shown by the significant collateral development and the lack of symptoms. Another was a 14month-old child, who presented with bilateral MCA occlusion that was demonstrated on angiogram.2 The autopsy determined that was likely due to high output heart failure. Another reported a 53-year-old man who presented after a motor vehicle crash who had right hemiparesis and aphasia.3 Angiography revealed bilateral MCA occlusions of unknown etiology. He improved to understand some simple words and was discharged to an extended care facility without further neurological improvement. The only reported case of bilateral thrombectomies occurred 20 days apart; the patient was a 66-year-old man who was hypercoagulable Figure 2. Mechanical thrombectomy of R M1 occlusion using Embotrap device (Cerenovus, Miami, FL) and React 71 catheter (Medtronic, Fridley, MN). Anteroposterior digital subtraction angiography showing (A) right M1 166 www.SCIENCEDIRECT.com (black arrow) and an L M2 occlusion (black circle). An axial CT perfusion showing (B) increased in mean transit time along with preserved (C) cerebral blood volume consistent with partial compensation. due to adenocarcinoma.4 TICI 3 was achieved in both thrombectomies and he had recovery of his hemiparesis after each instance. In our case with simultaneous and uncompensated MCA occlusions, the patient likely had bilateral M1 occlusion due to a presentation at the outside hospital with a Glasgow Coma Scale score of 5, but as the thrombus moved to the M2 branch, it decreased the bilateral cortical dysfunction. These cases demonstrate the devastating outcome of bilateral MCA occlusion without mechanical thrombectomy. In our case, we chose to start with right MCA occlusion. Although the left side is the dominant side, we felt that treating the side with the worst neurological exam and largest at-risk territory was essential. There is a recent report in which the authors used bilateral groin access to perform bilateral simultaneous thrombectomies in a similar occlusion (black arrow); (B) deployment of the Embotrap device across the R M1 occlusion; and (C) TICI 3 revascularization. WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.236 CASE REPORT CHRISTOPHER STOREY ET AL. SIMULTANEOUS BILATERAL MCA OCCLUSIONS Figure 3. Mechanical thrombectomy of L M2 occlusion using Embotrap device (Cerenovus, Miami, FL) and React 71 catheter (Medtronic, Fridley, MN). Anteroposterior digital subtraction angiography showing (A) left M2 patient.5 We used the Embotrap device with a modified captive technique. The Embotrap device has an embolization protection on the end that should retrieve any clot that is sheared when retrieving through the aspiration catheter. Using our technique, we were able to obtain bilateral TICI 3 on each first pass. By lodging the aspiration catheter in the distal MCA segment, there is theoretical flow arrest to prevent distal embolization due to occlusive nature of the large aspiration catheter. Patients on anticoagulation who require procedures pose a challenge to their surgeons on the appropriate management of their anticoagulation in the periprocedural period. Our patient’s leading risk factor for her stroke was her recently held apixaban for her coronary angiogram. Historically, Figure 4. Diffusion-weighted magnetic resonance axial imaging showing a right basal ganglia infarct and small left-sided infarcts. occlusion (black arrow); (B) deployment of the Embotrap device across the L M2 with good distal filling; and (C) TICI 3 revascularization. anticoagulation was held prior to the procedure with or without a bridging therapy depending on the indication and individual risk factors of each patient. As our anticoagulation options have evolved from vitamin K antagonist to novel oral anticoagulants, this issue has become more challenging. A meta-analysis in 2010 was performed on reports of patients undergoing coronary angiography that determined that not stopping anticoagulation was as safe as stopping anticoagulation, but more studies were needed.6 A 2015 study looked at this issue further and concluded that transradial coronary angiography is safe and does not pose any additional complications.7 Multiple studies have shown the safety and efficacy with reduced complication without holding anticoagulants for cardiac ablations.8-11 With the evidence we have, especially with patients at high risk of thromboembolic events, the evidence and our experience are in favor of continuing anticoagulants for endovascular procedures. Several studies have shown transient hypercoagulability after abrupt withdrawal of oral anticoagulants.12 Biochemical analysis has shown that withdrawal from oral anticoagulants can cause a hypercoagulable state.13 A meta-analysis showed that withdrawal from newer anticoagulants over warfarin had a higher risk of thromboembolic events.14 Patients also were shown to undergo transient hypercoagulable state when holding apixaban for cardiac ablation.15 This “rebound effect” could cause thromboembolic events, as in our patient. Therefore, if a high-risk patient does require oral anticoagulants to be held, it would wise to err on the side of caution and bridge with a heparin infusion. WORLD NEUROSURGERY 132: 165-168, DECEMBER 2019 CONCLUSIONS The transient hypercoagulable state that was created with the withdrawal of apixaban likely increased our patient’s risk of stroke. The literature supports continuing oral anticoagulants for endovascular procedures. The devastating consequences of thromboembolic events, whether stroke or pulmonary embolism, can be catastrophic, but luckily, mechanical thrombectomy provides the means to minimize the morbidity and mortality from bilateral infarctions. Patient consent was taken before the inscription of this case report. REFERENCES 1. terPenning B, Litchman CD, Heier L. Bilateral middle cerebral artery occlusions in neurocysticercosis. Stroke. 1992;23:280-283. 2. Pascual Castroviejo I, Larrauri J. Bilateral thrombosis of the middle cerebral artery in a child aged 14 months. Dev Med Child Neurol. 1971;13:613-620. 3. Jacques S, Shelden CH, Rogers DT, Trippi AC. Posttraumatic bilateral middle cerebral artery occlusion. Case report. J Neurosurg. 1975;42:217-221. 4. Inoue S, Fujita A, Mizowaki T, et al. [Successful treatment of repeated bilateral middle cerebral artery occlusion by performing mechanical thrombectomy in a patient with Trousseau syndrome]. No Shinkei Geka. 2016;44:501-506. 5. 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Received 17 July 2019; accepted 29 August 2019 Citation: World Neurosurg. (2019) 132:165-168. https://doi.org/10.1016/j.wneu.2019.08.236 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 14. Hermans C, Claeys D. Review of the rebound phenomenon in new anticoagulant treatments. Curr Med Res Opin. 2006;22:471-481. 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.236