Mechanical Thrombectomy via Transbrachial Approach in the Emergency Management of Acute Ischemic Stroke Patients with Aortic Pathologies: Our Experience and Literature Review

Abstract

Study design: Mechanical thrombectomy (MT) via the transbrachial approach (TBA) is a very rare option used in cases of patients with aortic pathologies and acute ischemic stroke (AIS) due to the insufficient evidence in the literature, the difficulty from a technical point of view and the result of this technique influenced by the complications that frequently accompany it.

Background: Only a few cases of patients with aortic pathologies and acute ischemic stroke where MT via TBA were reported in the literature, and its application in the emergency management of AIS has still not been dealt with in detail.

Objectives: Out of a need to clarify and clearly emphasize the effectiveness of this approach in emergency MT via TBA in patients with AIS and aortic pathologies, this literature review and case report has the following objectives: the first one is the presentation of an emergency MT via transbrachial approach performed in a 44-year-old patient with AIS and diagnosed aortic coarctation during transfemural approach (TFA), with successful reperfusion in our department and the second one is to review the cases reports of patients with different aortic pathologies and AIS reperfusion therapy performed by MT via TBA from the literature.

Methods: A total of nine cases (one personal case and eight published cases) were revised in terms of aortic pathologies type, reperfusion therapy type, and the complication of both mechanical thrombectomy and local transbrachial approach.

Results: Mechanical thrombectomy through the transbrachial approach was the first choice in more than half of these cases (55.55%, n = 5 cases) in the treatment of acute ischemic stroke in the presence of previously diagnosed aortic pathologies. In one-third of all cases (33.33%, n = 3, our case and 2 case reports from the literature), the transbrachial approach was chosen after attempting to advance the guiding catheter through the transfemoral approach and intraprocedural diagnosis of aortic pathology. In only one case, after an ultrasound evaluation of the radial artery that showed a monophasic flow, MT was performed via TBA. Local transbrachial complication was reported in one case, and in two other cases, it was not stated if there were such complications. Hemorrhagic transformation of AIS was reported in two cases that underwent MT-only cerebral reperfusion via TBA, one with acute aortic dissection type A and our case of previously undiagnosed aortic coarctation. In the cases in whom short and long-term follow-up was reported, the outcome of treatment, which was not exclusively endovascular (77.77% cases with only MT and 33.33% with association of first thrombolysis and after MT), was good (six from nine patients). In two case reports, the outcomes were not stated, and one patient died after a long hospitalization in the intensive care unit from respiratory complications (our patient).

Conclusions: Being a clinical emergency, acute ischemic stroke requires urgent medical intervention. In patients with aortic pathologies, where acute ischemic stroke emergency care is a challenge, mechanical thrombectomy via the transbrachial approach is a safe alternative method for cerebral reperfusion.

Keywords: acute ischemic stroke emergency management; aortic pathologies; case report; literature review; mechanical thrombectomy.

Figure 1

The left image displays the initial CT scan of the head, revealing no significant indications of ischemic or hemorrhagic events. The PC-ASPECTS score was 10. A hyperdense right middle cerebral artery is visible, indicated by a blue arrow. The right image shows a multiphase head angiography-CT, confirming the presence of a thrombus at the level of the MCA as segment M1, as indicated by a red arrow.

Figure 2

The lateral view of the digital subtraction angiography shows the occlusion of the right anterior cerebral artery (MCA) before the endovascular thrombectomy (left image). After the procedure (right image), a complete revascularization of the previously occluded arterial territory was successfully achieved.

Figure 3

Head CT scan performed at 24 h after mechanical thrombectomy showed residual contrast substance in the nucleus basalis after revascularization—without established cerebral ischemia (red circle). The PC-ASPECTS was 10.

Figure 4

Head CT scan perform at 7 days after MT showed ischemia in the vascularized territory (lentiform nucleus and in the fronto-temporal-insular right lobe) (red circle).