Tandem Extracranial and Intracranial ICA Occlusions Treated Through Balloon Angioplasty and Double Stent Retriever Thrombectomy (Telescoped Stent-in-Stent Array)

Mechanical thrombectomy has become the standard treatment for acute ischemic stroke caused by large vessel occlusion; however, refractory occlusions still occur. The double stentriever technique, which employs two stentrievers simultaneously at the occlusion, can be helpful for such refractory occlusions. This technique has recently been proposed as the first line for M1/T-internal carotid artery (ICA) occlusions. In our experience, when dealing with large clot masses or refractory clots, the double stentriever technique is a valuable option, with a high first-pass effect and acceptable safety profile. Due to its encouraging results, this technique became the first-line technique of choice for T-ICA and selected vertebrobasilar occlusions, as well as dural sinus thromboses in our center. As a note of caution, we believe hemorrhagic complications are more frequent with this technique. The case presented here exemplifies the use of the double stentriever technique. We present the case of a 69-year-old woman with a history of dyslipidemia, diabetes, ischemic heart disease, and a recent diagnosis of colon cancer under oncological treatment. She developed left-side weakness and was brought by her family to the emergency room 30 min after the stroke onset. Upon evaluation, she presented signs and symptoms of a major right hemispheric stroke with an initial National Institutes of Health Stroke Scale (NIHSS) score of 12. Admission noncontrast cranial CT showed hypodensity of the caudate nucleus, lenticular nucleus, and internal capsule, leading to an admission Alberta Stroke Program Early CT Score (ASPECTS) of 7 points. CT angiography (CTA)CT angiography (CTA) studies revealed an occlusion of the distal right ICA (carotid T occlusion). On CT perfusion (CTP), a 16 ml region with total cerebral blood flow reduction to less than 30%, located predominantly in a deep zone, was seen. The region with a time-to-maximum prolongation >6 s had a volume of 156 mL. The patient received an intravenous recombinant tissue plasminogen activator (rtPA) with no significant clinical effect. She was then transferred to the neuroangiography suite and underwent urgent endovascular revascularization of tandem right ICA occlusions, with angioplasty of the proximal right ICA atherothrombotic occlusion and double stentriever-assisted embolectomy of the ICA T occlusion. The procedure allowed revascularization of the right ICA, complete reperfusion, and filling of all proximal and distal branches for a modified Thrombolysis in Cerebral Infarction (mTICI) score of 3. The patient improved neurologically immediately after extubation, with a post-procedure National Institutes of Health Stroke Scale (NIHSS) score of 8. Post-procedure noncontrast CT revealed subinsular and lenticular hemorrhagic foci associated with a Sylvian fissure subarachnoid hemorrhage, with preservation of the hemispheric cortical structure. Dual antiplatelet therapy was reinitiated 72 h after a second CT (performed after 6 h) that confirmed stable hemorrhagic lesions. Despite intensive rehabilitation, her neurological recovery was incomplete with residual left arm and leg paresis, and she remained with a 90-day modified Rankin Scale (mRS) score of 2 points. Double stentriever thrombectomy is the main topic of this chapter.