Superselective thrombolysis in basilary artery thrombosis

Clinical History

Acute basilary thrombosis

Imaging Findings

A 51-year-old male had been found unconscious at home. After being admitted to the hospital and after intubation, cerebral CT was performed showing a hyperdense basilary artery at native scans (Fig. 1 a). In contrast-enhanced imaging reduced perfusion of the basilary artery was seen being suspicious for acute basilary thrombosis (Fig. 1 b) . Without further delay, angiography of all cerebral arteries was performed showing no further abnormalities but an occlusion of the top of the basilary artery (Fig 2a) Through a 4 F head-hunter catheter placed into the left vertebral artery, a 3 F superselective catheter was advanced into the basilary artery and superselective angiography stated a non-wall-adherent thrombus within the top of the basilary artery protruding into the right posterior cerebral artery (Fig. 2b). Due to the severeness of findings, thrombolysis was immediately started using a dose of 30 mg rtPA/ h over two hours. After two hours complete recanalization of the basilary artery and right posterior cerebral artery was achieved but some of the samller branches remained partially occluded (Fig. 3). Intervention was thus terminated. Leaving the arterial sheath in the right common femoral artery, the patient was transferred to the intensive care unit. The next couple of hours were uneventful but after 6 hours, the patient became hypertensive by sudden and died within 30 minutes despite continuous attempts to resuscitate. No autopsy was performed

Discussion

Basilary thrombosis is a majorly life threatening situation. If not lethal major neurological deficits may occur including a locked-in syndrome or larger cerebellar and pontine infarction. It is accepted as an indication for selective thrombolysis requiring high doses of lytic agents in order to quickly reopen the occluded segment. A dosage from 0.5 mg/ min to 2 mg/ min up to a total of 90 to 100 mg have been used. Nevertheless, technical success is moderate with about 60% of success. Lytic period should not exceed two hours even if remaining unsuccessful. Potential complications are bleeding into the infarcted brain, bleeding elsewhere, recurrent basilar artery thrombosis or upward herniation due to swelling of the infarcted brain tissue. In our case, bleeding into the cerebellum and herniation are the probable causes of death. Contraindications to thrombolysis are lack of symptoms however and brain infarct visible on primary CT. Nevertheless, indication for thrombolysis is granted liberally due to the malignancy of the event and to offer at least a very last chance for survival.

Differential Diagnosis List

Final Diagnosis

Technically successful thrombolysis of basilary thrombosis

URL:	https://www.eurorad.org/case/1050
DOI:	10.1594/EURORAD/CASE.1050
ISSN:	1563-4086