Endovascular treatment of acute ischemic stroke I. Valkadinov, Dj. Stoilova, J. Hinov, S. Nizorkova, Ch. Bachvarov Medical University of Varna

Causes of ischemic stroke Embolism – most common Heart Carotids Aorta Paradoxical emboli Thrombosis Dissecation - rare MRA of the Circle of Willis

MCA Anatomy Blumenfeld, Hal (2010). Cerebral Hemispheres and Vascular Supply (2nd), Neuroanatomy through Clincial Cases (pp. 391-456). Sunderland, MA: Sinauer M3 M2 М1 M2 M3

MCA Anatomy Blumenfeld, Hal (2010). Cerebral Hemispheres and Vascular Supply (2nd), Neuroanatomy through Clincial Cases (pp. 391-456). Sunderland, MA: Sinauer M3 M2 М1 M2 M3

Case Report Female 78 y.o. Risk factors: Presentation Male 69 y.o. Arrhytmia Rivaroxaban cessation Presentation Complication of external iliac artery thrombosis treatment Left-sided neurological deficits Male 69 y.o. Risk factors: Daily alcohol consumption Bradycardia (anamnesis) Presentation Acute onset at home of typical for stroke symptoms Right-sided neurological deficits Case Report

Early findings in ischemic stroke of ischemic stroke Early findings in ischemic stroke Hyperdense artery sign Hypoattenuation of deep nuclei Cortical hypodensity with gyral effacement Hyperdense artery sign Depends on the age of the clot Flowing blood ≈40HU Acute thrombus ≈40HU Clot retraction ≈100HU Thromboembolism – clot is old, thus significantly hyperdense Imaging Non-contrast CT CT Contrast-Enhanced CT MRI

Early findings in ischemic stroke Hypoattenuation of the basal ganglia Ribbon sign Deep nuclei Insular cortex Surface cortex Ischemia Cellular edema Grey Matter Hypodensity * * Time Blumenfeld, Hal (2010). Cerebral Hemispheres and Vascular Supply (2nd), Neuroanatomy through Clincial Cases (pp. 391-456). Sunderland, MA: Sinauer Hyperdense artery sign Hypoattenuation of deep nuclei Cortical hypodensity with gyral effacement Ribbon sign – most distal to collateral bracnhes of ACA, PCA Caudate head Lentiform nucleus LSA – terminal braches White matter becomes hypodense and GWD becomes lost due to edema of grey 1-3hrs Surfece cortex – collateral delayed chenges Ribbon sign Surface cortex

Why was not intravenous fibrinolysis performed? The female patient had an open thromectotomy the same day. The male patient had NIHSS score too high to allow fibrinolysis and more than 4 and a half hours have passed from onset. Treatment plan and Devices

Insertion of compound needle (with inneр cannula). Placement of needle in lumen of vessel (inner cannula is removed). Insertion of guide wire. Removal of needle. Threading of catheter to area of interest. Removal of guide wire.

Convey™ Guiding Catheter Headway® Microcatheter 17

Alligator™ Retrieval Device

CT immediately after procedure 14-38 ct sled procedurata Posle pri izpisvane ct nai-trudno mi e za razchitane Results CT immediately after procedure CT 24h after procedure

- MRI in ischemic stroke Results - MRI in ischemic stroke T2 DWI - cell - molecules - parenchmya

Both patients were discharged with only mild neurological deficits Both patients were discharged with only mild neurological deficits. The vast clinical improvement in both patients implies the relevance of performing this procedure in the setting of acute brain infarction.

Thank you! Questions?