Permanent Y-Stent Implantation as Bailout Strategy After Failed Mechanical Thrombectomy for Acute Embolic Occlusion of a Middle Cerebral Artery

A 77-year-old woman was observed by her husband suddenly falling in the garden. Her symptoms were associated with right-sided hemiparesis and severe expressive dysphasia. At the presentation in the local hospital, the neurological examination revealed a National Institute of Health Stroke Scale (NIHSS) score of 26. She was otherwise hemodynamically stable. At baseline, she was functionally independent with a modified ranking score (mRS) of 0, and her past medical history was significant only for hypertension, for which she was on medications. An hour into the onset of symptoms, she was urgently taken into the scanner for noncontrast computed tomography (NCCT) and computed tomographic angiography (CTA) of the head, which showed a large vessel occlusion (LVO) in the left middle cerebral artery (MCA). The decision was to proceed with intravenous (IV) thrombolysis and eventually referred to the comprehensive stroke center (CSC) for endovascular therapy (EVT). Reassessment after having arrived at the CSC, the NIHSS score was 17. General anesthesia was induced due to marked agitation, and the procedure commenced with a standard right common femoral artery puncture approach. The access was gained with an 8Fr Arrow (Teleflex Medical) catheter, which was traced in the cervical ICA; however, due to tortuous anatomy, it was retracted back. Subsequently, an 8F Flowgate 2 catheter was navigated to reach into high cervical ICA through which 5Fr SOFIA (MicroVention), Headway 21 (MicroVention), and Synchro 2 (Stryker) were navigated to cross the clot. A 4/45 mm Envi stent-retriever (Neurovasc Technologies) was used for the initial thrombectomy with combined double aspiration using a pump (Medela) on the SOFIA and a VacLok syringe (Merit Medical) on the Flowgate 2 BGC. After two attempts using this combined approach, there was no change in the appearance, and therefore a 4.5/28 mm Nimbus device (Cerenovus) was used, which also failed to achieve recanalization. At this point, the decision was then made to acutely deploy two Neuroform Atlas (Stryker) stents in the ascending frontal and angular artery of the left MCA, achieving an initial TICI 2c recanalization. A weight-adapted IV bolus of Integrilin (GlaxoSmithKline) and 500 mg IV Aspirin were given prior to stenting. The last angiographic run of the treated vessel confirmed a TICI 3 recanalization. At the end of the procedure, a nasogastric tube was inserted, and 30 mg of crushed prasugrel was also given. The patient was extubated and transferred to the hyper-acute stroke unit (HASU). The following day on assessment, the patient had mild improvement in neurological status. Twenty-four-hour NCCT and CTA demonstrated maturation of the infarction involving the insular cortex, frontal operculum, and inferior parietal lobule with no definite hemorrhage and an ASPECTS of 5. Both intracranial stents were patent with good flow. The patient was then transferred to the local acute stroke unit (ASU) for ongoing investigations and rehabilitation. This chapter describes the bailout strategy using permanent intracranial stenting following failed mechanical thrombectomy (MT).