Middle cerebral artery thromboembolism with clot retrieval

Case contributed by Prof Peter Mitchell

Presentation

Acute onset right hemiplegia 2 hours ago. Fluctuating neurological state (NIHSS 3-14).

Patient Data

Age: 60 years
Gender: Male
CT

2 hours post onset

Hyperdense left MCA with increased MTT in the left MCA territory. 

Left Hemisphere Stroke Endovascular Treatment 

Procedure: 

General Anaesthetic. Sterile technique. Right 8 Fr CFA retrograde sheath. Systemic heparinisation. 

Diagnostic angiography confirmed left extracranial ICA occlusion and critical right extracranial ICA stenosis. Major cerebral supply from enlarged right vertebral artery. Left M1 occlusion also demonstrated. 

8 Fr Merci balloon guide catheter to left CCA. Rebar 27 microcatheter and Synchro standard microguide wire through ICA occlusion, with the guide catheter subsequently advanced into the ICA. Microcatheter and wire through M1 occlusion into M2 origin. Solitaire (4 x 20 mm) deployed from distal M1 back into terminal ICA. Forward flow achieved. Solitaire retrieved under suction delivering a large amount of clot both on the device and within the aspirate. Good intracranial flow demonstrated. 

EZ-filter wire deployed in distal extracranial ICA and the 8 Fr guide catheter retracted into the CCA under suction, again delivering thromboembolus. Filling defects were noted within the filter wire consistent
with embolic debris. A single bolus of 3 mg of Verapamil was given IA. The ICA origin stenosis was angioplastied using a 5 mm balloon. A 9 x 40 mm Carotid Wall Stent (Stryker) was deployed with post dilatation with the 5 mm balloon.

Follow up shows no significant infarct, patient modified Rankin Scale = 0, full normal activity.

Case Discussion

This case is a great example of the efficacy of the endovascular treatment of acute thrombo-embolic stroke, with what would have otherwise been a potentially devastating stroke. 

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Case information

rID: 23823
Case created: 10th Jul 2013
Last edited: 15th Sep 2015
Inclusion in quiz mode: Included

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