Occlusion, Acute Left M1
H&P
- HPI:
- Acute onset of right hemiparesis and aphasia
- LKN: 2.5 hours ago
- NIHSS: 6
- Received tPA at OSH
- Transferred for evaluation of MT
- PE:
- GCS 4/1/6
- Right facial droop
- Left gaze preference
- Aphasic
- Left side strength antigravity
- Right side strength 1/5
- Repeat NIHSS: 16
- Workup: CT/CTA/CTP head
Imaging
CTA head - Coronal (thick), 3D reconstruction
CTP head - AIF and VOF
CTP head - CBF and Tmax
Diagnosis
- Acute distal left M1 occlusion (LVO)
- Status post tPA
- Meets DEFUSE 3[1] criteria for MT
- Ischemic core < 70 mL
- Mismatch volume ≥ 15 mL
- Mismatch ratio > 1.8
Diagnostic Cerebral Angiography and Mechanical Thrombectomy
- Right common femoral access
- 8F Endophys sheath
- 8F 90 cm Walrus catheter
- 5F 130 cm Neuron Select, Simmons 2 tip
- 180 cm 0.035'' Glidewire
- Room 71 137 cm
- Phenom 27 160 cm
- Aristotle 24 200 cm standard
- Embotrap 6.5 mm x 45 mm
- 8F AngioSeal
DSA - Left CCA, PA and lateral
Torturous left cervical ICA
DSA - Left ICA, PA and lateral
Distal left M1 occlusion
DSA - Left ICA, PA and lateral
- M1 occlusion (red arrow)
- Patent left anterior temporal artery (yellow arrow)
DSA - Left ICA, PA and lateral
Patent left anterior temporal artery (yellow arrow)
DSA - Left ICA, PA and lateral
Patent left anterior temporal artery (yellow arrow)
DSA - Left ICA, PA and lateral
DSA - Left ICA, PA and lateral
Post-thrombectomy (1st attempt) - mTICI 2B
Post-Op Recovery
- Improved neurological function
- GCS 4/4/6
- Improved speech
- Right-sided strength grossly 4/5
Discussion
- Occlusion was distal to the origin of anterior temporal artery
- Good collateral supply from left ACA - small core, large penumbra
- Atresic/hypoplastic right A1 on CTA