Recurrent Large Vessel Occlusion Requiring Repeat Mechanical Thrombectomy Within 24 Hours with Good Clinical Evolution: Atrial Fibrillation Meets Malignancy and Immunotherapy – 1st Procedure, Stent Retriever; 2nd Procedure, Aspiration

Mechanical thrombectomy (MT) in the first 24 h after system onset has become the standard of care for the treatment of acute ischemic stroke due to large vessel occlusion (LVO). The 5-year risk of recurrent acute ischemic stroke is 24% for women and 42% for men. This risk is highest in the first 2 weeks after the index event. Cardioembolism, especially from atrial fibrillation, and large-vessel atherosclerotic disease are associated with an increased risk of early stroke recurrence. Coexisting conditions such as active malignancy and oncologic therapies may increase the risk of thrombotic events. It has been estimated that 65,000–90,000 patients meet the eligibility criteria for MT annually in the United States, and the number of patients who may experience a recurrent LVO (rLVO) requiring repeat MT (rMT) may therefore be substantial. The optimal timing for initiation of antithrombotic therapy in patients with acute cardioembolic LVO is controversial. Current guidelines do not include prospective data on the appropriate timing of initiation of anticoagulation or antiplatelet therapy after MT, particularly when intravenous thrombolysis is administered. The literature on safety and outcomes after rMT, especially in the same vascular territory, is limited. We present our experience with a 73-year-old woman who had a history of ischemic heart disease, atrial fibrillation treated with apixaban, and metastatic melanoma treated with immunotherapy with nivolumab (PD-1 blocker). She was admitted to the hospital to undergo cardiovascular revascularization and apixaban was temporarily discontinued. The night before the procedure, after a single 5 mg dose of apixaban was withheld during her hospital stay, she developed an acute large left hemispheric ischemic stroke that was rapidly recognized by nursing staff. The patient developed gaze deviation, global aphasia, and dense right hemiparesis with an initial National Institutes of Health Stroke Scale (NIHSS) score of 18. While the results of a noncontrast cranial CT were unremarkable, CT perfusion (CTP) and CT angiography (CTA) revealed occlusion of the M1 segment of the left middle cerebral artery (MCA) and a large hemispheric penumbra. The patient underwent successful and uneventful stentriever-assisted endovascular revascularization of the left MCA with rapid neurological recovery observed immediately after extubation and a postprocedural NIHSS of 2. Head CT obtained 10 h after thrombectomy showed subtle left capsular hypodensity and complete preservation of the right cortical mantle. However, while still in the ICU 16 h after her first stroke, she suddenly developed gaze deviation, global aphasia, right-sided weakness, and right hemianopia. Her NIHSS score was 22. Urgent repeat CT, CTP, and CTA revealed occlusion of the left intracranial internal carotid artery (ICA) and a large hemispheric penumbra. The patient underwent a second endovascular revascularization procedure to recanalize the left ICA occlusion. Her post-extubation NIHSS score was 6. Cranial CT performed 8 h after the second procedure showed extension of the hypodense area to the right caudate head, anterior capsular and anterior lenticular areas, and complete preservation of the right cortex. Early anticoagulation with low-dose low-molecular-weight heparin (enoxaparin sodium, Clexane; Sanofi-Aventis) was initiated. The patient underwent planned cardiac revascularization and was discharged after 8 days on apixaban and clopidogrel, with an NIHSS score of 4 and a modified Rankin Scale (mRS) score of 2. There are few studies on early large vessel reocclusion after successful MT. Do some patients need early anticoagulation after thrombectomy? Do patients with coexisting conditions that may increase the risk of stroke require special monitoring and most likely early anticoagulation? Recurrent LVO is the main topic of this chapter. Spoiler: Repeat MT may be safe and effective, but more data and evidence are needed.