My best case of 2023 is a TICI 0!

# Stroke Game: Best Case TICI 0 - Bilateral Carotid, Right M1 & A1/A2 Occlusion

This case highlights challenges in treatment decision-making and surgical techniques. The patient presented with chronic occlusion of the left internal carotid artery and acute occlusion of the right internal carotid artery, right middle cerebral artery, and right anterior cerebral artery over 24 hours after onset. Hemodynamic decompensation led to deterioration beyond the very late window. Two endovascular treatments and carotid stenting restored critical neurological functions, raising key questions to discuss about endovascular treatments for acute ischemic stroke.

## Thrombectomy Beyond the 24-Hour Window

Mechanical thrombectomy for large-vessel occlusion beyond 24 hours may benefit select patients compared to standard medical treatment (SMT), though it carries higher symptomatic intracranial hemorrhage (sICH) risk. High-quality evidence is limited. Trials such as LATE-MT and ANGEL-BAO are exploring thrombectomy versus SMT for anterior and posterior circulation strokes within a 72-hour window. 

Patient selection involves DAWN/DEFUSE 3 and BAOCHE/TENSION criteria, focusing on clinical/imaging mismatch and penumbra-infarct core assessment. Collateral circulation evaluation, in-situ stenosis, and thrombotic embolism are critical for decision-making.

## Multiple Vessel Occlusion (MVO)

MVO management requires identifying chronic occlusions and responsible vessels through imaging. Thrombectomy strategies depend on etiology, with intraoperative adjustments as needed. Embolic occlusions often affect anterior/posterior circulation or peripheral arteries, and are common at bifurcations.

Successful reperfusion rates (mTICI ≥2b) and complete reperfusion rates (mTICI = 3) are lower in MVO, particularly with tandem occlusions. Addressing critical vessels first and proceeding from simpler to more complex occlusions optimizes outcomes. Persistent distal occlusions may exacerbate cerebral edema, requiring monitoring and surgical decompensations.

## Anterior Cerebral Artery (ACA) Occlusion

Acute ACA occlusion accounts for 1.1%-2.3% of ischemic strokes, with secondary MCA occlusion in 1.7%-15% of cases. Distal ACA occlusion accelerates collaterals and penumbra loss and worsens prognosis. The pericallosal artery is a common target for thrombectomy, despite its small diameter and tortuosity increasing complication risks.

Bilateral ACA infarction often arises from thromboembolism in shared pathways and can result in severe symptoms such as akinetic autism, incontinence and poor outcomes. Timely thrombectomy at the anterior communicating artery or A1-A2 junction may enable successful recanalization.

## Transcirculation Approach Thrombectomy

Initially developed for aneurysm treatment, the transcirculation approach is a non-conventional thrombectomy technique used when proximal recanalization fails or anatomical variations preclude standard methods. It involves risks such as vascular damage and embolism.

Feasibility depends on Circle of Willis integrity and vascular pathway characteristics. Suitable devices include intermediate catheters (e.g., 3MAX, 4MAX, ZOOM45, Vecta46) and suction catheters. Success requires precise lesion identification and minimizing vascular trauma. Combined techniques, such as SWIM or dual aspiration (MAT), improve first-pass success.To reduce mechanical damage during retrieval, techniques include partial stent deployment in the parent vessel and careful tension management within the system.

Refined techniques and advanced strategies in transcirculation thrombectomy can enhance outcomes in complex stroke cases.

Reference

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