14 The Classical Setup: Carotid-T with Balloon
14.1 Case Description
14.1.1 Clinical Presentation
A 62-year-old female presented 4 hours 30 minutes after sudden-onset facial asymmetry, dysarthria, and left-sided weakness and numbness. She had a National Institutes of Health Stroke Scale (NIHSS) score of 18.
14.1.2 Imaging Workup and Investigations
Noncontrast CT of the brain demonstrated no early ischemic changes (Fig. 14.1). There is evidence of a hyperdense vessel sign seen in the region of the right internal carotid artery (ICA) terminus.
CT perfusion demonstrated a large perfusion mismatch involving the right middle cerebral artery (MCA) and ACA territory (Fig. 14.2).
Fig. 14.1 Noncontrast CT of the brain demonstrated no early ischemic changes. There is evidence of a hyperdense vessel sign seen in the region of the right ICA terminus. 
Fig. 14.2 CT perfusion demonstrates a large perfusion mismatch involving the right MCA and ACA territory.
14.1.3 Diagnosis
Right anterior circulation stroke secondary to an ICA T occlusion.
14.1.4 Treatment
Given the patient had no contraindications for intravenous (IV) recombinant tissue plasminogen activator, IV thrombolysis was commenced. The patient demonstrated no clinical improvement and findings were compatible with a large vessel occlusion; so, the patient was taken to the angiography suite for endovascular treatment.
Endovascular Therapy
Equipment
8-Fr short vascular access sheath.
8-Fr balloon-guiding catheter.
6-Fr diagnostic catheter.
4 × 40 mm Solitaire platinum stent retriever device.
2.95-Fr microcatheter.
The procedure was performed with local anesthesia only. Puncture of the right CFA was performed and an 8-Fr short vascular access sheath was inserted over a slip catheter (see upcoming cases for the different types of slip catheters best suited to accessing the right and left carotid arteries for different arch anatomy).
Once the balloon guide catheter (BGC) was in place, right ICA angiography was performed confirming the right ICA terminus occlusion (Fig. 14.3).
The microcatheter was then advanced intracranially into the ICA and then the tip was left in the proximal M2 (Fig. 14.4).
The Solitaire stent retriever was then delivered via the microcatheter and unsheathed in the right M1 (Fig. 14.5).
After 5 minutes, the balloon on the BGC was inflated (Fig. 14.6) and the Solitaire device slowly withdrawn while maintaining constant aspiration on the BGC.
Once the Solitaire device was within the microcatheter outside of the body, the rotating hemostatic device was removed so as to not pull the solitaire device through the valve and strip the clot or damage the device. The balloon was deflated and the BGC allowed to back bleed. The clot was successfully extracted and TICI 3 reperfusion achieved with a single pass (Fig. 14.7).
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