Carotid Angioplasty, Intracranial Thrombectomy, and Carotid Stenting for the Treatment of Acute Stroke Due to Tandem Occlusions: The Use of a High Tip Stiffness Microguidewire, Balloon-Assisted Microguidewire Deflection and Drilling, and Balloon-Assisted Guiding Catheter Climbing Techniques

Microguidewire crossing can be the most challenging and time-consuming step during neuroendovascular procedures for the treatment of acute internal carotid artery (ICA) occlusions. Angiographic identification of the proximal end of the acutely occluded artery is critical. The “spike sign” is a transient finding that represents the proximal patent remnant of the stenotic corridor. The spike guides the interventionalist through the fresh clot that has complicated the atherosclerotic plaque. The spike provides access to the “path of least resistance” to cross the more fibrocalcified and resistant occluded segment. In this chapter, we describe a particularly challenging condition, a total occlusion with only a hair-like spike branching perpendicular to the axis of the common carotid artery (CCA) origin, and some valuable technical points that we found very useful during the procedure. A 73-year-old man with a history of arterial hypertension, dyslipidemia, heavy smoking, ischemic heart disease, myocardial infarction 4 years earlier and repeated coronary angioplasties, and prostate disease under oncological management was brought to the emergency department after a witnessed collapse followed by vomiting. He was intubated and ventilated by paramedics at his home and transferred to a nearby primary hospital. From there he was transferred to our center. On admission, 5 h after the therapeutic window for intravenous tissue-type plasminogen activator (tPA), he was tachycardic and hypertensive (right arm blood pressure was 182/94 mmHg). A limited neurological examination revealed left-sided gaze and head deviation, and pupils that were miotic, equal, and reactive. Despite the effects of sedation, it was clear that the patient had mixed aphasia and right faciobrachiocrural hemiplegia, with an initial National Institutes of Health Stroke Scale (NIHSS) score of 28. Admission noncontrast CT showed advanced microvascular brain disease and an Alberta Stroke Program Automated CT Early Score (ASPECTS) of 9. CT perfusion (CTP) images showed a 17 ml volume in the lenticular and subinsular areas with a reduction in cerebral blood flow to <30% of expected levels (core) and a significantly larger hypoperfused area of 123 ml with time-to-maximal prolongation >6 s (penumbra) that corresponded to the entire left middle cerebral artery (MCA) territory. CT angiography (CTA) confirmed occlusion of the left proximal MCA with a good collateral pattern. The patient was transferred to the neuroangiography suite for urgent revascularization. Under general anesthesia, the patient underwent revascularization of the ICA and MCA, which required the use of a high tip stiffness microguidewire, balloon-assisted microguidewire drilling, and balloon-assisted guidewire climbing techniques. The endovascular procedure was technically challenging but successful. The patient had a remarkably rapid and complete reversal of his symptoms and an uncomplicated hospital stay, and was discharged directly to his home. This chapter focuses on useful technical nuances required for acute carotid revascularization and thrombectomy that may be of value in the management of tandem occlusions.