Mechanical Thrombectomy in a Patient Presenting with a Co-dominant Right M2 Occlusion and a Low National Institutes of Health Stroke Scale (NIHSS) Score: First-Pass Effect and Excellent Clinical Outcome

While current evidence supports the overall efficacy of mechanical thrombectomy (MT) to treat patients presenting with acute stroke secondary to large vessel occlusion, the use of this method to address occlusions of the M2 branches of the middle cerebral artery remains controversial. Numerous studies have demonstrated that MT can be both effective and beneficial in this patient subgroup and that it is not associated with a higher rate of periprocedural complications. Here we present the case of a 60-year-old male who presented to the emergency department of our hospital with symptoms of a stroke that had lasted for longer than 1 h. His National Institutes of Health Stroke Scale (NIHSS) score was 5 at admission because of significant dysarthria and left-sided facial paralysis. Computed tomography (CT) angiography revealed an occlusion of a co-dominant M2 segment of the right middle cerebral artery and a CT perfusion study revealed an ischemic penumbra. Non-contrast cranial CT revealed no acute cerebral infarction and a baseline Alberta Stroke Program Early CT Score of 10. Intravenous thrombolysis with 90 mg recombinant tissue plasminogen activator (rtPA; Actilyse, Boehringer Ingelheim) was initiated. Digital subtraction angiography (DSA) performed 2 h after the clinical onset and 1 h after the bolus injection of rtPA confirmed the diagnosis of embolic right M2 occlusion. Aspiration-augmented MT was performed under general anesthesia and complete recanalization of the arterial supply was achieved in a single pass. Post-procedural magnetic resonance imaging revealed a single lacunar lesion in the right semioval center with no territorial infarction. Secondary prophylaxis with apixaban (Eliquis; Pfizer) was initiated to treat newly diagnosed paroxysmal atrial fibrillation. During the hospitalization, the patient recovered completely and was discharged home 1 week later with NIHSS and modified Rankin scale scores of 0. This chapter provides an overview of treatment options and anticipated outcomes in patients presenting with acute cerebral stroke and isolated M2 occlusion with an emphasis on the use of MT as a safe and effective therapeutic modality.