Major Stroke Caused by Acute Petrocavernous Internal Carotid Artery Atherothrombotic Lesion Causing Near-Total Occlusion (Incomplete Circle of Willis): Urgent Thrombectomy Under Proximal Aspiration, Coronary Stent Angioplasty of Atherosclerotic Stenosis, and Telescoping Bailout Self-Expanding Stent Implant for Thrombus Jailing with Very Good Angiographic and Clinical Outcome

Intracranial atherosclerosis (ICAS) is one of the most common causes of stroke worldwide and is associated with a high risk of stroke recurrence. While the most common clinical presentation is acute-subacute transient ischemic attack (TIA) or ischemic stroke, patients with underlying ICAS occassional present with acute occlusion of the affected vessel. The primary proposed mechanism for ICAS-related large vessel occlusion (LVO) is a ruptured, unstable plaque with subsequent in situ thrombosis and resultant occlusion and reocclusion. In the Asian populations, ICAS is estimated to be responsible for approximately one-third of acute LVOs, compared to <10% in Western populations. ICAS-related acute LVO poses unique challenges for endovascular thrombectomy. Classic techniques such as stent-retriever or aspiration thrombectomy are less efficacious in LVOs with underlying intracranial atherosclerosis. In addition, the tendency for reocclusion of the affected vessel and residual stable fixed severe stenosis impairing distal flow commonly requires rescue treatment for successful revascularization. Rescue treatment options include intra-arterial treatment with thrombolytics, antiplatelets, angioplasty, and stenting. The safety and efficacy of such rescue treatments have not yet been established, and current evidence is driven mainly from small retrospective case series; there is no current consensus on how to best manage these patients without randomized data. We present our experience with a 64-year-old man with a past medical history significant for arterial hypertension and diabetes mellitus type 2, who was brought to the Emergency Room (ER) due to severe language disorder and right-sided weakness that had appeared abruptly 2 hours before admission. He was not under any medication. Neurological examination upon admission revealed global aphasia, facial asymmetry on the right, severe right-sided hemiparesis, and hypoesthesia. Upon admission, the patient’s National Institutes of Health Stroke Scale score (NIHSS) was 16 points. Admission noncontrast cranial CT was unremarkable, but CT angiography (CTA) revealed an atherothrombotic occlusion of the left internal carotid artery (ICA) in the petrocavernous segment with an associated clot, confirmed the patency of the left middle cerebral artery (MCA), and depicted an incomplete circle of Willis. CT perfusion (CTP) images showed a sizeable hypoperfused area in the left hemisphere. The patient was urgently transferred to the angiography suite. Angiograms confirmed near-total occlusion of the left ICA at the petrocavernous segment caused by a short, tapered, concentric atherosclerotic lesion complicated with a large thrombus extending from the plaque into the posterior vertical cavernous portion of the ICA. The patient underwent successful endovascular revascularization using stentriever-assisted thrombectomy and stent-assisted angioplasty of the stenotic lesion. He demonstrated a significant neurological improvement after the procedure with an NIHSS of 3 on repeat examination. Post-procedure noncontrast cranial CT revealed a small periventricular infarction in the left parietal lobe. The patient had an unremarkable clinical course and was discharged within 3 days on dual antiplatelet therapy with a modified Rankin Scale score (mRS) of 1. He was asymptomatic at the 1-month follow-up and has regained his usual activity. Endovascular revascularization of ICAS-related acute LVO is the main topic of this chapter.