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World J Clin Cases. 2013 Dec 16;1(9):290-4. doi: 10.12998/wjcc.v1.i9.290.

Tissue plasminogen activator via cross-collateralization for tandem internal carotid and middle cerebral artery occlusion.

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Ketan R Bulsara, Joshua Pepper, Joseph Schindler, Neurosurgical Department, Yale and New Haven Hospital, New Haven, CT 06520, United States.


Tandem internal carotid and middle cerebral artery occlusion after carotid dissection predicts poor outcome after systemic thrombolysis. Current treatments include the use of endovascular carotid stenting, which carries with it a high risk of propagating further embolic events and worsening the dissection. New strategies for avoiding the aforementioned side-effects include recanalization using cross-collaterals for delivery of intra-lesional tissue plasminogen activator (tPA). We present two cases that provide further support for this novel approach. Both patients presented with a National Institute of Health Stroke Scale of 20, received intra-arterial tPA via cross-collateralization, and made full recoveries without the need for stenting.


Carotid artery dissection; Intra-arterial tissue plasminogen activator; Tandem internal carotid artery and middle cerebral artery occlusion

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