ICA occlusion

• 53YO female mFisher 3 WFNS 1 – Bilateral ICA dysplasia
• Day 1 : Left terminal ICA ruptured Blister aneurysm – First FD (Agrastat IV then aspirin and prasugrel)
• Day 3 : Second FD covering the terminal ICA (minimal left intra petrous ICA dissection without perfusion impairment)
• Day 5 : New increase in size : Third FD, distal M1 incomplete apposition, no flow impairement

Day 1 & 3

Day 5

Poll #1

Day 8

• ICU calls for right –sided hemplegia and impaired consciousness, CTA reveiled a complete occlusion of the left M1 segment, severe hypoperfusion and ischemic lesion core of 77mL and hypoperfusion of 146mL (TMax>6sec)
• NIHSS 17, Aspirin and Prasugrel taken the same day,
• No IVtPA
• Transferred to the angiosuite under general anesthesia

Devices in use :​

• Femoral Sheath 9F​
• NeuronMax 90cm then Walrus 90cm​
• Sofia 6F​
• Headway Duo ​
• Synchro 14 Select

M1 occlusion

3 days after the last FD

 Poll #2

MT attempt

Adjustable SR  (Tigertriever 13) in inferior branch

With aspiration

Adjustable SR  (Tigertriever 13) in superior branch

Progressive re-occlusion despite initiation of Agrastat

Poll #3

Continuous injection of Agrastat
Subnominal angioplasty Neurospeed 2x8

Superior branch stenting
Through Neurospeed 2x8
pEGASUS 3.5x20

PEGASUS covering the "fish mouth"

Before AIS

M1 occlusion

 

Superior Branch angioplasty & pEGASUS after 10 min

Poll #4

HeadWay17 and Synchro Select

pEGASUS 3.5x15

ICA dysplasia & dissection
Blood-flow slowed

Stenting to prevent reocclusion and access difficulty in case of new intracranial complication

Complete recanalisation

Stable dissection and no more active dysplasia

Patient Outcome

• Full recanalization 
• mRS 3 at discharge, 1 at 6 months
• At 36 months : mRS 1, lives her normal life, under Aspirin for life

Follow-up

Control at one month

Control at 36 months

Comments

After how many thrombectomy passes should rescue stenting with pEGASUS-HPC be considered  in ICAS?

Does the pEGASUS-HPC offer a specific advantage over other stents in the rescue setting after multiple interventions?

Selections criteria optimize outcome when deploying pEGASUS-HPC after a multiple failed intervention? 

Should flow-diverter poor opening lead to preventive stenting with pEGASUS-HPC ?

References

• Al Kasab S, Almallouhi E, Jumaa M, Inoa V, Capasso F, Nahhas M, et al. Outcomes of adjunct emergent stenting versus mechanical thrombectomyalone: the RESCUE-ICAS registry. Stroke. 2025 Feb;56(2):390-400. doi:10.1161/STROKEAHA.124.049038.
• Cai J, Xu H, Xiao R, Hu L, Xu P, Guo X, et al. Rescue intracranial stenting for acute ischemic stroke after the failure of mechanical thrombectomy: asystematic review, meta-analysis, and trial sequential analysis. Front Neurol. 2023 Jan 25;14:1023089. doi:10.3389/fneur.2023.1023089.
• Gao F, Tong X, Jia B, Wei M, Pan Y, Yang M, et al. Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusionin China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet Neurol. 2024 Aug;23(8):797-806.doi:10.1016/S1474-4422(24)00186-8.
• Mohammaden MH, Haussen DC, Al-Bayati AR, Hassan A, Tekle W, Fifi J, et al. Stenting and angioplasty in neurothrombectomy: matched analysis ofrescue intracranial stenting versus failed thrombectomy. Stroke. 2022 Sep;53(9):2779-2788. doi:10.1161/STROKEAHA.121.038248.
• Pielenz D, Klisch J, Fiorella D, Gawlitza M, Steinbrecher A, Leinisch E, et al. The pEGASUS-HPC stent system for intracranial arterial stenosis: a single-center case series. J Neurointerv Surg. 2025;17(6):613-619. doi:10.1136/jnis-2024-021737.
• Premat K, Dechartres A, Baptiste A, Guedon A, Mazighi M, Spelle L, et al. Comparison of rescue intracranial stenting versus best medical treatmentalone in acute refractory large vessel occlusion: study protocol for the PISTAR multicenter randomized trial. J Neurointerv Surg. 2025;17(4):360-367.doi:10.1136/jnis-2024-021502.
• Romano DG, Tortora R, Di Gregorio M, Siani A, Locatelli G, Flora G, et al. Pegasus stent as a rescue therapy in large vessel occlusions with underlyingintracranial atherosclerosis: a retrospective single-center experience. Neuroradiology. 2025;67(10):2519-2526. doi:10.1007/s00234-025-03724-9

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