DOI: https://doi.org/10.21203/rs.3.rs-2044174/v1
PCI is a safe procedure and the preferred reperfusion method for patients with NSTEMI. However, certain complications may occur, including the possibility of stroke. Despite this risk, the occurrence of it is low (approximately 0.2-0.4%) [1]. Various mechanisms can cause cerebral ischemia, such as embolization of atherosclerotic plaque, clot formation in catheters, and air embolism during contrast injection during the surgery [2]. The main risk factors of CAD, in this case, are hyperlipidemia and long history of smoking. Some ischemic stroke risk factors are linked to catheterization, such as vascular anatomy, previous angiography, long cardiac procedures, amount of contrast, and wiring.
The aortic arch is a common source of emboli, and aortic arch atheromas are a separate risk factor for recurrent stroke. Cerebral microemboli are assumed to be the principal cause of PCI -related periprocedural ischemic strokes. This is corroborated by transcranial Doppler investigations performed during angiography, which reveal the presence of cerebral microemboli [3]. Preparation for complications owing to the complexity of lesions is essential for the safe treatment of all types of procedures; the availability of equipment to address complications, and an expert Cath lab staff are essential for success in complex PCIs [4].
A 49-year-old obese man was transferred from a rural hospital to the second affiliated hospital of XX University with acute myocardial infarction, having chest tightness and chest pain radiating to the back and shoulder. The patient has a 60-year smoking history, multivessel disease with hyperlipidemia, but no evidence of hypertension or diabetes. At the village clinic, a diagnostic catheterization was performed, and it was found that he had acute coronary syndrome and multivessel disease. Due to the lack of experienced doctors in the countryside, he was transferred to the city hospital. The patient's lung examination showed no alterations. A heart assessment showed a systolic murmur in the lower left sternal border. He had no neurological defects. The electrocardiogram showed HR of 66 bpm, sinus rhythm, the QRS complex of 104 bpm, and left atrial and ventricular enlargement. ST depression in V3, V4, and V5 leads and QS in the inferior wall, III, and aVF (Figure 1). Echocardiography revealed left atrial and ventricular enlargement, calcification of the aortic and mitral valves, and a 51% ejection fraction in the left ventricle. He was diagnosed with three-vessel disease, AMI Killip Grade I, and underwent cardiac catheterization, during which he suffered a severe ischemic stroke as a complication.
On the third day of admission, the patient was brought to the emergency Cath lab for revascularization. To enhance cardiomyocyte status before surgery, oral anticoagulants, lipid-lowering medication, and dual antiplatelets were given, as well as eptifibatide and nicotinamide IV injections, and blood pressure was 130/80. By using a right radial approach, 3000u of heparin sodium and 200ug of nitroglycerin were infused. The RCA ostium was reached with a SAL1.0 catheter, and angiography showed a 100 % acute total occlusion at the proximal end of the RCA, with a TIMI 0 forward blood flow (Figure 2A).
After 15 min of the procedure, the patient experienced sudden involuntary resistance in the left upper and lower limb activity with frequent head raising, and slurred speech, blood pressure was 133/85. According to the above clinical symptoms and signs, the patient was initially diagnosed with acute cerebral embolism. Given that the patient's vital signs were normal, but the RCA had a life-threatening subacute complete occlusion, the cardiologists recommended that the RCA be opened first to maintain heart perfusion before treating the cerebral embolism. After 5000u of heparin sodium was injected, a 2.0mm x 15mm balloon was inflated in the upper and middle parts of the RCA. Angiography revealed that the RCA still had no-reflow, indicating that the occluded segment was near the RCA's opening. Two 3.5x16mm and 3.0x28mm stents were inserted into the RCA's proximal end respectively. Although blood flow was restored, the middle and distal segments remained more than 90% occluded. A 3.0x24mm stent was placed in the middle of the RCA, and the RCA's forward blood flow reached a TIMI 3.
After 20 minutes of the occurrence of stroke, the neurologist decided to perform a CT scan first, which revealed acute cerebral thrombosis without hemorrhage. Cerebral angiography via a right femoral approach revealed an acute occlusion of the right middle cerebral artery (MCA) (Figure 3A). A stent retriever device was inserted along the entire length of the occlusion, and a tissue fragment measuring 0.5x0.4x0.3 cm was extracted. The right MCA was successfully revascularized within 50 minutes after the stroke occurred (Figure 3B), and the tissue was sent for analysis where it was identified as a fragment tissue thrombus (Figure 3C,3D).
After mechanical thrombectomy, the cardiologist decided to complete RCA revascularization as there was severe stenosis in the distal part of the right RCA. The RCA was revascularized with TIMI 3 blood flow after a 2.5x13mm Lacrosse balloon was inflated first, followed by two drug-coated balloons (DCB) (2.5.5x20mm,2.75x31mm) along the occluded segment. (Figure 2B)
The staged method for non-culprit lesions has improved short and long-term survival and should remain the standard approach for primary PCI in AMI patients [5]. The team decided to revascularize the left coronary vessels after a few days because a single complete multivessel recanalization may be linked to increased risks of renal failure. Three days after rehabilitation, the patient had normal eye movements whereas extremity movements occurred within 5 weeks.
The LAD and LCx vessels were recanalized a week later. In order to avoid secondary cerebral embolism caused by the radial artery approach, the femoral artery approach was selected. Angiography showed that there were multiple atherosclerotic plaque lesions along LAD, 70% stenosis of the diagonal D1 orifice, and chronic occlusion of proximal LCx with forwarding blood flow TIMI 1. (Figure 4A).
In the proximal LAD, a 2.5x13mm Lacrosse balloon was inflated, and a 15x15mm balloon was in the D1 orifice. Then, two (2.75x16mm, 30x16mm) stents were sequentially inflated in the proximal end and a 2.0x31mm DCB in the distal end. Angiography showed normal TIMI3 forward blood flow. At the proximal end of LCx, CSW135 microcatheter penetrated the occlusion. A 1.5x15mm balloon was inflated in the proximal segment OM1 and LCx, then two (2.0x24mm, 2.0x16mm) DCB were released along the proximal LCx. Angiography showed that the stenosis was relieved and forward blood flow was TIM3. (Figure 4B) After surgery, the patient was stable and safely returned to the ward.
The patient has recanalized the culprit artery (RCA) and the non-culprit arteries (LAD, LCx) with a 58% ejection fraction. The right MCA was successfully revascularized. Three days after rehabilitation, the patient regained normal eye movements whereas extremity movements recovered within 5 weeks.
This case contains several points, including acute coronary syndrome NSTEMI, triple coronary artery disease, and acute ischemic stroke as a complication during the procedure. Obviously, there are studies that investigate these cases separately, but in this report, the study combines these cases into one investigation.
Acute myocardial infarction requires immediate medical attention. Treatment of a stroke within 8 hours after its occurrence, on the other hand, is equally critical to avoid its complications and preserve the patient's health [6]. Revascularization of the completely narrowed culprit and non-culprit arteries takes precedence over revascularization of the affected culprit artery alone in multi-vessel patients because it reduces mortality rates. [2]. Performing PCI procedures in stages improves outcomes and increase the patient's ability to tolerate greater risks [5].
There are several contraindications to tissue plasminogen activator (t-PA) therapy, including a history of nontraumatic cerebral bleeding and early ischemic abnormalities on CT or MRI [7]. Because anticoagulation with heparin and a prolonged APTT are contraindications to systemic thrombolysis, intravenous t-PA was not used, and the thrombus was removed by MT [6].
A case of ischemic stroke was treated endovascularly with a stentriever. Histopathologic examination of the salvaged material revealed endothelialized tissue resembling the internal portions of an artery with atherosclerotic wall changes [8]. These and our results demonstrate that mechanical thrombectomy techniques can remove tissue from cerebral arteries.
Contrast is the focus of this investigation on Left MCA strokes with cardio-cerebral infarctions (CCI): a case series and literature analysis to highlight the different methods to care. Medical therapy and mechanical thrombectomy were both shown to be beneficial, but further research is needed to determine the optimal treatment strategy [9].
In patients with acute ischemic stroke (AIS) caused by an emergent large vessel occlusion, the American Heart Association/American Stroke Association (AHA/ASA) recommends strongly that endovascular MT be used when the causative occlusion occurs in the internal carotid (ICA) or proximal MCA [10].
Finally, for patients previously operated on PCI with a radial approach, it is not recommended to use it again without making sure that there is no radial vasospasm or else a femoral approach is preferred for further treatment [11]. The use of appropriate catheters for each case in terms of size and quality and administration of necessary medications before the procedure are considered safe methods to avoid the formation of thrombi and vascular dissections [12].
Ischemic stroke is a rare complication in PCI procedures and mechanical thrombectomy is the preferred treatment of choice.
ETHICAL APPROVAL
In this case, the University Ethics Committee XX (2021- XX) approved the study, and IRB approval was not required. This study followed the criteria of the guidelines for case reports and clinical management of patients with acute myocardial infarction followed by an ischemic stroke.
Footnotes
Informed consent statement: This study followed the criteria of the guidelines for case reports and clinical management of patients with acute myocardial infarction followed by an ischemic stroke. the patient was informed of written consent prior to study enrollment.
Conflict-of-interest statement:
All authors have nothing to disclose.