Neurointervention.  2019 Sep;14(2):137-141. 10.5469/neuroint.2019.00143.

Endovascular Thrombectomy for Distal Occlusion Using a Semi-Deployed Stentriever: Report of 2 Cases and Technical Note

• Wan Y
• Yang IH
• Orru E
• Krings T
• Tsang AC

• KMID: 2458494
• DOI: http://doi.org/10.5469/neuroint.2019.00143

Abstract

Distal intracranial occlusions can sometimes cause significant neurological deficits. Endovascular thrombectomy in these vessels may improve outcome but carry a higher risk of haemorrhagic complications due to the small calibre and tortuosity of the target vessel. We report two cases of isolated M2/3 artery occlusion causing dense hemiplegia that was successfully treated with stent retrieval thrombectomy. A "semi-deployment technique" of a 3 mm stentriever was employed at the M2/3 bifurcation of the middle cerebral artery. Partial stent unsheathing allowed adequate clot engagement while avoiding excessive tension by the stent metal struts along the tortuous course of a distal vessel. Complete revascularization was achieved after first-pass of the stent retriever without complication, resulting in good clinical outcome in both cases. The described semi-deployment technique reduces the radial and tractional force exerted by the stentreiver on small branches, and may reduce the risk of vessel laceration or dissection in distal vessel thrombectomy.

Keyword

Thrombectomy; Stroke; Endovascular procedures

MeSH Terms

Arteries
Endovascular Procedures
Hemiplegia
Lacerations
Middle Cerebral Artery
Stents
Stroke
Thrombectomy*
Traction

Figure

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  Fig. 1. (A) Non-contrast CT brain showing hyperdense MCA thrombus in the M2/3 segment at the Sylvian fissure and (B) contrast CT angiogram with sagittal reconstruction demonstrating the filling defect at the M2/3 bifurcation of the opercular branch of MCA (arrow). (C) Lateral projection right ICA angiogram and (D) selective microcatheter angiogram from right precentral artery demonstrating the M3 precentral artery occlusion (arrows) and perfusion defect in the Rolandic area (dotted circle). CT, computed tomography; MCA, middle cerebral artery; ICA, internal carotid artery.

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  Fig. 2. (A, B) Antero-posterior and lateral fluoroscopy showing the semi-deployed “Baby” Trevo stent retriever in right precentral artery across the occluded segment, with the proximal half of the stent retriever still captured within the microcatheter. (C, D) Post thrombectomy right ICA angiogram showing revascularization of the occluded precentral artery (arrows). (E) Gradient echo MRI and (F) diffusion weighted image 72 hours after thrombectomy demonstrating no evidence of subarachnoid haemorrhage, and foci of diffusion restriction corresponding to distal emboli without a large wedge cerebral infarction. ICA, internal carotid artery; MRI, magnetic resonance imaging.

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  Fig. 3. (A, B) Antero-posterior and lateral view of left ICA angiogram, demonstrating the M2/3 branch occlusion (white arrow); (C) anterio-posterior fluoroscopic image showing the semi-deployed baby Trevo stent retriever, with the proximal half of the stent still restrained within the microcatheter. (D) Lateral ICA angiogram after first pass of thrombectomy demonstrating TICI 3 reperfusion and reopening of previous occluded vessel (white arrow). (E) Carotid bifurcation stenosis treated with stenting and angioplasty. (F) Brain CT 24-hours after thrombectomy showing no significant cerebral ischemia or hemorrhagic complication. ICA, internal carotid artery; TICI, treatment in cerebral infarction; CT, computed tomography.

Reference

1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018; 49:e46. –e110.

2. Saber H, Narayanan S, Palla M, Saver JL, Nogueira RG, Yoo AJ, et al. Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis. J Neurointerv Surg. 2018; 10:620–624.

3. Tan IY, Demchuk AM, Hopyan J, Zhang L, Gladstone D, Wong K, et al. CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol. 2009; 30:525–531.

4. Fanous AA, Siddiqui AH. Mechanical thrombectomy: stent retrievers vs. aspiration catheters. Cor et Vasa. 2016; 58:e193. –e203.

5. Haussen DC, Lima A, Nogueira RG. The Trevo XP 3x20 mm retriever (‘Baby Trevo’) for the treatment of distal intracranial occlusions. J Neurointerv Surg. 2016; 8:295–299.

6. Machi P, Jourdan F, Ambard D, Reynaud C, Lobotesis K, Sanchez M, et al. Experimental evaluation of stent retrievers’ mechanical properties and effectiveness. J Neurointerv Surg. 2017; 9:257–263.

7. Imahori T, Tanaka K, Koyama J, Arai A, Shiomi R, Iwahashi H, et al. Mechanical thrombectomy using the Trevo ProVue in 50 consecutive patients with anterior circulation stroke: a single-center experience after approval of the stent retriever in Japan. Neurol Med Chir (Tokyo). 2017; 57:128–135.

8. Premat K, Bartolini B, Baronnet-Chauvet F, Shotar E, Degos V, Muresan P, et al. Single-center experience using the 3MAX reperfusion catheter for the treatment of acute ischemic stroke with distal arterial occlusions. Clin Neuroradiol. 2018; 28:553–562.

9. Kim YW, Son S, Kang DH, Hwang YH, Kim YS. Endovascular thrombectomy for M2 occlusions: comparison between forced arterial suction thrombectomy and stent retriever thrombectomy. J Neurointerv Surg. 2017; 9:626–630.

10. Tsang COA, Cheung IHW, Lau KK, Brinjikji W, Kallmes DF, Krings T. Outcomes of stent retriever versus aspiration-first thrombectomy in ischemic stroke: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2018; 39:2070–2076.