Abstract Number ‐ 149: Mechanical stent retriever thrombectomy of distal medium vessel occlusiono in acute ischemic stroke.
Authors: Lodi Yahia M , Reddy Varun V , Singh Amrinder , Khan Irfan 
Published: April 2023

Introduction

Randomized clinical trial (RTC) have demonstrated benefit of stent retriever mechanical thrombectomy (SRMT) of large vessel occlusion (LVO) in acute ischemic stroke (AIS) including with those present in 24 hours. However, trials have included predominately proximal middle cerebral artery (MCA, M1) and current recommendation is to perform SRMT in M1/M2. Therefore, AIS patients with distal medium vessel occlusion (DMVO)) with high NIHSS has no recommendation or options leading to disabilities. Objective of our study is to present the safety and feasibility of SRMT of DMVO who underwent SRMT. Additionally, we will describe technical aspect including their clinical and radiographic outcomes.

Methods

From a stroke‐endovascular databased, consecutive patient with SVO underwent SRMT from 2015–2022 were selected. Patient demographics including recanalization data with clinical and radiographic outcomes were collected.

Results

7 patients (4 female) with median age of 65.66 (range 41–86), median NIHSS of 13 (range 7–19) and median ASPECT 8 (7‐10) presented with SVO; right M3 in 2 and left M3/M4 in 5 patients. Of 7 DMVO patients, one presented in 4 hours and receives intravenous rTPA, 2 presented in 12 hours and 4 presented in unknown time of onset but last known normal was 24 hours. One of the left M3/4 patients was a singer who (41 years old) absolutely do not wanted to be alive if she didn’t regain her speech. Similarly, another 42‐year‐old woman with left M3/4 clot was teacher wanted her speech restored for teaching. Endovascular strategies: all but one received rectal 300 mg aspirin and 500 ml normal saline bolus. Under conscious sedation, 8 French balloon catheters were used in all cases and the guide was flushed with heparin and nitroglycerine mixed saline. Solitaire SRMT in 5 cases (4×20 in 1 and 4×40 in 6 cases) and trevo in one (3×20 mm). Patient with solitaire SRMT required single pass in which trap technique (suction through CAT6 and retriever of SRD as a unit without shaving of clots) was utilized using CAT6 132 mm catheter 6 cases and Trevo SRMT required 3 passes. All achieved TICI 3 recanalization without complications. Outcomes: immediate post STMT, median NIHSS 2 (0‐6), 24 hours median NIHSS 1 (1‐6) and 90 days NIHSS 0 for all. 90 days mRS0 in 4, mRS1 in 1 and mRS2 in 1. 24 hours CT scan demonstrated small stroke in 2 patients. One patient lost follow up. 41‐year‐old singer immediately regained her speech after SRMT discharged home in 36 hours. 42‐year‐old teacher improved her speech and continue to teach.

Conclusions

Our case series demonstrated that SRMT in DMVO with disabling NIHSS is feasible and safe if performed carefully. All patient achieved TICI 3 perfusion and first pass effect was better in trap technique using long solitaire STD. Good function outcomes were achieved in all cases irrespective of the types of SRD used and passes required to achieve TICI 3 perfusion. Further studies are required.