Intracranial mechanical thrombectomy without extracranial revascularization for a tandem occlusion with robust Circle of Willis: Case report

Mateja de Leonni Stanonik, Christopher Sy, Cameron McDougall, Lee Birnbaum, Justin Mascitelli

Research output: Contribution to journalArticle

Abstract

A 59-year-old male presented with a severe left middle cerebral artery (MCA) syndrome, a National Institutes of Health Stroke Scale (NIHSS) of 17, and was last known well 26 h prior. Computed tomography angiography (CTA) of the head demonstrated a tandem extracranial ICA and intracranial ICA/MCA occlusion. Computed tomography perfusion (CTP) demonstrated a large mismatch. The patient underwent a mechanical thrombectomy using a stent retriever resulting in a modified thrombolysis in cerebral infarction (mTICI) score of 2b. A balloon angioplasty of the extracranial carotid occlusion only resulted in temporary restoration of flow so stent placement was considered. Prior to stent placement, however, cerebral angiography revealed good collateral supply to the left MCA territory via the Circle of Willis. The procedure was thus terminated given good collateral supply from the right side and the unknown risk of dual antiplatelet therapy in a patient with an unknown stroke burden. Postoperatively, the patient immediately improved and magnetic resonance imaging (MRI) of the brain revealed minimal stroke burden. The patient was discharged to acute rehab with an NIHSS of 6. At 4 weeks, the patient's NIHSS was 2 and his modified Rankin Scale (mRS) was 1. This case highlights important considerations, as well as one potential option, when treating tandem occlusions in patients with a robust Circle of Willis.

Original languageEnglish (US)
Article number100582
JournalInterdisciplinary Neurosurgery: Advanced Techniques and Case Management
Volume19
DOIs
StatePublished - Mar 2020

Fingerprint

Circle of Willis
Thrombectomy
Stroke
National Institutes of Health (U.S.)
Stents
Middle Cerebral Artery Infarction
Cerebral Angiography
Balloon Angioplasty
Cerebral Infarction
Middle Cerebral Artery
Perfusion
Head
Tomography
Magnetic Resonance Imaging
Brain

Keywords

  • Circle of Willis
  • Internal carotid artery
  • Ischemic stroke
  • Mechanical thrombectomy
  • Stent
  • Tandem occlusion

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

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title = "Intracranial mechanical thrombectomy without extracranial revascularization for a tandem occlusion with robust Circle of Willis: Case report",
abstract = "A 59-year-old male presented with a severe left middle cerebral artery (MCA) syndrome, a National Institutes of Health Stroke Scale (NIHSS) of 17, and was last known well 26 h prior. Computed tomography angiography (CTA) of the head demonstrated a tandem extracranial ICA and intracranial ICA/MCA occlusion. Computed tomography perfusion (CTP) demonstrated a large mismatch. The patient underwent a mechanical thrombectomy using a stent retriever resulting in a modified thrombolysis in cerebral infarction (mTICI) score of 2b. A balloon angioplasty of the extracranial carotid occlusion only resulted in temporary restoration of flow so stent placement was considered. Prior to stent placement, however, cerebral angiography revealed good collateral supply to the left MCA territory via the Circle of Willis. The procedure was thus terminated given good collateral supply from the right side and the unknown risk of dual antiplatelet therapy in a patient with an unknown stroke burden. Postoperatively, the patient immediately improved and magnetic resonance imaging (MRI) of the brain revealed minimal stroke burden. The patient was discharged to acute rehab with an NIHSS of 6. At 4 weeks, the patient's NIHSS was 2 and his modified Rankin Scale (mRS) was 1. This case highlights important considerations, as well as one potential option, when treating tandem occlusions in patients with a robust Circle of Willis.",
keywords = "Circle of Willis, Internal carotid artery, Ischemic stroke, Mechanical thrombectomy, Stent, Tandem occlusion",
author = "{de Leonni Stanonik}, Mateja and Christopher Sy and Cameron McDougall and Lee Birnbaum and Justin Mascitelli",
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T1 - Intracranial mechanical thrombectomy without extracranial revascularization for a tandem occlusion with robust Circle of Willis

T2 - Case report

AU - de Leonni Stanonik, Mateja

AU - Sy, Christopher

AU - McDougall, Cameron

AU - Birnbaum, Lee

AU - Mascitelli, Justin

PY - 2020/3

Y1 - 2020/3

N2 - A 59-year-old male presented with a severe left middle cerebral artery (MCA) syndrome, a National Institutes of Health Stroke Scale (NIHSS) of 17, and was last known well 26 h prior. Computed tomography angiography (CTA) of the head demonstrated a tandem extracranial ICA and intracranial ICA/MCA occlusion. Computed tomography perfusion (CTP) demonstrated a large mismatch. The patient underwent a mechanical thrombectomy using a stent retriever resulting in a modified thrombolysis in cerebral infarction (mTICI) score of 2b. A balloon angioplasty of the extracranial carotid occlusion only resulted in temporary restoration of flow so stent placement was considered. Prior to stent placement, however, cerebral angiography revealed good collateral supply to the left MCA territory via the Circle of Willis. The procedure was thus terminated given good collateral supply from the right side and the unknown risk of dual antiplatelet therapy in a patient with an unknown stroke burden. Postoperatively, the patient immediately improved and magnetic resonance imaging (MRI) of the brain revealed minimal stroke burden. The patient was discharged to acute rehab with an NIHSS of 6. At 4 weeks, the patient's NIHSS was 2 and his modified Rankin Scale (mRS) was 1. This case highlights important considerations, as well as one potential option, when treating tandem occlusions in patients with a robust Circle of Willis.

AB - A 59-year-old male presented with a severe left middle cerebral artery (MCA) syndrome, a National Institutes of Health Stroke Scale (NIHSS) of 17, and was last known well 26 h prior. Computed tomography angiography (CTA) of the head demonstrated a tandem extracranial ICA and intracranial ICA/MCA occlusion. Computed tomography perfusion (CTP) demonstrated a large mismatch. The patient underwent a mechanical thrombectomy using a stent retriever resulting in a modified thrombolysis in cerebral infarction (mTICI) score of 2b. A balloon angioplasty of the extracranial carotid occlusion only resulted in temporary restoration of flow so stent placement was considered. Prior to stent placement, however, cerebral angiography revealed good collateral supply to the left MCA territory via the Circle of Willis. The procedure was thus terminated given good collateral supply from the right side and the unknown risk of dual antiplatelet therapy in a patient with an unknown stroke burden. Postoperatively, the patient immediately improved and magnetic resonance imaging (MRI) of the brain revealed minimal stroke burden. The patient was discharged to acute rehab with an NIHSS of 6. At 4 weeks, the patient's NIHSS was 2 and his modified Rankin Scale (mRS) was 1. This case highlights important considerations, as well as one potential option, when treating tandem occlusions in patients with a robust Circle of Willis.

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