Reason: left MCA ischemic stroke NIHSS 19 History: NIHSS 19, right sided weakness, global aphasiaFLUOROSCOPY TIME: 115.9 minutesFrontal: 2784.03 mGyLateral: 1909.21 mGyOPERATORS: Greg Christoforidis Left common carotid artery: There is no evidence for carotid stenosis on the basis of NASCET criteria. There is a cobblestone appearance to the left ICA with broad pseudoaneurysms.Left internal carotid arteryThere is opacification of the left anterior cerebral arteries. There is occlusion of the left middle cerebral artery at the distal left mm1 segment with grade 4 leptomeningeal collaterals. The anterior temporal artery is proximal to the occlusion site.Intraprocedural arteriograms:Early on the microcatheter was noted to bulge into the left cavernous sinus, when the microcatheter was placed in the left M2 segment.There was a carotid cavernous fistula that developed during the procedure at the site of a 1 mm aneurysm.There is progressive recanalization of the left middle cerebral artery territory with TICI 2B reperfusion. Initially 70% of the territory reperfused, by the time the CCF was treated 95% of the territory had reperfused.There was progressive occlusion of the left sided direct cavernous carotid fistula.Left internal carotid artery following the procedure:There is recanalization of the left middle cerebral artery including superior and inferior divisions with some slow flow in a couple M5 branches.The cavernous carotid fistula was occluded at the end.Right common iliac artery: No contraindications to closure device.
1.Left middle cerebral artery distal m1 occlusion.2.Embolectomy with recanalization and reperfusion of the left middle cerebral artery using the Trevo embolectomy device.3.Direct carotid cavernous fistula development at site of a 1mm aneurysm at the ascending portion of the left cavernous internal carotid artery.4.Successful occlusion of left direct cavernous carotid fistula.5.Successful retrieval of prematurely detached embolic occlusion coil.6.Findings were discussed with Dr Cueva at the end of the procedure.