Case presentation

This 67-year-old woman presented on 3 March 2008 at 16:00 to the neurological emergency room. Earlier that day (at 14:50), her relatives had witnessed the acute onset of a fluctuating paresis of her left arm and leg. Diffusion weighted MR images, carried out at 16:30, revealed an area of restricted diffusion in the right basal ganglia and the deep periventricular white matter and an MR angiogram demonstrated complete occlusion of the right middle cerebral artery (MCA) in the M1 segment. The emergency stroke team decided to initiate intravenous thrombolysis, which started within a 2 h window (16:45). As the patient did not show any clinical improvement within the next 30 min, the attending stroke physician decided to proceed with a bridging concept and endovascular treatment was initiated, after the patient was informed of the proposed procedure. This information included a description of the procedure, the potential risks and benefits and an explanation that extensions of the procedure (eg, surgical craniectomy) or the off-label use of medical devices (eg, coronary stents, etc) might become necessary. The patient gave informed consent to the operator. The neurological examination before digital subtraction angiography (DSA) showed a severe dysarthria and a left-sided hemiplegia with facial nerve palsy (National Institutes of Health Stroke Scale (NIHSS) score of 10). The emergent angiography began 3 h and 20 min after the onset of symptoms and the first DSA run was recorded at 18:12.

Using a 4 F diagnostic catheter, selective injection of both vertebral arteries and internal carotid arteries (ICAs) was carried out to show the extent of leptomeningeal collaterals and to rule out distal emboli, eventually not visible on MR angiography. Complete embolic occlusion of the right MCA at the M1 segment with moderate leptomeningeal collaterals between the right anterior cerebral artery and MCA was confirmed (figure 1A,B).

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Figure 1

Embolic occlusion of the right middle cerebral artery (MCA), treated by mechanical thrombectomy using a Solitaire stent. (A) Digital subtraction angiography (DSA) with injection of the right internal carotid artery (ICA) shows embolic occlusion of the right M1 segment. (B) In the late phase of this DSA run with injection of the right ICA, the leptomeningeal collaterals between the right anterior and MCA were visualized. (C) Solitaire stent loaded with thrombus, which was removed from the right M1 segment. (D, E) DSA with injection of the right ICA after Solitaire thrombectomy confirms the recanalization of the short M1 and both M2 segments (D, magnified view) without vasospasm or distal emboli (E, whole head run). There might be a minor remnant of the previously occluding thrombus in the inferior trunk to the MCA/M2 (D). (F) CT 22 months after the Solitaire thrombectomy of the right MCA shows a small post-ischemic scar of the right basal ganglia.

Systemic anticoagulation with 5000 U of heparin was initiated. Via a 6 F Envoy guiding catheter (Cordis, Miami, USA) in the right ICA, a straight Rebar27 was gently advanced to the thrombus under the guidance of a SilverSpeed16 microguidewire (both ev3). Under road map, a thrombectomy brush (pCR, phenox; Bochum, Germany) was deployed in the right angular artery and subsequently slowly withdrawn under continuous aspiration. The brush was loaded with clot material but no recanalization of the target vessel was observed (TICI 1). During the catheterization, the thrombus appeared organized and firm. The chances of success of either LIF or repeated pCR passages were considered low as previous experience has shown very low recanalization rates with pCR and LIF in firm organized emboli. It appeared evident to the operator (HH) that in this situation, more interaction between clot and retrieval device was required. While contemplating the use of either a Catch or a Merci retriever (at this time the only other approved devices for mechanical thrombectomy), we recognized that neither of these tools was in stock. After balancing the potential risks and benefits to this patient and given the uncertain outcome if there was no recanalization, we decided to use a Solitaire stent in the way we would have otherwise used a Catch or a Merci device. The right angular artery was again gently catheterized with a Rebar18 catheter. After removal of the microguidewire, a self-expanding Solitaire stent (4 mm diameter, 20 mm length) was inserted under continuous slow flush with saline solution to the distal end of the microcatheter and was deployed by slowly pulling back the microcatheter. Correct deployment of the Solitaire stent over the whole length of the thrombus was observed under continuous fluoroscopy. In order to avoid mechanically induced vasospasm, 2 mg of glycerin trinitrate were injected intra-arterially. After several minutes of incubation and with the rotating hemostatic valve tightly closed, a 50 ml Luer lock syringe was used for high volume aspiration through the 6 F guiding catheter during withdrawal of the open Solitaire stent and the microcatheter into the guide catheter. Withdrawal was possible with minor effort and was observed under continuous fluoroscopy. As soon as the device became visible, the rotating hemostatic valve was quickly removed from the guiding catheter and another 50 ml of blood were aspirated. The Solitaire stent was loaded with a thrombus (figure 1C). Contrast injection of the right ICA after removal of the Solitaire confirmed total recanalization of the right MCA (figure 1D,E; TICI 3). Neither peripheral emboli nor vasospasm at the previously occluded vessel site was encountered.

The entire procedure (from the first to the final DSA run) lasted 59 min. The patient awoke from general anesthesia with only mild neurologic deficit (NIHSS 2). The patient was discharged to a rehabilitation center. At the 30 day follow-up, NIHSS was 0.

The patient was heparinized and received 100 mg of acetylsalicylic acid daily as secondary prophylaxis. ECG monitoring revealed atrial fibrillation as a potential source of cardiac embolism and hence the patient was anticoagulated with phenprocoumon. MRI examinations were refused by the severely claustrophobic patient. DSA 24 days after treatment showed a completely normal M1 segment and patent cortical branches of the entire right MCA. Follow-up CT 22 months later showed a small post-ischemic lesion of the right basal ganglia and normal cortex (figure 1F).