J Stroke.  2024 May;26(2):190-202. 10.5853/jos.2023.02649.

Distal Medium Vessel Occlusion Strokes: Understanding the Present and Paving the Way for a Better Future

• Nogueira RG
• Doheim MF
• Al-Bayati AR
• Lee JS
• Haussen DC
• Mohammaden M
• Lang M
• Starr M
• Rocha M
• Câmara CPd
• Gross BA
• Bhatt NR

• KMID: 2556041
• DOI: http://doi.org/10.5853/jos.2023.02649

Abstract

Distal medium vessel occlusions (DMVOs) are thought to cause as many as 25% to 40% of all acute ischemic strokes and may result in substantial disability amongst survivors. Although intravenous thrombolysis (IVT) is more effective for distal than proximal vessel occlusions, the overall efficacy of IVT remains limited in DMVO with less than 50% of patients achieving reperfusion and about 1/3 to 1/4 of the patients failing to achieve functional independence. Data regarding mechanical thrombectomy (MT) among these patients remains limited. The smaller, thinner, and more tortuous vessels involved in DMVO are presumably associated with higher procedural risks whereas a lower benefit might be expected given the smaller amount of tissue territory at risk. Recent advances in technology have shown promising results in endovascular treatment of DMVOs with room for future improvement. In this review, we discuss some of the key technical and clinical considerations in DMVO treatment including the anatomical and clinical terminology, diagnostic modalities, the role of IVT and MT, existing technology, and technical challenges as well as the contemporary evidence and future treatment directions.

Keyword

Distal medium vessel occlusion; Stroke; Thrombolysis; Mechanical thrombectomy

Figure

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  Figure 1. A 39-year-old female with acute onset of right hemiplegia, left gaze, and aphasia. Non-contrast computed tomography demonstrated the presence of hyperdense “dot signs” in the Sylvian (indicated by arrows, A) and opercular (indicated by arrows, B) regions consistent thrombi involving the M2- and M3 segments of the left middle cerebral artery (indicated by arrows, C) which were successfully recanalized post-thrombectomy (D).

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  Figure 2. A 68-year-old male with acute onset of left leg weakness. Quantitative computed tomography (CT) perfusion demonstrated a large area of hypoperfusion (Tmax >6 s) involving the right anterior cerebral artery territory with a significant mismatch (A). Conventional angiography confirmed complete occlusion of the A2 segment of the left anterior cerebral artery (indicated by arrows, B) which was successfully recanalized post-thrombectomy (indicated by arrows, C). Post-treatment brain magnetic resonance imaging disclosed an infarct similar to the “ischemic core” (relative CBF <30%) area previously identified on the CT perfusion (D). CBF, cerebral blood flow.

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  Figure 3. A 55-year-old male with acute onset of left homonymous hemianopsia. Brain magnetic resonance imaging (MRI) gradient echo sequence showed a “susceptibility vessel sign” consistent with a red-blood-cell-rich thrombus within the distal right posterior cerebral artery (indicated by arrows, A). Qualitative MRI perfusion demonstrated a large area involving the right posterior cerebral artery territory (as circled, B). Conventional angiography confirmed occlusion of the fetal-type distal right posterior cerebral artery (indicated by arrows, C) which was successfully recanalized post-thrombectomy (indicated by arrows, D).

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  Figure 4. Distal mechanical thrombectomy with contact aspiration: blind navigation.

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  Figure 5. Distal mechanical thrombectomy with stent retriever.

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  Figure 6. Distal mechanical thrombectomy with stent retriever showing retraction Injury.

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  Figure 7. Distal mechanical thrombectomy with contact aspiration and stent retriever.

Reference

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