Ultra distal session - Ep.1/3: Is it too distal? - SLICE Worldwide 2023

How far should we go?

Presented case: a 31-year-old male patient with thrombophilia and a history of left M1 occlusion sequelae. The patient now presents with a suspected stroke, exhibiting agitation, confusion, and a worsening of his baseline aphasia but no motor deficit. How should we manage this patient? Should we treat, and if so, should we opt for thrombolysis or mechanical thrombectomy? Let's find out!

The first step is determining whether it's a primary distal vessel occlusion (DVO) or a secondary DVO due to emboli or thrombus migration. The second step involves assessing any pertinent deficits that match the location of the occlusion. If there is a match, or if you can prove salvageable brain tissue with CT/MRI perfusion, proceed to the next phase.

Evaluate the risk of endovascular treatment. Is it too far? Are there issues with anatomy tortuosity? If everything is deemed acceptable, proceed with thrombectomy! However, pause to consider: are you planning to perform thrombectomy with local anesthesia or general anesthesia? Are you thinking of starting with local anesthesia and, if necessary, transitioning to general anesthesia, or continuing with sedation? Watch the session to find out what the faculty is suggesting.

Lytics are an option if endovascular treatment appears too risky; however, it's crucial to acknowledge that at least 50% of distal-medium vessel occlusions do not adequately respond to lytics1,2. Additionally, distal-medium vessels, with a very small caliber (0.75-2.0 mm)3, necessitate the use of low-profile tools compatible with a 0.017 microcatheter (e.g., PRESET Light 4 mm, Catch mini 3 mm, Trevo 3 mm, Solitaire 3 mm) for effective distal stent retriever thrombectomy. The 3MAX aspiration catheter is an alternative for aspiration thrombectomy. It's important to note that these small-caliber distal vessels are more prone to vasospasm. In such cases, 2 mg intra-arterial Milrinone or Nimodipine may be considered.

*Tips and Tricks*: 

•    Generally, the inferior MCA M2 trunk exhibits a larger diameter, less angulation, straighter anatomy, and is easier to navigate compared to the superior trunk.

•    Stentretrievers are preferable in cases of curved anatomy, while the advantages of aspiration lie in not needing to cross the lesion or navigate distally with a wire. A triaxial system is also a viable option.

•    Employing 3D roadmapping can be advantageous for catheterizing occluded distal branches.

The patient had two small distal occlusions in the temporal and angular branches of the right MCA.

How could these distal occlusions lead to such significant clinical findings? Understanding functional plasticity and the anatomic connectivity of the brain with functional MRI and diffusion tensor imaging may be helpful for us to discover it. Please watch the session to find out.

Thanks to the patient and his family for sharing the video at the end of the session. Once again, it strongly reminds us why we should consider distal thrombectomy.

References

1-Menon BK, Al-Ajlan FS, Najm M, Puig J, Castellanos M, Dowlatshahi D, Calleja A, Sohn SI, Ahn SH, Poppe A, et al; INTERRSeCT Study Investigators. Association of clinical, imaging, and thrombus characteristics with recanalization of visible intracranial occlusion in patients with acute ischemic stroke.JAMA. 2018; 320:1017–1026. 

2-Ospel JM, Goyal M. A review of endovascular treatment for medium vessel occlusion stroke. J Neurointerv Surg. 2021 Jul;13(7):623-630. doi: 10.1136/neurintsurg-2021-017321

3- Saver JL, Chapot R, Agid R, Hassan A, Jadhav AP, Liebeskind DS, Lobotesis K, Meila D, Meyer L, Raphaeli G, Gupta R; Distal Thrombectomy Summit Group*†. Thrombectomy for Distal, Medium Vessel Occlusions: A Consensus Statement on Present Knowledge and Promising Directions. Stroke. 2020 Sep;51(9):2872-2884.