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

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

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

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

5. 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

6. 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

7. 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 ). 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

8. 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

9. 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.

10. Convey™ Guiding Catheter
Headway® Microcatheter 17

11. Alligator™ Retrieval Device

26. 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

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

28. 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.

29. Thank you!
Questions?