Supraclinoid Internal Carotid Artery Perforation During Stentriever-Assisted Mechanical Thrombectomy for Acute Ischemic Stroke: Controlling Hemorrhage with a Double-Lumen Balloon and Time

Arterial perforation is a rare but severe complication of stentriever-assisted thrombectomy procedures that requires urgent life-saving measures. In our practice, we proceed with general measures and maneuvers tailored to every case. General measures include reversal of heparin effects, reduction of blood pressure, and flow control maneuvers (i.e., ascending the balloon, guiding catheter, and inflating the balloon until proven proximal flow arrest is achieved). Particular maneuvers may include techniques involving intracranial balloon catheters and microcatheters aimed at controlling the arterial hemorrhage by transiently reducing flow, or permanently implanting coils, or injecting embolizing agents such as glue or thrombin. This 70-year-old man with a history of hypertension, hyperlipidemia, and ischemic heart disease was recently diagnosed with pancreatic cancer, and had a poor oncological prognosis estimated to be 3–6 months. He was admitted to the emergency room after a major right-hemispheric ischemic stroke with a baseline National Institutes of Health Stroke Score (NIHSS) of 19. He was last seen well 3 h before admission. The Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast head CT was 7. CT angiography (CTA) showed a cutoff in the M1 segment of the right middle cerebral artery (MCA) and poor collaterals. The patient did not receive intravenous thrombolysis and was directly transferred to the angiography suite for endovascular intervention. Under general anesthesia, right internal carotid artery (ICA) angiograms confirmed proximal occlusion of the right MCA, a small supraclinoid carotid artery aneurysm, and diffuse intracranial atheromatosis. The patient underwent stentriever-assisted thrombectomy, which achieved partial endovascular revascularization of the right MCA (Thrombolysis in Cerebral Infarction [TICI] score of 2b) after two passes using pRESET 5/40 mm (phenox) and Solitaire 4/40 mm (Medtronic) stents. In order to improve the reperfusion grade, we cleared a minor residual filling defect at M1 by attempting the third pass using a Solitaire stentriever. The stentriever was deployed across the M1 segment. While attempting to withdraw the stentriever, we perceived increased transient resistance and suspected the stentriever was trapped by the atherosclerotic plaque. Resistance was overcome by increasing traction; however, the first angiographic image obtained after this third pass showed extravasation of contrast medium from the distal ICA of imprecise origin. The patient reacted by moving as a sign of pain or discomfort, and blood pressure rose from a stable mean arterial pressure of 80–90 mmHg to 120 mmHg. We inflated the balloon of the guiding catheter achieving proximal arterial flow arrest. Anesthesia was deepened, analgesia was added, and arterial pressure was reduced to a mean arterial pressure of 64 mmHg. A double-lumen balloon was rapidly prepared, navigated to the distal ICA, and inflated in an occlusive fashion for 2 min. This maneuver was ineffective. We inflated the balloon again but for 8 min this time. Angiograms after balloon deflation confirmed no active contrast extravasation and a patent MCA. An angiogram obtained after 10 min of observation confirmed no extravasation. The procedure was discontinued. Post-procedure CT revealed contrast medium in the subarachnoid space, but not hydrocephalus. The patient was left intubated under general anesthesia and controlled arterial pressure, maintaining a mean arterial pressure of 70 mmHg. The patient was extubated 24 h after the procedure and showed signs of neurological improvement (NIHSS 15). Repeat cranial CT showed clearing of the subarachnoid hemorrhage with no hydrocephalus and an ischemic stroke in the right MCA territory. The patient had a prolonged hospital stay and was discharged to a rehabilitation facility with NIHSS of 14 and mRS of 5. Unfortunately, he died 32 days later due to systemic complications related to his oncological disease. This case focuses on the rare perforation of a large artery associated with the use of stentrievers. This chapter presents and discusses the occurrence, risk factors, and management of this life-threatening complication.