Successful mechanical thrombectomy with an aspiration catheter for fenestrated basilar artery occlusion guided by preoperative basi-parallel anatomical scanning

Abstract

Basilar artery (BA) fenestration and its occlusion are relatively rare conditions. Mechanical thrombectomy for fenestrated BA occlusion has a high risk of complications. One limb occlusion or partial occlusion of fenestration mimics arterial stenosis or dissection. We present the case of a 75-year-old woman who presented with slight dysarthria, which subsequently worsened. Magnetic resonance imaging, magnetic resonance angiography, and basi-parallel anatomical scanning (BPAS) revealed BA fenestration and occlusion of the larger limb of the fenestrated BA, for which we performed thrombectomy with aspiration and achieved Thrombolysis in Cerebral Infarction Grade 3 flow restoration without procedure-related complications. If BA occlusion occurs at a site where a thrombus does not normally occur, confirming the anatomy of the BA before thrombectomy is desirable. As we obtained information on BA fenestration and occluded limb diameter using preoperative BPAS, we were able to safely achieve effective recanalization by guiding a relatively large-diameter aspiration catheter to the thrombus coaxially with a micro-guidewire and microcatheter.

Keywords: Aspiration; Basi-parallel anatomical scanning; Cerebrovascular disease; Endovascular treatment; Fenestrated basilar artery occlusion; Ischemic stroke.

Fig. 1

Magnetic resonance angiography (MRA) at admission. Although the basilar artery is poorly visualized on MRA, it is visible on the periphery. Severe stenosis of the basilar artery was suspected.

Fig. 2

Magnetic resonance angiography (MRA) 8 hours after admission. (A) MRA indicates severe stenosis of the basilar artery, similar to the initial one. (B) Basi-parallel anatomical scanning reveals basilar artery fenestration and that the diameter of the left side major thick lumen is approximately the same as the proximal or distal side of the fenestration of the basilar artery. The left anterior inferior cerebellar artery originates from the occluded major limb.

Fig. 3

Digital subtraction angiography and thrombectomy. (A) Under local anesthesia, a 6-Fr guided catheter (FUBUKI; ASAHI INTECC, Aichi, Japan) is positioned at the right vertebral artery (VA) via the right brachial artery. Preoperative right VA angiography reveals thrombus occlusion of the major limb of the fenestration and basilar artery (BA) distal. (B) The microcatheter (⁑) (Phenom 21; Medtronic, California, USA) is placed distal to the fenestration of the BA through the major limb along with a 0.014-inch microguidewire (*) (Synchro SELECT soft; Stryker, Michigan, USA). A 5-Fr aspiration catheter (⁂) (SOFIAFLOW; TERUMO, Tokyo, Japan) is navigated to the major limb along with a microcatheter, where it is brought into contact with the thrombus, and the thrombus is aspirated. (C) Although the thrombus of the major limb was removed, and the fenestration of the BA was recanalized, the thrombus at the distal BA remained. (D) The microcatheter (⁑) is placed in the right posterior cerebral artery through the major limb along with a microguidewire (*). The aspiration catheter (⁂) is navigated to the distal BA along with the microcatheter, where it is brought into contact with the thrombus, and the thrombus is aspirated. (E) The thrombus of the BA distal is removed, and the BA is completely recanalized.