Very late stroke + prehospital management issues
Presentation of case resolution in the form of a “serious game”. Misdiagnosed and very late double M2-MCA stroke with severe symptoms in a young patient. Video covers some interesting topics:
- artificial intelligence applications improving diagnosis
- which one of the M2 branches should be treated and how
- ICA dissection management
- outcome predictors supporting the decision-making process whether to treat or not.
Stroke mimic and initial manifestation of stroke as seizure prevalence - in publications:
Highlight*: CVAID AI-based platform for stroke management (from early detection to follow-up)
The important role of check-list approach to avoid misdiagnosis and omission of stroke:
Highlight*: Methinks - AI-based application detecting ischemic stroke in imaging findings
Beyond 8 hours of stroke onset you should use advance imaging and/or clinical-radiological mismatch to qualify patient for thrombectomy.
If cortical areas are preserved despite the hypodensities in white matter, it may be worth performing thrombectomy, especially if the patient is young and there is clinical-radiological mismatch.
It is possible to extend the window for IVT based on EXTEND trial! (decision based on advance imaging modalities CTP and PWI MRI).
ASPECT scale has a lot of imperfections:
Much better is clinical and profound imaging evaluation of the patient:
If the answers above are YES = there is clinical-radiological mismatch à go to the angio!
Distal MCA Stroke in 10 rules:
1.Beyond the M1 occlusion it is worth analyzing the occlusion and its impact on multimodality viewer with coronal and MIP reconstructions.
2. If the clots are located in two M2 MCA branches:
For inferior trunk (bigger, straighter) à combined technique with stent-retrievers
3. If the occlusion is distal it is worth considering general anesthesia:
May improve the visibility due to reduction of the patient’s movement
4. You should always go with the smallest microcatheter that is possible to effectively treat the lesion:
Easier to pass the thrombus
Less risk of clot migration while passing the lesion
5. Try to go as distal as possible with your microcatheter (before the next curve).
6. Consider using i.a thrombolysis for distal occlusion and tortuous vessels.
7. Combined technique improves the safety and reduces the amount of vascular injury when used with stent-retrievers placed distally:
It optimizes the force vector and decreases the vessel’s retraction.
8. To deliver the aspiration catheter to its desired position when performing distal thrombectomy, you can first pass with microcatheter, deploy SR within the clot and then use the SR as an anchor to make the exchange over its wire and pull in the aspiration catheter.
9. If you have difficulties to pass the thrombus you are maybe dealing with fibrine-rich clot and contact aspiration alone instead of combine technique may be reasonable.
10. To decide if it is necessary to reopen 2nd branch, you can combine the defect of parenchymal filling in your post-recanalization control DSA with NECT or perfusion CT to evaluate its viability and eloquence. You can also do the CBCT in angio-suite (contrast staining is a bad sign – already established infarct).
Cervical loop is a risk factor for dissection.
Dissection – approaches:
It is not hemodynamic – it is worth not stenting, especially if there is some established infarct and it is a late stroke
If it is hemodynamic – you should keep the ICA patent either with carotid stent or the flow-diverters depending of the level of dissection
Stenting in publications:
Outcome is inversely proportional to: