Secondary MeVO Rescue

• 60-year-old, Right handed male
• Late window: last seen well 07:30hrs, in-house referral 17:00hrs =9.5 hours post onset
• Favourable non-contrast CT; ASPECTS 8
• CTA: Tandem, Left M1 MCA / ICA occlusion – mixed calcified/soft plaque
• Large syndrome, hemiparesis, NIHSS: 16
• No thrombolysis – out of window

Notification received via RAPID mobile - Left distal MCA occlusion (circle)

CTA shows tandem occlusion

CTP Summary – large potentially salvageable ‘penumbra’ (green) v small core (pink)

CTP Summary (2)
Favourable Hypoperfusion index, suggests good collaterals

Thrombectomy Setup

• General Anaesthesia – complex case
• Consent 4; lacks capacity to consent
• DSA: No antegrade ICA flow
• Terumo 035 wire and Neuron 5Fr Select catheter via Walrus balloon guide
• Difficult lesion to cross, no evidence of arterial dissection
• Aspiration below lesion through Walrus Balloon Guide (low position); thrombus delivered
• Diagnostic catheter switched for React 071 device over exchange 035 wire to maintain access

Initial Angiography- tandem occlusion (arrows)

Primary Target

Left M1 MCA
Initial perfusion: TICI 0
No of passes: 2
Technique: Combined Aspiration (REACT™ 71) and Solitaire™ X (Aspiration catheter left in situ to maintain access)

Stent: Solitaire™ X 6*20mm
Microcatheter: Trevo Trak™ 21
Microwire: Synchro™ 14

Final perfusion: TICI 3 but embolization to new territory

First Pass- Secondary MeVO, TICI 0

Second pass, MCA TICI 3, MeVO remains

Secondary Target

Left ACA (embolic occlusion, ENT)
Headway 17, Traxcess™ Mini 007 wire with J for safe distal navigation. Microcatheter injection to understand distal anatomy prior to stent placement
No of passes: 1
Technique: Combined Aspiration and Stent (*1)

Final perfusion: TICI 3

Microcatheter injection (tip arrow) - Stent deployed (arrows)

Stentriever deployed (arrows)

TICI 3, minor ACA spasm

Left ICA Stent and Antithrombotics

• Left internal carotid artery- appearance concerning for re-occlusion
• Eptifibatide (Integrillin) bolus IA and infusion 24 hours prior to DAPT conversion
• Wallstent™ Carotid Stent deployed across the lesion 9mm*40mm
• Aviator™ Balloon angioplasty 6*20mm throughout stent
• Eptifibatide (Integrillin) bolus IA and infusion 24 hours prior to DAPT conversion

Stent (arrows) deployment through BGC

24 hour NCCT- small volume infarction

Results

• TICI 3 reperfusion
• No complication on immediate flat panel CT, no haemorrhage, minimal contrast staining in basal ganglia from the infarct
• 24 hour non contrast CT minimal infarction
• 24 hours NIHSS 8
• Discharged to rehabilitation after 5 days
• mRS 2 at 6 weeks

Conclusion

• Secondary MeVO despite combined BGC aspiration technique
• Successful distal stentriever thrombectomy using Solitaire™ X 3mm
• Complex case requiring carotid stent and antithrombotics
• No haemorrhagic complication, minimal infarction

• Good patient outcome despite late window, tandem, stent and secondary MeVO
• Don’t give up on the patient!

This case is sponsored by Medtronic.