Tandem Occlusion of ICA and MCA

53 year old female with acute 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 occlusion
Collaterals: 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

 

 



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.



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.

 

 


5] 24 hours MRI Head:


Multifocal acute infarcts in right MCA territory with petechial hemorrhages.