We report the case of a 60 year-old right-handed gentleman who became acutely “Locked-In” several days after a lower extremity orthopedic procedure. He underwent emergent endovascular treatment and had complete resolution of his neurologic findings except for mild dysarthria and dysphagia. Endovascular intervention for posterior circulation thrombosis is highly effective when patients are treated within 24 hours

Pandey MD, Aditya S.

Severson III MD, Meryl A.

Veznedaroglu MD, Erol

English

Jefferson Digital Commons

JHN JournalVolume 4 | Issue 1 Article 3Summer 6-1-2008Endovascular Cure of a "Locked-In" PatientMeryl A. Severson III MDThomas Jefferson University, meryl.severson@jefferson.eduAditya S. Pandey MDThomas Jefferson University, Aditya.pandey@jefferson.eduErol Veznedaroglu MDThomas Jefferson University, Erol.veznedaroglu@jefferson.eduFollow this and additional works at: https://jdc.jefferson.edu/jhnjPart of the Neurology CommonsLet us know how access to this document benefits youThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inJHN Journal by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationSeverson III MD, Meryl A.; Pandey MD, Aditya S.; and Veznedaroglu MD, Erol (2008) "Endovascular Cure of a "Locked-In" Patient,"JHN Journal: Vol. 4 : Iss. 1 , Article 3.DOI: https://doi.org/10.29046/JHNJ.004.1.006Available at: https://jdc.jefferson.edu/jhnj/vol4/iss1/31JHN J O U R N A L Endovascular Cure  of a “Locked-In” PatientWe report the case of a 60 year-old right-handed gentleman who became acutely “Locked-In” several days after a lower extremity orthopedic procedure. He underwent emergent endovascular treatment and had complete resolution of his neurologic findings except for mild dysarthria and dysphagia. Endovascular intervention for posterior circulation thrombosis is highly effective when patients are treated within 24 hours.CaseFC is a 60 year-old right-handed gentleman that underwent uncomplicated total knee arthroplasty and was started on low dose warfarin therapy for deep venous thrombosis prophylaxis. On postoperative day number two the patient had an acute change in his neurologic status.A computed-tomography scan of his head was obtained showing a hyperdense basilar artery. He was emergently transferred to our institution.On arrival the patient was lethargic but able to follow commands with eye blinks only. His pupils were equal and reactive but he only had vertical gaze. The right extremity minimally withdrew to stimulation. Computed-tomography angiogram of the head showed a dominant right vertebral artery with occlusion just distal to the posterior inferior cerebellar artery origin extending to just below the superior cerebellar arteries.The patient was taken emergently to the Endovascular Neurosurgery Suite and the right femoral artery accessed. The right vertebral artery was selectively catheterized and digital subtraction angiography performed revealing complete occlusion of the right vertebrobasilar junction without distal runoff or PCA filling. A Hyperglide balloon was positioned at the VB junction and seven inflations were performed, revealing a focal stenosis at the junction. A Gateway 4 balloon was positioned next and inflated to six atmospheres of pressure. Subsequent angiographic runs revealed complete resolution of the thrombus and filling of both PCAs and SCAs, as well as the basilar perforators. A Wingspan 4x5x20 stent was then deployed at the location of the stenosis resulting in complete resolution of the stenosis and thrombus. Additional angiographic runs showed distal occlusions bilaterally in the P4 segments; these were treated by placing an SL-10 microcatheter in the P4 segments and injecting 150,000 units of Urokinase on the right and 200,000 units on the left.Post-procedurally the patient remained intubated for less than twenty-four hours. His neurologic exam improved to normal except for mild dysarthria and dysphagia and a right upper extremity drift without associated weakness. Magnetic resonance imaging of his brain revealed acute infarcts in the left pons, right occipital lobe, right dentate nucleus, both mesial temporal lobes, and the right posterolateral thalamus. He was gradually mobilized with the assistance of physical therapy/occupational therapy and eventually discharged in good condition.DiscussionUnlike anterior circulation thromboses, the time window for posterior circulation thrombosis treatment extends up to 24 hours after the ictus. Cases of complete improvement in an adolescent treated 20 hours1 and a child almost 50 hours after symptom onset2 are Meryl A. Severson, III, MD, Aditya S. Pandey, MD, Erol Veznedaroglu, MDJefferson Hospital for Neuroscience, Philadelphia, PAFigure 1. Non-contrast computed tomography scan of the head showing a hyperdense basilar artery (arrow).Figure 2. Digital subtraction angiography AP projection of a selective right vertebral injection showing complete obstruction of flow at the  right vertebrobasilar junction.Figure 3. Digital subtraction angiography AP projection demonstrating inflation of the Hyperglide balloon at the right vertebrobasilar junction. Note the microcatheter extending into the proximal basilar artery and the “waist” (arrow) on the balloon reflecting the location of the obstruction.Case Report: Vascular 1Severson III MD et al.: Endovascular CurePublished by Jefferson Digital Commons, 20091 JHN J O U R N A L reported. However, we recommend treating up to 24 hours post-ictus only. An additional study reviewed outcome predictors for basilar artery thrombosis and found that recanalization after thrombolysis and low NIH stroke scale at admission were associated with a favorable outcome; initiating thrombolysis early after ictus as well CT evidence of a hyperdense basilar artery were positively associated with recanalization rates.3 “Locked-In” Syndrome resulting from acute basilar artery thrombosis is curable but requires the patient be quickly diagnosed and transferred expeditiously to a specialized center with a highly experienced endovascular neurosurgical team.ReferencesKirton A, Wong JH, Mah J, Ross BC, Kennedy J, Bell K, Hill MD. Successful endovascular therapy for acute basilar thrombosis in an adolescent. Ped. 2003 Sep: 112(3 Pt 1):e248-51.Grigoriadis S, Gomori JM, Grigoriadis N, Cohen JE. Clinically successful late recanalization of basilar artery occlusion in childhood: what are the odds? Case report and review of the literature. J Neurol Sci. 2007 Sep 15;260(1-2):256-60. Arnold M, Nedeltchev K, Schroth G, Baumgartner RW, Remonda L, Loher TJ, Stepper F, Sturzenegger M, Schuknecht B, Mattle HP. Clinical and radiological predic-tors of recanalisation and outcome of 40 patients with acute basilar artery occlusion treated with intra-arterial thrombol-ysis. J Neurol Neurosurg Psychiatry. 2004 Jun; 75(6):857-62.1.2.3.Figure 4. Digital subtraction angiography LAT projection of a right vertebral injection after Hyperglide balloon inflation. Note the improved filling of the basilar artery. A Gateway balloon has been advanced to the vertebrobasilar junction.2JHN Journal, Vol. 4 [2009], Iss. 1, Art. 3https://jdc.jefferson.edu/jhnj/vol4/iss1/3DOI: https://doi.org/10.29046/JHNJ.004.1.006

Endovascular Cure of a  Locked-In  Patient

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Endovascular Cure of a Locked-In Patient

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