Too old too distal - SLICE Worldwide 2023

Too old Too Distal

A catchy SLICE 2023 session`s name ‘’Too Old Too Distal” was chosen to refer to a more complex group of distal medium vessel occlusion (DMVO) clinical scenarios that can challenge any Neuro interventional specialist or expert under the huge Stroke umbrella. Through the previous years, the DMVO topic was raised in the literature and SLICE's past episodes aiming at establishing a protocol for the management of this distinctive patient group either to stay as conservative as possible using intravenous (IV) thrombolytics or go further for more invasive mechanical thrombectomy (MT) techniques. This sort of unique scientific debate, as usual, triggers the curiosity of the SLICE community to find out what is happening in this grey-zoned area and share experiences from different world regions.

How was the session`s kick-off?... an interesting complex case scenario!!!

An 89-year-old male with multiple risk factors like hypertension, dyslipidemia, and previous Transient ischemic attack (TIA), was admitted during the stroke window with a left hemicorporeal deficit while fishing with an NIHSS of 15.

What was complex about it? Everything seems to be calm till now! … let us see further!!! 

Computed tomography (CT) and CT angiography revealed no significant or specific eye catchy vessel occlusion except for bilateral severe atherosclerotic internal carotid changes. Large vessel occlusion and intracranial hemorrhage were excluded.

Old age patient, severe complex unhealthy vessels … The first debate was raised! Disabling neurological deficit or TIA or DMVO?! … Start IV thrombolytics or go for Magnetic resonance imaging (MRI)?! 

Some of the expert panels have chosen to start IV thrombolytics immediately (as it could be DMVO and IV thrombolytics are well-known for their scientifically proven efficacy in such cases). Others suggested deeper pathology understanding would be helpful to specify the next step. 

On the spot, MRI was decided…. What did the MRI say? A second look at the CT angiography was helpful?... The puzzle was completed, though followed by a bunch of debates!! ….

Multiple ACA and MCA territory small infarcts on DWI sequence. A Retrograde second look at the CT angiography revealed some small hypodensities and discontinuing vessels corresponding to the patient`s neurological deficit.

The patient`s neurologic deficit worsened! Multiple distally affected territories! variable management options! complex scenario! Risky?! what would have been your decision?!! … Finally! The word was announced… Intervene!... but why?! Explained!

The previously mentioned conditions were enough for digital subtraction angiography (DSA) and mechanical thrombectomy decisions. First, two simultaneously affected territories will negatively impact the good collateralization and consequently, the patient`s clinical outcome and improvement. Furthermore, Neurological symptoms are well-matched and correlated to the patient`s occlusive anatomical territory status. Eventually, this gives the patient the best chance to have a better outcome.

DSA findings were: A2 (Callosomarginal artery) and M3 (angular and posterior parietal branches) were occluded … A row of decisions and debates started all over again. Start with MCA or ACA better? General or local anesthesia? Thrombus characters and accurate site?! MCA inferior or superior branch first? Were there specific anatomical considerations?! … Let us have a closer look at the panel`s recommendations for such complex cases!!!

1. Distal occlusions are highly risky for hemorrhage, spasms, and dissections … Be careful and use suitable planning imaging modalities, microtools, second opinions, and experiences as much as possible to decide the best next step for the patient.
2. Be fully aware that IV thrombolytics has about 50% good clinical outcome in such DMVO cases. Good planning is the key to success.
3. Reassess and take more angiographic runs to have a deeper understanding of the anatomy and correlate the clinical deficits with occluded arteries. Additionally, Accurate prediction of the branches' course and anatomical directions, expects the microcatheters' course and largely lessens the complications.
4. General Anesthesia is always recommended when managing distal occlusions.
5. Technique suggested: wedging the thrombus between the micro stent retriever and aspiration catheter while using a larger aspiration catheter proximally. Although different techniques can be suggested as well (In detail practically explained in the video).
6. Start with MCA or ACA first, still concerned about the time to recanalize and the technicality is debatable, however beginning with ACA can sometimes be technically easier.
7. It doesn`t matter to start with superior or inferior branches but suggest either the superior or the easier to navigate.
8. The pericallosal and callosomarginal branches which originate from ACA are to be considered, however, the latter is a clinically crucial artery as it supplies supplementary motor and paracentral areas through the posterior internal frontal artery and paracentral branches. (More interesting details are mentioned in the session`s video).
9. Be gentle while passing through the thrombus in order neither to push it further distally and make the situation worse nor drag the thrombus to occlude proximally and affect more small branches resulting in more deficits.
10. Be careful in general during microvessel manipulations to avoid the post-operative motor unneeded deficits.
11. Control angiography aims at spasms, dissections, extravasations, and residual clots assessment.

Were these recommendations eventually efficient in helping the patient?! 

NIHSS from 15 to 1 …... isn`t it interesting?!

If the DMVO issue caught your attention, it is highly recommended to watch more SLICE sessions which include more exciting cases, highly scientific-based discussions, and presentations explaining the topic in detail. 

Catch the links: 

What to do for distal vessel occlusion at initial presentation in 2021 by Dr. Demetrius LOPES - SLICE Worldwide 2021: https://masterandfellow.com/video/61936d17b8257

Distal vessel occlusion - SLICE Worldwide 2021: https://masterandfellow.com/video/616ebdf29ff0f

Distal Vessel Occlusion - SLICE Worldwide 2020: https://masterandfellow.com/video/6086ee8a9ec09