Technique: The patient presented with decreasing conscious state / left hemiplegia. CTA confirmed occlusion of right MCA M1 segment extending into both superior and inferior division.
After discussions with the stroke team - last seen well, first observed with left hemiplegia and neglect and speech difficulty, moderate core but mismatch and large vessel occlusion, referred for consideration of endovascular clot retrieval.
Under sterile technique, the right CFA was accessed using an 8Fr sheath, and selective injections were made into the Right CCA and ICA.
Findings: Procedure performed with the patient awake - limited ability for subsequent more selective vessel access. There is a greater than 70% stenosis of the origin of the right internal carotid artery, and occlusion of the mid M1 segment, with moderate collaterals.
An 8 Fr Balloon Guide Catheter was placed in the right internal carotid artery, carefully passed the ostial atheroma, 3 passes with Solitaire 4 x 20 / 2 passes with the Trevo 6 x 40 stent retriever concomitant aspiration under balloon inflation. Subsequently, the using a 5-French Sofia catheter, and the penumbra suction equipment, direct aspiration of a resistant cough was performed with 2 separate passes.
IA Verapamil used to manage ICA vasospasm.
Despite this, there was minimal retrieval of thrombus, and only limited reperfusion with ongoing high-grade narrowing at the MCA bifurcation.
Procedure took 2 hours; 5 passes with moderate and large stent retriever; 2 passes of 5Fr aspiration distal access catheter - as time of onset unknown, oedema on CT, modest infarct on CTP, no further intervention (and no stent placement).
At end of the procedure groin was closed with the 8Fr Angioseal device.
Conclusion: Unknown time of onset of right MCA syndrome, high NIHSS, ICA atheroma presumed source of M1 occlusion, but proved resistant to multiple devices and techniques for clot retrieval.
Poor - TICI 2a at most - reperfusion.