A Case of Mechanical Thrombectomy with Stent-retriever Avoiding Vessel Linearization for Occluded Tortuous Distal Branch of Middle Cerebral Artery (M2)

Abstract

Objective: We report a case of mechanical thrombectomy with stent-retriever for the insular segment of the middle cerebral artery (M2). Stent was deployed on a relatively linear vessel, which was not the culprit lesion for hemiparesis, with avoidance of excessive straightening of the culprit vessel.

Case Presentations: A 66-year-old man presented with sudden onset of left hemiparesis. MRI showed no ischemic changes and intravenous administration of t-PA was started. Cerebral angiography showed occlusion at the M2 bifurcation. Recanalization was unsuccessful using mechanical thrombectomy with a Penumbra Reperfusion Catheter 3-MAX. Therefore, thrombectomy with a Solitaire FR 4.0/15 mm stent-retriever was then performed. Stent was deployed to the other straight running culprit branch to avoid linearization of morbid vessel. Flow restoration occurred immediately after stent deployment and there was no reocclusion at 10 min after deployment. The stent-retriever was then drawn back via the guiding catheter, and clots were retrieved outside the stent struts. Immediately, angiography showed complete recanalization of the parietal and central arteries, which resulted in neurological improvement.

Conclusion: In thrombectomy with a stent-retriever for acute occlusion due to a clot at the M2 bifurcation, the site at which the stent is deployed should be determined based on efficacy, with deployment in the active zone, and safety, with avoidance of excessive vessel linearization. This should result in clot retrieval outside the stent struts, as in this case.