Transbrachial Mechanical Thrombectomy for Acute Ischemic Stroke in Marfan's Syndrome: A Case Report

Abstract

Objective: Marfan's syndrome (MFS) is a systemic connective tissue disorder with autosomal dominant inheritance. Cardiovascular complications of MFS such as aortic root or valve disease and aortic aneurysm or dissection are potential cause of access route problems of mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Here, we report a case of a patient with MFS who underwent MT for AIS.

Case presentation: A 58-year-old woman with MFS presented with a sudden onset of consciousness disturbance and right hemiparesis, and was referred to our hospital. After the infusion of tissue plasminogen activator, CTA showed a type III arch in the aortic arch and severe tortuosity of the thoracoabdominal aorta; thus, angiography was performed using the transbrachial approach. Left common carotid angiogram showed complete recanalization of the left middle cerebral artery. On the sixth day, the patient presented a sudden consciousness disturbance and left hemiparesis. MRA showed right internal carotid artery occlusion. MT was performed by the transbrachial approach, and complete recanalization was achieved on the first pass.

Conclusion: MT via the transbrachial approach is a treatment option that should be considered, especially in MFS, where the transfemoral approach is difficult due to anatomical problems.

Keywords: Marfan’s syndrome; acute ischemic stroke; mechanical thrombectomy; transbrachial approach.

Fig. 1. (A) In the anterior view, preoperative 3D CTA showed that flexion of the aorta and the angle between left common carotid artery (white arrow) and the aortic arch were very steep. (B) In the posterior view, an artificial vascular stent was placed in the thoracoabdominal aorta and a thoracoabdominal aortic aneurysm was also observed.

Fig. 2. Postoperative findings in the imaging studies. (A) On day 1, echocardiography revealed a 17-mm thrombus in the left atrial appendage (white arrow). (B) After MT, the thrombus in the left atrial appendage had disappeared on day 7. MT: mechanical thrombectomy

Fig. 3. (A–C) On day 6, DWI showed a high-intensity area in the right insular cortex and deep white matter; T2-weighted imaging showed a low-intensity area (black arrow) in the right ICA; and MRA showed right ICA occlusion. (D) In the anterior view, the transbrachial approach was selected again, and cerebral angiography before MT showed right carotid artery occlusion. (E and F) In the anterior view, we performed MT using a combined technique with a stent retriever (white arrowheads) and an aspiration catheter (black arrowhead). (G) Angiogram after MT showed complete recanalization of the right ICA (TICI 3). DWI: diffusion-weighted imaging; ICA: internal carotid artery; MT: mechanical thrombectomy; TICI: thrombolysis in cerebral infarction

Fig. 4. On 30 days after MT, no local complications were found in the puncture site. MT: mechanical thrombectomy