Left MCA stroke with tandem carotid occlusion

Case contributed by Peter Mitchell
Diagnosis certain

Presentation

Acute onset hemiparesis, aphasia. NIHSS = 21

Patient Data

Age: 60 years
Gender: Male

CT 1h28min post symptom onset

ct

A hyperdense MCA is present on the left. Possible minor loss of grey white matter differentiation of the left putamen. No hemorrhage. Congenital anomaly posterior fossa with cranial defect and sinus.

CT perfusion demonstrates a large left MCA territory Tmax/MTT region of prolongation with only a small core infarct in basal ganglia.

CTA demonstrates an occluded left M1 segment as well as occlusion of the ICA origin (tandem lesion). The ICA distal to its origin is not filled; however, this does imply that the vessel is occluded throughout its length as it can be collapsed due to occlusion on both ends.

ICA occluded at origin. Passed with BGC, M1 occlusion, poor collaterals. Single pass with stentriever, clot retrieved in both aspirate and on device. TICI 2b. Balloon angioplasty, followed by stent insertion in origin ICA disease.

Minor contrast staining particularly of the left lentiform nucleus. Note capillary blush and AV shunting shown during DSA. 

Case Discussion

Tandem lesions (carotid atherosclerosis and occlusion, with concomitant MCA embolization) offer challenges to endovascular thrombectomy, may require stent placement and require dual antiplatelet therapy.

Pooled analysis of the RCT's into endovascular clot retrieval showed benefit in patients with or without tandem disease.

The order of treatment - stent first or last - is on an individual basis. In general clot retrieval followed by angioplasty alone or stent placement avoids potential complications related to retrieval device and stent interaction.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.