INR scope

Secondary MeVO Rescue

Author: Rane Neil

Find out how Dr. Rane (Twitter contact: @neil_rane) treated a complex case requiring carotid stent and antithrombotics, with secondary MeVO.
Thanks also for this case to Dr. Gavin Fatania, Dr. David Ryan  and Dr. Oishik Raha’’

Sunday 11 June 2023
  • Case presentation
    • 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

     

    Left distal MCA occlusion (circle)

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

     

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

    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

    24 hour NCCT- small volume infarction

  • Conclusion

    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.

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