Mechanical Thrombectomy of Acute Middle Cerebral Artery Occlusion Using Trans-Anterior Communicating Artery Approach

Intraoperative decision-making in thrombectomy for bilateral cerebral embolism: a mimic of thrombus migration

This study thoroughly examines the challenges in managing bilateral embolization, emphasizing intraoperative judgment. It aims to underscore the necessity of accurate etiological judgments and the limitations of cross-circulation thrombectomy. A 59-year-old male with hypertension and atrial fibrillation developed sudden limb twitching, progressing to limb paralysis and speech impairment. Neurological assessments identified multiple symptoms, while a head CT scan excluded intracranial hemorrhage. A mechanical thrombectomy revealed occlusions in the right internal cerebral artery (ICA) and left middle cerebral artery (MCA). Thrombus migration from the ICA terminus was misinterpreted as an escape from the anterior communicating artery, leading to unsuccessful thrombus retrieval. This study highlights the infrequency of bilateral embolic infarctions and intraoperative misjudgments arising from thrombus migration during thrombectomy. It underscores the limitations of cross-circulation thrombectomy and emphasizes a comprehensive risk-benefit analysis. The insights provided deepen the comprehension of thrombus migration patterns and inform strategies for bilateral embolism, focusing on optimal revascularization techniques.

The Rationale Behind Transcirculation Neuroendovascular Interventions: Literature Review Through a Case-Series Approach

BACKGROUND

With the development of advanced endovascular techniques and materials, neurointerventionalists can perform challenging and complex cases that were previously difficult to perform. Transcirculation approaches could be a useful tool used in complicated cases, providing access to the target vessel, through the contralateral or opposite circulation, when anterograde access is difficult or nonachievable.

OBJECTIVE

To retrospectively review cerebrovascular interventions performed through a transcirculation approach performed by staff at our Institution.

METHODS

English-language studies, published until August 2022, reporting transcirculation interventions in the cerebrovascular circulation were retrospectively collected. Type of intervention, number of cases, rationale, and complications were analyzed. Furthermore, similar cases performed by staff currently at our institution were also reviewed and described.

RESULTS

Including our cases, a total of 273 transcirculation treatment approaches have been reported. Intracranial aneurysm embolization, stroke thrombectomies, intra-arterial ophthalmic chemotherapy, arteriovenous malformationss, arteriovenous fistulas embolizations, and intracranial angioplasty and stenting are common indications. Reason for using a retrograde approach were stent/balloon-assisted coiling of wide neck aneurysm in 116 cases, difficult angulation of branch in 91 cases, occlusion of parent vessel in 55 cases, and bailout/other in 11 cases.

CONCLUSION

Transcirculation approaches can be considered for cases where conventional anterograde treatment options are not feasible or as a bailout strategy in failed or complicated treatment attempts. They represent a strategy to consider when facing challenging cases, and if performed by experienced and dedicated neurointerventionalists, they can represent a safe alternative.

Clot Meniscus Sign Is Associated With Thrombus Permeability and Choice of Mechanical Thrombectomy Technique in Acute Middle Cerebral Artery Occlusion

Background and Purpose

The method of mechanical thrombectomy (MT) is related to vascular anatomy and stroke etiology. Meniscus sign and thrombus permeability as imaging markers may be instructive for the selection of MT. This study aims to clarify the relationship among meniscus sign, thrombus permeability, and choice of MT in patients with acute middle cerebral artery occlusion.

Materials and Methods

A total of 111 patients with acute middle cerebral artery occlusion (MCAO) who underwent MT were retrospectively analyzed. Clot meniscus sign was defined as the appearance of meniscoid/edge-like or single- or double-wall contrast channels besides or around insular blood clots. The radiographic, clinical, and surgical data of patients with MCAO with or without meniscus sign were compared.

Results

The meniscus sign positive group (n = 26) has higher thrombus permeability (HUs) (26.92 ± 9.69 vs. 22.84 ± 7.88, p = 0.031) than those without it. Shorter puncture-to-recanalization (P2R) time (65.5 vs. 88, p = 0.012), higher complete recanalization rate (85.71 vs. 33.33%, p < 0.01), and better clinical outcome (p < 0.01) were obtained by selecting contact aspiration (CA) over stent retriever (SR) in patients with positive meniscus sign. In patients with negative meniscus sign, there was no significant difference in clinical outcome after receiving CA or SR.

Conclusion

Patients with MCAO with positive meniscus sign have higher thrombus permeability and are more suitable for CA to acquire better clinical outcomes.

Transcirculation Approach for Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Study and Review of the Literature

Background: Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, provide alternate endovascular routes when anterograde interventions are not feasible. We aimed to assess the safety and efficacy of mechanical thrombectomy (MT) through a transcirculation route.

Methods: Six centers provided retrospective data on acute ischemic stroke (AIS) patients who underwent MT via transcirculation approaches. Demographics and technical details of the endovascular intervention were collected. Recanalization rates, peri-procedural complications and clinical/angiographic outcomes immediately after the procedure and at last available follow-up were assessed. A review of the literature reporting on AIS patients whom underwent transcirculation MT was also performed.

Results: Our multicenter study included 14 AIS patients treated through transcirculation routes. Mean age was 57.8 ± 11.9 years, and 10 (71.4%) were men. Mean NIHSS at admission was 18.4 (range 8–27). TICI 2b-3 recanalization was achieved in 10/14 (71.4%) patients. Three patients died after intervention: one due to late recanalization, one due to acute in-stent thrombosis, and one due to a procedure-related thromboembolic brainstem infarct. Of 11 surviving patients with follow-up available (mean 9.7 months), mRS 0–2 was achieved in 6 (54.5%) cases. Our review of the literature pooled a total of 37 transcirculation MT cases. Most common occlusions were tandem lesions (ICA + MCA = 64.9%) and BA + bilateral VA (18.9%). ACOM and PCOM were crossed in 18 (48.6%) cases each; one patient required a combined ACOM-PCOM approach. Primary recanalization technique included intra-arterial (IA) thrombolytics alone in 10 (27%), angioplasty ± stenting in 6 (16.2%), stent-retriever in 8 (21.6%), contact aspiration in 6, and combined (MT ± IA-thrombolytics) in 6 cases. Twenty-eight (75.7%) AIS patients achieved successful TIMI 2-3/TICI 2b-3 recanalization. After a mean follow-up of 6.7 months, 23/31 (74.2%) patients achieved a favorable functional outcome.

Conclusions: Transcirculation approaches may be used to access the target lesion when the parent artery cannot be crossed through conventional antegrade routes. These techniques are feasible but should be reserved as a bailout maneuver when anterograde MT is not possible. Newer endovascular devices have improved neurological and angiographic outcomes in transcirculation cases.