Acute Proximal Internal Carotid Artery and Middle Cerebral Artery Occlusion: Endovascular Treatment of an Acute Ischemic Stroke Due to a Tandem Occlusion; the Stuttgart Modus Operandi

A 76-year-old man with no previous illness suffered a fall at approximately 9 a.m. which left him hemiparetic on the left-hand side. Upon admission at the referring hospital, 1 h after the clinical onset, his condition was rated as NIHSS 10 and mRS 4. CT, CTA, and CTP showed a hyperdense thrombus in the right MCA, occlusion of the right ICA, and a mismatch between rCBF and rCBV in the right-hand MCA supply territory. The patient was transferred for emergency endovascular treatment. Reevaluation of the patient’s clinical status yielded an NIHSS score of 20. General anesthesia was induced, and 500 mg ASA IV, 180 mg ticagrelor PO, and 14.6 mg eptifibatide IV were given. DSA at 11:47 a.m. confirmed the atherosclerotic occlusion of the right ICA and embolic occlusion of the right MCA with poor leptomeningeal collaterals for the right-hand MCA supply territory. The proximal occlusion of the right ICA was catheterized and dilated with a 4/30 mm balloon at 8 atm. Following balloon dilation, a 7/40 mm Carotid Wallstent (Boston Scientific) was deployed. A 5MAX reperfusion catheter (Penumbra), a Velocity delivery microcatheter (Penumbra), and a Synchro2 microguidewire were inserted through the carotid stent. A pRESET 6/30 (phenox) was deployed into the right M1 segment and the distal part of the right ICA. A combination of mechanical thrombectomy with stent retriever and distal aspiration removed a sizeable red thrombus. While the right M1 segment and the inferior trunk of the MCA were patent, the superior trunk of the MCA remained occluded. A second thrombectomy, this time of the superior MCA trunk, with a pRESET 4/20, was successful. The recanalization, achieved 4 h after clinical onset, was rated as TICI 2b. Postprocedural CT and MRI showed a hemorrhagic infarction type 2 (HI 2) of the basal ganglia without relevant mass effect and a subarachnoid hemorrhage (SAH) with blood in the left temporal sulci. Upon discharge 6 days after the clinical onset and treatment, the patient’s condition had improved considerably (NIHSS 5). During a follow-up examination 3 months after the acute stroke treatment, the patient’s clinical condition had improved further (mRS 0, NIHSS 1). We typically perform acute stroke treatment, including tandem occlusions, under general anesthesia. Balloon angioplasty and carotid stent deployment are routinely the first step in treating tandem occlusions. Thrombus formation is prevented by administering ASA IV, ticagrelor PO, and eptifibatide IV. Intracranial large vessel occlusions are recanalized by a combination of stent retriever mechanical thrombectomy and distal aspiration. This chapter describes the method in which acute ICA and MCA tandem occlusions are currently treated in Klinikum Stuttgart.