Intra-arterial Thrombolysis in Acute MCA Occlusion from an Extracranial ICA Aneurysm

Abstract

A case of acute occlusion of the right ICA and MCA from a fusiform/dissecting aneurysm of the upper cervical ICA was successfully treated with an entirely endovascular approach. Long-term clinical follow-up is available. This 41 year-old-woman presenting with TIAs underwent magnetic resonance angiography that showed total occlusion of the right ICA. The day after she suddenly became hemiplegic, hemianopic, and confused. Three vessel angiography demonstrated occlusion of the right ICA and MCA. Super-selective angiography showed a fusiform/dissecting aneurysm of the upper cervical ICA. Urokinase infusion in the occluded right MCA was performed, thus establishing collateral blood flow via the contralateral carotid artery within 4 hours from the onset of the symptomatology. To prevent further repeated thrombo-embolic events, the right ICA was permanently occluded with GDC coils, trapping the aneurysm. The patient gradually improved and, at the three-year follow-up she had resumed her previous occupation being completely independent, with only a mild difficulty in writing. This is the first reported case of an acute MCA embolism from a fusiform/dissecting extracranial ICA aneurysm treated with MCA thrombolysis followed by aneurysm trapping. The possible aetiology of the underlying lesion and the different therapeutic options are discussed.