38 Intraprocedural Vasospasm during Thrombectomy
38.1 Case Description
38.1.1 Clinical Presentation
A 45-year-old African American female with past medical history of hypertension and diabetes mellitus type II was brought to the hospital after her husband found her shaking in bed with right lower facial droop and left-sided weakness.
At presentation, the patient’s Glasgow Coma Scale (GCS) was 6, withdrawing bilaterally to pain, less on the right side, and not opening eyes to voice stimulus. The National Institutes of Health Stroke Scale (NIHSS) score could not be accurately assessed due to intubation. She was intubated in the emergency department. Alteplase was not given due to unknown time of onset.
38.1.2 Imaging Workup and Investigations
Noncontrast CT (NCCT) demonstrated subtle hypodensity in the right frontotemporal region with poor gray-white differentiation (Fig. 38.1a).
CT angiography showed right M2 artery occlusion and left M1 artery occlusion (Fig. 38.1b).
Perfusion imaging showed a mismatch volume of 33 mL and a ratio of 5.7, bilateral penumbra with core on the right only.
Fig. 38.1 Noncontrast CT showed no gross ischemic stroke (a), while CT angiography showed signs of bilateral MCA occlusion (b).
38.1.3 Diagnosis
Left M1 artery occlusion and right M2 artery occlusion.
38.1.4 Treatment
Initial Management
Alteplase was not given due to unknown time of onset of symptoms.
Endovascular Management
The right groin was prepped and draped in the usual sterile manner. An 8-Fr sheath was placed in the right femoral artery.
A JB 1 catheter was advanced over a 0.035 Glidewire and selective catheterization of the following vessels was obtained: bilateral common carotid arteries and bilateral internal carotid arteries (ICA).
Initial diagnostic angiogram showed a complete occlusion of the right M2 (Fig. 38.2).
A Neuron Max catheter was placed into the distal cervical segment of the right ICA.
A microcatheter was advanced over a 0.014-in microwire.
Jet 7 aspiration catheter was advanced over the microcatheter and placed at the M1 segment proximal to the occlusion and proceeded to aspirate using the aspiration pump.
TICI 3 was achieved in the right M2 (Fig. 38.3).
Same procedure was performed on the left M1 occlusion along with a Trevo stent retriever deployment.
This was followed by vasospasm of the left M1 and distal clot migration (Fig. 38.4, Fig. 38.5).
After a total of seven stent passes combined with aspiration, the vasospasm was resolved, and the clot was retrieved (Fig. 38.6).
Overall, TICI 2a reperfusion was achieve on left M1.
Fig. 38.2 Prethrombectomy digital subtracted angiography confirmed the presence of complete right M2 occlusion. 
Fig. 38.3 Postthrombectomy digital subtracted angiography showed complete reperfusion of the previously occluded right M2. 
Fig. 38.4 Prethrombectomy digital subtracted angiography confirmed the presence of complete left M1 occlusion. 
Fig. 38.5 Intraprocedural digital subtracted angiography shows left M1 vasospasm. 
Fig. 38.6 Postthrombectomy digital subtracted angiography showed resolution of the left M1 vasospasm and partial reperfusion of the previously occluded left M1.
38.1.5 Progress
Postprocedure, the patient continued to have poor neurological condition with right-sided hemiplegia and a GCS score of 6.
NCCT at 24 hours showed evolved left MCA and right basal ganglia stroke.
The patient was started on aspirin 81 mg.
The family elected not to proceed with further treatment and the patient was placed on comfort measures.
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