Elective thrombectomy with combined technique in M2 occlusion

An 82-year-old patient presented with a stroke (NIHSS 8) due to a right middle cerebral artery occlusion at the M2 segment. Part of the area affected by the occlusion presented established ischemia. Thrombectomy with a combined technique successfully recanalized only the penumbra-affected area.

• Gender: male
• Age: 82
• Arrival situation: Previously functionally independent (baseline mRS 0), he was admitted under a stroke code after the sudden onset of left hemianopsia and left facial paralysis
• The patient underwent mechanical thrombectomy following an interhospital transfer
• Arrival in the thrombectomy suite ocurred at 14:00 pm. Last time seen well  was at 22:00 pm of the previous day. 
• Symptoms: left hemianopsia, left anesthesia, nystagmus in all directions of gaze, left arm lenght discrepancy in finger-to-nose, left leg weakness and left facial paralysis

Baseline CT- ASPECTS 7

Linear hyperdensity in the inferior division path of the right MCA, and hypodensity areas with loss of cortico-subcortical differentiation in the right insular territory, M2 and M3.

AngioCT- right M2 occlusion

Oclcusion at the bifurcation of the M2 segment of the inferior division of right MCA, with distal recanalization of both branches of the bifurcation.

CT Perfusion

Treatment

• Medical imaging: CT, CTA, CT Perfusion
• Treatment chosen: Mechanical thrombectomy using combined technique with a distal aspiration catheter placed at the origin of the occlusion and stent retriever released at the superior branch of the occluded bifurcation of M2
• Devices used: Right femoral access, 8F guide catheter (NeuronMax), 0.035” guidewire (Terumo), 6F Simmons diagnostic catheter (Select), 0.062” aspiration catheter (RED62), aspiration system (pump), 0.021” microcatheter (Phenom), 0.014” microguide wire (Synchro), 4mmx40mm stent-retriever (Solitaire), femoral vascular closure device (Perclose)
• Description of the treatment: An 8F guide catheter and a 6F simmons diagnostic catheter were advanced over a 0.035” guidewire with coaxial approach into right internal carotid artery. Diagnostic angiography confirmed a right M2 segment occlussion at the leveL of inferior division of MCA, with adequate retrograde collateral circulation only towards the territory of the superior branch of the occlusion

A decision was made to perform thrombectomy with combined technique, and a 0.062” aspiration catheter was advanced over a 0.021” microcatheter to the origin of the occlusion. A 4x40 mm Solitaire stent retriever was released through the occlusion across the superior branch, since priority was given to opening the branch whose territory was in ischemic penumbra.

The stent retriever and aspiration catheter were withdrawn simultaneously under continuous pump aspiration, resulting in partial clot removal  and recanalizarion of the upper branch of the previously occluded M2 bifurcation (eTICI 2b67).

Baseline Angiography

Result after first pass (eTICI 2b67)

Results

• Near-complete recanalization (eTICI 2b67) of the right M2 occlusion was achieved after a single pass, with a puncture-to-recanalization time of 30 minutes. The occluded upper division was succesfully recanalized (territory with ischemic penumbra) and the lower branch remained occluded (territory with established ischemia)
• At 24 hours, NIHSS score improved to 2 (left anesthesia)
• Follow-up CT showed no hemorrhagic transformation, with only established right infarct at the previous area of ischemic core on CT perfusion (territory of the inferior branch of the occluded M2)
• At 90 days the patient was functionally independent (mRS 0), the same functional status as prior to the index stroke

24h control CT

Supported by Medtronic