Answer 1: She should be treated with mechanical thrombectomy with or without carotid stenting.
Based on the information provided above, the patient should certainly be considered for mechanical thrombectomy unless specified in advanced directives. No additional perfusion or MRI imaging is necessary as she is within 6 hours of time window with CT ASPECT > 6. Intubation should only be considered if patient is not able to protect airway or there is any other compelling reason. Intubation for the sole purpose of thrombectomy is not indicated.
Answer 2: Non occlusive thrombus at carotid bifurcation with proximal flow-limiting stenosis
The CTA shows flow-limiting right internal carotid artery stenosis in addition to a non-occlusive thrombus attached to it in the proximal cervical segment. There is proximal M1 segment occlusion without evidence of significant collaterals. Once committing to thrombectomy, the operator should determine a strategy to treat proximal and distal lesions.
Answer 3: Closed cell stent
Considering critical stenosis and free floating thrombus, the cervical lesion was treated first. Balloon guide catheter was used to achieve proximal flow arrest and prevent distal embolization during stent placement. To adequately tag the free floating thrombus, two overlapping closed cell carotid stents were used. If the free floating thrombus was not an issue, advancing a distal access catheter through the carotid bifurcation stenosis with or without balloon angioplasty would also be reasonable to be able to decrease the time for MCA recanalization.
Answer 4: This is a must-do step for use of stent retriever.
If cervical internal carotid artery is stented, it is always advisable to advance the guide catheter beyond the distal landing zone of the stent in order to safely use stent retriever for intracranial thrombectomy. When stent retrievers are pulled back, there is always a chance that they get entangled in the cervical stent. Advancing guide catheter beyond the stent is not necessary if only aspiration thrombectomy is used.
Answer 5: Stent retriever with direct aspiration with proximal flow arrest
The image shows mechanical thrombectomy using stent retriever with direct aspiration and proximal flow arrest. There are multiple ways to perform thrombectomy. Vascular anatomy, size of the occluded branch, existence of tandem proximal lesion, and several other factors play roles in selecting the type of thrombectomy method. Overall, there is emerging data for proximal flow arrest being associated with successful recanalization.
Use of antiplatelet medications or anticoagulation in the setting of acute large vessel stroke treatment requiring carotid artery stenting or angioplasty is highly operator dependent irrespective of whether the patient has received intravenous thrombolytics or not. Factors like suspected infarct size, hemorrhagic transformation, underlying coagulopathy, and co-treatment with thrombolytics should be considered on individual case basis for determination of anti-stent thrombosis regimen.
- Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American heart Association/American stroke association. Stroke. 2019 Dec;50(12):e344-418.
- Kim B, Kim BM, Bang OY, Baek JH, Heo JH, Nam HS, Kim YD, Yoo J, Kim DJ, Jeon P, Baik SK. Carotid Artery Stenting and Intracranial Thrombectomy for Tandem Cervical and Intracranial Artery Occlusions. Neurosurgery. 2019 Mar 8.
- Mehta T, Desai N, Mehta K, Parikh R, Male S, Hussain M, Ollenschleger M, Spiegel G, Grande A, Ezzeddine M, Jagadeesan B. Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics. Interventional Neuroradiology. 2018 Aug;24(4):392-7.
- Wilson MP, Murad MH, Krings T, Pereira VM, O’Kelly C, Rempel J, Hilditch CA, Brinjikji W. Management of tandem occlusions in acute ischemic stroke–intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis. Journal of neurointerventional surgery. 2018 Aug 1;10(8):721-8.