Endovascular Treatment of Acute Ischemic Stroke Due to Tandem Occlusion of Cerebral Arteries

This report describes the successful endovascular treatment of a patient with acute ischemic stroke of the right anterior circulation due to tandem occlusions of the right internal carotid artery (ICA) and the right middle cerebral artery (MCA). The peculiarity of this case is the rather unusual clinical course of the disease and associated endovascular attempts to solve the problem. A 47-year-old male patient had an acute onset of illness at home when he experienced sudden weakness and numbness in his left limbs, left-sided facial weakness and numbness, and visual disturbances. His National Institute of Health Stroke Scale (NIHSS) score was 12. Within 2 h of symptom onset, the patient was admitted to the Mechnikov Dnipropetrovsk Regional Clinical Hospital. On admission, a cranial computed tomography (CT) scan ruled out hemorrhage, large focal changes, or early ischemic brain damage. The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) was 10. CT angiography (CTA) showed right ICA occlusion at the C1 segment due to dissection and right MCA/M1 occlusion. Intravenous (IV) thrombolysis was initiated, and the patient was referred to the neuro-angiosuite for further evaluation and revascularization. Cerebral digital subtraction angiography (DSA) of the right common carotid artery (CCA) confirmed a right ICA occlusion with characteristics of a C1 segment dissection. Failed attempts to recanalize the right ICA took 35 min, during which time complete neurological recovery (NIHSS 0) was achieved with continuous intravenous thrombolysis. The completed DSA study confirmed adequate collateral supply through the circle of Willis. This finding led us to discontinue further attempts to endovascularly restore patency of the right ICA. The next day, the patient’s condition worsened again with more severe neurological symptoms corresponding to an NIHSS score of 22. Follow-up DSA showed partial spontaneous recanalization of the right ICA lumen with reocclusion of the right MCA. Mechanical thrombectomy of the right MCA was performed. The right ICA was occluded with microcoils and a microvascular plug device to prevent further distal embolization from the ICA lumen. A CT scan the next day showed ischemic lesions of the right temporal and parietal lobes with hemorrhagic transformation that did not require treatment. The patient recovered to NIHSS 3 and mRS 1. The management of tandem occlusions in acute ischemic stroke is the focus of this chapter.