Intravenous Cangrelor as Rescue Treatment for Refractory Proximal Intracranial Artery Occlusion

A 33-year-old man with no significant medical history was admitted to the referring hospital with acute onset of right hemiplegia and aphasia (NIHSS 22). There, an MRI revealed an occlusion of the M1 segment of the left middle cerebral artery. Lesions of the basal ganglia, operculum, and M2 region on the left side seen on diffusion-weighted MRI did not correlate with FLAIR imaging. Intravenous fibrinolysis was performed approximately 3.5 h after the clinical onset of symptoms. Endovascular treatment under conscious sedation was started almost 5 h after clinical onset. The first aspiration thrombectomy was unsuccessful. The second aspiration thrombectomy resulted in transient recanalization of the left M1 segment with significant stenosis. This was followed by early reocclusion of the vessel. The third thrombectomy (this time with a Solitaire stent retriever) was also only able to open the target vessel for a short time. The intravenous infusion of cangrelor, started 6 h after clinical onset, resulted in recanalization of the early reocclusion of the left middle cerebral artery within 15 min. There were no further reocclusions or hemorrhagic complications. The patient recovered very well and after 90 days, his condition corresponded to an mRS score of 2. The treatment of early target vessel reocclusion after thrombectomy by intravenous infusion of the P2Y12 receptor inhibitor cangrelor is the main topic of this chapter.