The Road not taken – a rare case of Tandem stroke

Discover the case of a 31-year-old female patient presenting with right hemiplegia and aphasia, unraveling the complexity of a rare tandem stroke involving the left common carotid artery and left M1 middle cerebral artery occlusions.

Case presentation

Patient presentation

31-year-old female patient,
Right hemiplegia and aphasia for 5 hours
NIHSS 16
no comorbidities

CTA was planned for better characterization

CT angiogram

Diagnosis: Left CCA and Left M1 MCA Tandem occlusion, Takayasu Arteritis

Decision

DSA, assess the circulation & decide on procedure

Right vertebral angiogram

How do we access and treat the left M1 MCA clot?

Intervention

Crossing the “Takayasu” lesion with coaxial catheters

A 0.035” hydrophilic angled tip wire failed to cross the CCA occlusion

Navigating the guide sheath to the ICA

Left ICA angiogram demonstrating the left M1 occlusion

Mechanical thrombectomy (Solumbra technique)

Post MT, TICI 3 reperfusion

Good cross circulation through ACOM and PCOM
The Takayasu lesion in the LCCA origin did not warrant treatment

A miraculous escape! It was not to be…

Reperfusion hemorrhage (PH2) on immediate post-intervention SWI

Underwent decompression craniectomy (floating) and evacuation of sICH

Rx

IV Methylprednisolone 500 mg for 5 days followed by oral corticosteroids; After a brief period of neurological improvement, her sensorium worsened (E2VtM5)
Brain imaging was repeated.
Diffuse hemispheric cortical restricted diffusion, left MCA was patent; areas of cortical hyperperfusion on ASL
? Post-ictal changes/ ischemic

She improved with medical management; MRI was repeated 10 days later

Resolution of the cortical diffusion restriction; however the LMCA branches were attenuated with hypoperfusion on ASL (? Cause)
Discharged on day 30 of admission, mRS 1 at 12 months follow up

Learning points

Arteritis at the CCA origin can rarely cause a tandem occlusion stroke; can be confusing on initial imaging; Always do a CTA in young strokes!
Attempt must be made to cross the occlusion at CCA origin with a suitable technique and “Dottering” helps
Cross circulation is usually good if the patient has a large penumbra in carotid occlusions; hence, addressing the proximal lesion is not a necessity.
The goal of treatment should be to address the acute event (“MCA occlusion”) rather than getting a beautiful result
Arteritis affects a young population, and the final clinical outcome may be favorable, irrespective of immediate post-MT outcome