Solitaire 3x20 and 6x40 in simultaneous 2 branch occlusions with TICI 2c reperfusion in first pass

Author: Murias Eduardo

Watch now this simultaneous Solitaire stenting procedures in 2 branch occlusions with TICI 2c reperfusion in first pass’ performed by Dr. Eduardo Murias 

• Case presentation
  • 69-year-old female patient
  • Arterial hypertension (AHT)
  • No other diseases
  • NIHSS: 18
  • Weakness of the right limbs and expressive aphasia

   

  • Onset time: 11.00 am
  • Arrival at the hospital: 12.24 pm

  

   

  

  Neuroimaging - CT: aspect 7

  

  

  AngioCT: M2 left occlusion

   

   

  

  AngioCT: M2 left occlusion

   

  

  Perfusion: Even though the perfusion parameters are not favorable, we ignored this information due to the time of evolution since the beginning of the clinic.

   

  Thrombectomy

  • Arrival into angiosuite: 13.15
  • Time of puncture: 13.33
  • First imaging: 13.52
  • Recanalization: 14.21

  Treatment with alteplase (bolus + start of perfusion) is indicated and MT is performed, which must be performed under sedation due to intense agitation (13 mg of Midazolam was required).

  Devices Used: Double Solitaire

  • Parietal Branch: Phenom 21, Traxcess, Solitaire 6x40
  • Silvian Branch: SL10, Traxcess, Solitaire 3x20
  • Flow gate 2
  • Final result TICI 2C after 1 pass

  In our experience, the use of first-intention stentrievers in acute ischemic stroke is safe and effective. In patients with two or more affected branches, it is possible to act on both occlusions in the same pass.

  Imaging – Pre MT

  Imaging Pre MT 1 - You do not have permission to view this object.

  Imaging Pre MT 2 - You do not have permission to view this object.

   

  

  Imaging – Pre MT

   

  

  

  

   

  Double stenting technique - You do not have permission to view this object.

  Double stenting technique where both stents are removed at the same time

   

  Imaging – post MT

  Imaging post MT 1 - You do not have permission to view this object.

  Imaging post MT 2 - You do not have permission to view this object.

   

  

  

  Comparison of pre and post MT imaging

  Post MT

  • The patient was admitted to ICU for clinical surveillance and early extubation.
  • Very significant clinical improvement to NIHSS = 0 after 24 hours were observed and patient started rehabilitation.
  • 24-hour control cranial CT showed a slight sylvian petechial bleed which wasn’t symptomatic.
  • Simple antiplatelet therapy was started with clopidogrel.
  • Patient was discharged from hospital 9 days post-MT and was neurologically asymptomatic.

   

  

  CT 24-hour post-MT

   

• Conclusion
  • Advances in endovascular technology enable access to more distal vessels in acute ischemic stroke patients.
  • As the profile of the instruments used during access decreases, the risk of complications may also decrease.
  • Small-Stent retrievers, like Solitaire 3x20, are effective and safe in distal branches.

   

  This case is sponsored by Medtronic.