53 year old female with left hemiparesis, hemineglect and dysarthria. NIHSS >15. LSN Unknown.

Baseline Imaging: NCCT: 12:17 pm

Motion artifacts. ASPECTS: 6 (M2, M4, Insula, lentiform nucleus), Rt Hyperdense M1 sign seen

mCTA: 12:19 pm- Right M1 occlusion, Tandem occlusion with right cervical ICA occlusionCollaterals: Fair (patchy defects in the extent of collaterals- especially in the anterior M2 division, with delayed washout in the posterior M2 division)

Arch: Type 3 arch, difficult access


CT Perfusion (Perfusion images alone might not load in safari, due to an isolated browser compatability issue, try chrome or firefox)


Decision making:

IV tPA: Not given due to established ischemic changes, ASPECTS 6
EVT: Yes, proximal target occlusions, poor NIHSS
Challenges: Difficult arch, cervical ICA occlusion, may require angioplasty or stenting. Cardiac amyloidosis with poor cardiac output.

Endovascular treatment: Under GA, with intra-arterial BP monitoring.
Groin puncture: 12:35 pm
First run time: 12:41 pm
Procedure: Thromboaspiration of cervical ICA through guide catheter. Followed by intracranial stent-retriever thrombectomy. Distal clot fragmentation and migration noted. Cervical ICA acutely stented after angioplasty. Final mTICI score of 2a/b.
Immediate post-procedure CT performed to rule out intracranial hemorrhage before loading on dual antiplatelets.


24 hours MRI Head:
Multifocal acute infarcts in right MCA territory with petechial hemorrhages.