17.1.1 Clinical Presentation

An 86-year-old man presented to the emergency department (ED) at 6 a.m. after being found by his wife at approximately 5:30 a.m. His was last seen normal at 10 p.m. the night before. He presented with dysarthria, left hemiplegia, right gaze preference, left lower quadrant cut, and a mild left-sided neglect. Examination in the ED was consistent with a right middle cerebral artery (MCA) syndrome, and his National Institutes of Health Stroke Scale (NIHSS) score was 12. He has a past medical history of coronary artery disease, hypertension, hyperlipidemia (HLD), gastroesophageal reflux disease, benign prostatic hyperplasia, chronic kidney disease, sick sinus syndrome, and idiopathic pulmonary fibrosis.

17.1.2 Imaging Workup and Investigations

• 
  

  Noncontrast CT of the head performed at 6:15 a.m. demonstrated loss of the differentiation in the right basal ganglia; ASPECTS score was 9 ( Fig. 17.1 ).

  
  
• 
  

  CTA demonstrated a complete occlusion of the right internal carotid artery (ICA) at the bifurcation and isolated right hemispheric circulation with no opacification of the intracranial ICA or MCA (Fig. 17.2). Subsequent imaging demonstrated opacification of the ICA ophthalmic segment via sphenopalatine artery collaterals with tandem occlusion of the carotid terminus.

  
  
• 
  

  CT perfusion demonstrated a small core infarct in the right basal ganglia but a large area of prolonged mean transit time (MTT) and preserved cerebral blood volume (CBV) throughout the right MCA distribution consistent with a large area of ischemic penumbra.

  

  

17.1.3 Diagnosis

• 
  

  Acute ischemic stroke secondary to right ICA and MCA occlusion with large area of ischemic penumbra.

17.1.4 Treatment

• 
  

  The patient was outside the time window for intravenous tissue plasminogen activator (IV-tPA; 4.5 hours), given his last known normal was 8 hours prior to presentation.

  
  
• 
  

  Endovascular therapy was considered to be the best available therapy for the extensive clot burden of the MCA and carotid occlusion.

  
  
• 
  

  The patient was quickly transferred to the angiography suite and groin puncture was performed at 7:15 a.m. and complete recanalization was achieved in 39 minutes.

17.1.5 Materials and Endovascular Treatment

• 
  

  Anesthesia:

  
  
  
  
  • 
    

    Local, lidocaine 2%.

    
    
  • 
    

    No sedation, conscious or otherwise, was utilized.

  
  
• 
  

  Groin access:

  
  
  
  
  • 
    

    18 g Cook needle, 9 Fr pinnacle sheath.

  
  
• 
  

  Right common carotid artery access:

  
  
  
  
  • 
    

    6-Fr 088 Neuron Max sheath (Penumbra Inc., Alameda, CA) over a 5-Fr Berenstein insert (Penumbra Inc.) and 0.038 Terumo (Terumo, Tokyo, Japan) Glidewire. Angiography demonstrated complete occlusion of the internal carotid origin with partial reconstitution of the ICA ophthalmic segment via sphenopalatine artery collaterals. There was a tandem occlusion of the carotid terminus.

  
  
• 
  

  Right common carotid artery angioplasty and stenting:

  
  
  
  
  • 
    

    The carotid occlusion was crossed with a velocity microcatheter (Penumbra Inc.) and a 0.016 Fathom guidewire. This was exchanged for a 4 mm × 20 mm Apex balloon (Boston Scientific, Nantucket, MA) over a 0.014 Transend (Boston Scientific) exchange microwire for Percutaneous transluminal angioplasty (PTA) of the bifurcation. Subsequently, a 10 mm × 40 mm Cordis Precise ProRx stent (Cordis, Miami Lakes, FL) was deployed to maintain vessel patency (Fig. 17.3, Fig. 17.4, Fig. 17.5). At the time of stent deployment, 20 mg of ReoPro was administered intravenously and 600 mg of Plavix and 650 of ASA were given orally at the conclusion of the procedure.

  
  
• 
  

  Right ICA and MCA thrombectomy:

  
  
  
  
  • 
    

    The Neuron Max sheath was advanced across the carotid bifurcation into the distal cervical ICA. Repeat angiography demonstrates occlusion of the ICA at the level of the posterior communicating artery. A 5 MAX ACE reperfusion catheter (Penumbra Inc.) was advanced over a Velocity microcatheter and a 0.016 Fathom guidewire into the carotid terminus. The velocity microcatheter was removed and the 5 MAX ACE reperfusion catheter was slowly advanced across the carotid terminus and proximal right MCA M1 segment under direct aspiration (Fig. 17.5, Fig. 17.6, Fig. 17.7, Fig. 17.8). When flow (in tubing) was noted to be stagnant, the catheter was removed. A clot of 5 cm was present in the catheter tip (Fig. 17.9). Final control angiography demonstrated complete recanalization of the right ICA and right MCA (Fig. 17.10).