amrcpc
Contributor
Are my codes correct?36224- right internal carotid
36228 - M1 segment eventhough the M1 was selected more than once & distally
37184
CLINICAL INDICATION:
To better delineate the anatomy in a high resolution study, in order to optimize medical decision making and management of an acute stroke.
The patient is a 15-year-old male who presents with a waxing and waning neurologic exam. At the time of intervention he is plegic on the left side. CTA and CT perfusion demonstrate severe stenosis of the right M1 segment secondary to thrombus. The MTT
is increased, CBF is decreased, and CBV is relatively well-preserved in the right MCA distribution.
The patient was brought to the angiographic suite and administered general anesthesia. Both groins were prepped and draped in the standard fashion. An 18 gauge needle was used to gain access to the right femoral artery. An 8-French sheath was inserted
into the right femoral artery. A 5-French Davis catheter was advanced over a Terumo angled Glidewire into the descending aorta through a 6 Fr Neuron Max 088 (90 cm). The right common carotid artery was selected.
Right common carotid artery:
The right common carotid artery was selected. There is no evidence of atherosclerosis or flow-limiting disease within the internal carotid artery. The external carotid artery is clearly visualized and without disease.
Right internal carotid artery:
The right internal carotid artery was selected. Intracranial runs of the right internal carotid artery revealed the petrous, cavernous, and supraclinoidal segments to be of normal caliber and without flow limiting disease. The carotid bifurcation is
normal and without aneurysm.
Within the right M1 segment there is significant stenosis secondary to the presence of a large flow-limiting thrombus. There is a significant delay in filling of the distal MCA territory. The right anterior cerebral artery is normal in caliber and the
distal territory fills without delay. There is flash filling across the ACOM complex into the left A1 segment. The right middle meningeal artery appears to arise from the ophthalmic artery. This is a normal anatomic variant.
INTERVENTION:
The Davis catheter was removed from the right ICA. A Velocity microcatheter was fed through a Penumbra 5 Max reperfusion catheter over a Fathom wire. The entire system was advanced into the right ICA through the 6 Fr Neuron Max 088. The Fathom
microwire was advanced into the M1 segment to a point just proximal to the thrombus. The system was advanced over the wire to the proximal thrombus and the Penumbra aspirator was attached. After 5 minutes of sustained suction the system was removed.
Repeat runs at this time showed persistent thrombus in the M1. Aspiration was repeated in the same fashion without resolution of thrombus.
The microcatheter was again advanced to a point just proximal to the thrombus. The separator was inserted and agitation of the clot resulted in a significant amount of thrombus in the Penumbra aspirate. Repeat runs demonstrated normal filling of the M1
segment, however, additional thrombus was now noted at the MCA bifurcation and in the M2's.
The Penumbra 5 Max was exchanged for a Penumbra 4 Max, which was advanced into the distal M1 segment. Again the separator was used to agitate the thrombus in the M2s. Aspiration was again maintained for an additional 5 minutes. Subsequent runs showed
the M1 and M2s to fill with an improvement in distal filling of the MCA territory. The M2 branches demonstrated improved, but persistent irregularities consistent with residual thrombus.
The catheter was pulled into the right ICA and an intracranial run was performed. The M1 segment filled normally and the persistent irregularities of the M2s were again noted. There was a significant improvement in filling of the MCA territory and a
resolution of the delay initially noted.
The sheath was removed with a Perclose device. There was no evidence of a groin hematoma and distal pulses were stable compared to preop evaluation.
The total contrast dose for the procedure was: 85 cc of Omnipaque.
The total radiation dose was approximately: 8051 cGycm2.