Extensive thrombus burden: Using the right material in the right situation leads to success

Strategic use of a large aspiration catheter (React71) for the ICA and a stent retriever (Solitaire) for the MCA ensured successful recanalization in a complex thrombus scenario.

Patient situation

An 84-year-old woman presented with complete right middle cerebral artery syndrome (NIHSS 19) for 1 hour.

Global aphasia
Right-sided hemiparesis
Turning gaze to the left

The patient had arterial hypertension, with no other pre-existing conditions.
The ECG on admission revealed atrial fibrillation.

The CCT showed an extensive hyperdense vessel in the M1 segment, while the CTA confirmed a proximal M1 occlusion along with a proximal thromboembolic occlusion of the left ICA.

The CT scan also revealed an old infarct in the right middle cerebral artery territory.

Using the right material in the right situation leads to success - Figure 1

CT perfusion indicated a large penumbra in the left hemisphere with a small infarct core at the level of the basal ganglia.

Using the right material in the right situation leads to success - Figure 2

Treatment chosen

Set up:

No thrombolytic therapy due to early infarct demarcation
General anaesthesia
Right femoral artery puncture (8-French short sheath)
NeuronMAX long sheath
0.014” TransendEX Microwire

ICA occlusion:

React71 Aspiration Catheter

M1 occlusion:

6F Sofia Distal Access Catheter
Headway21 Microcatheter
Solitaire 4 mm x 40 mm Stent Retriever

Aspiration

ICA occlusion

The long sheath was positioned in the common carotid artery.
A large-bore aspiration catheter (React71) was used to recanalize the internal carotid artery through three aspiration manoeuvres, addressing the extensive thrombus burden.

Using the right material in the right situation leads to success - Figure 3

Using the right material in the right situation leads to success - Figure 4

Stent Retriever

M1 occlusion

A stent retriever was selected due to the long-segment thrombus in the M1 segment. After confirming the position with the microcatheter, the stent retriever (Solitaire 4 mm x 40 mm) was deployed in the M1 segment. Mechanical thrombectomy was then performed with distal aspiration, resulting in complete recanalization of the left MCA territory (first-pass).

Using the right material in the right situation leads to success - Figure 5

Using the right material in the right situation leads to success - Figure 6

Results

Outcome

Given the extensive thrombus burden and newly diagnosed atrial fibrillation, the patient was initiated on a heparin infusion immediately after thrombectomy, followed by Clexane therapy.

At discharge after 11 days, the patient had a residual mild facial paresis, with no other neurological deficits detected.

NIHSS 19 at admission
NIHSS 5 after 48h
NIHSS 1/mRS 1 at discharge

Using the right material in the right situation leads to success - Figure 7

CCT before discharge

Supported by Medtronic