Presentation
Right hemiparesis, facial droop, heart valve. Not on anticoagulation.
Patient Data
On the noncontrast CT, the terminal part of the left internal carotid artery appears hyperdense.
The right CCA and ICA show calcified plaque buildup but retained contrast filling.
The left terminal ICA is occluded. The left ACA and MCA are opacified via the circle of Willis.
Stagnant contrast into the left ICA bulb can still represent distal occlusion. First pass retrieved thrombus from ICA "T" but too tortuous to reach distal MCA clot. Post first pass of stent retriever opened ICA "L" occlusion but could not access distal M1 segment of the MCA. Second pass with distal access catheter and suction. Post second pass with distal access catheter for stability around proximal ICA. Grade of recanalization: TICI 2c.
Small volume left MCA territory ischemic lesions after near-complete recanalization.
Case Discussion
CTA commonly overcalls proximal extent of ICA occlusions - in this case, distal ICA at initial imaging. First DSA showed had progressed to ICA T and M1. Two passes and recanalization 6 hours post onset, 75 minutes post on table.
mRS = 0
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