Introduction: Mechanical thrombectomy is used to treat acute ischemic stroke patients with arterial occlusions but complications can include: reperfusion hemorrhage, distal embolization, and vessel dissection. We present a previously unreported complication of mechanical thrombectomy: brachial artery embolism.
Methods: Literature review and case presentation.
Results: A 72 year-old woman with recently diagnosed stage 3A lung cancer presented with a basilar stroke syndrome. Examination revealed the following: mild drowsiness, anarthria, bifacial weakness, lower extremity plegia, upper extremity paresis and ataxia, and bilateral upgoing toes. NIHSS was 21. CT head scan showed a hyperdense basilar artery. CT angiogram revealed a proximal basilar artery occlusion with no filling of the entire artery and a large left lung mass extending into the left subclavian artery, resulting in complete occlusion of the artery proximal to the vertebral artery origin.
She was treated with IV tPA, after which her NIHSS improved to 7, and subsequently underwent mechanical thrombectomy. Catheter angiography confirmed persistent, long segment basilar occlusion. Solitaire stent retriever was deployed and successful on the first pass with complete recanalization and no evidence of distal emboli. However, as no thrombus was found in the stent when it was withdrawn, angiography via a right vertebral injection demonstrated left subclavian steal phenomenon with retrograde contrast flow down the left vertebral artery into the subclavian artery with no flow beyond the brachial segment. Absent left radial pulse was noted clinically. Emergency brachial artery thrombectomy was successful. NIHSS after surgery was 1 for decreased right nasolabial fold. She was discharged home a few days later.
Conclusions: To our knowledge, this is the first reported case of brachial artery embolism complicating mechanical thrombectomy. It is important to consider this potential complication in patients undergoing mechanical thrombectomy for posterior circulation stroke with stenosis or occlusion of the subclavian artery.
Patient Care: Neurointerventional surgeons will be aware of this previously unreported complication of brachial artery embolism in patients undergoing mechanical thrombectomy for acute posterior circulation stroke that have stenosis or occlusion of the subclavian artery, which will potentially 1) prevent this complication from occurring in the first place or 2) allow early recognition of the complication such that irreversible limb ischemia does not occur.
Learning Objectives: By the conclusion of this presentation, participants should be able to:
1) Be aware of the risk of brachial artery embolism in patients undergoing mechanical thrombectomy for posterior circulation stroke that have stenosis or occlusion of the subclavian artery.
2) Describe which patients are at risk of brachial artery embolism during mechanical thrombectomy for acute ischemic stroke.