Endovascular treatment of intraluminal thrombus accompanying critical internal carotid artery stenosis in acute ischemic stroke: A case report

Introduction: Stenoses arising on the basis of carotid artery atherosclerosis are one of the important causes of ischemic stroke. In this case, endovascular treatment is presented in a stroke patient with dense intraluminal thrombus accompanying critical internal carotid artery (ICA) stenosis.Case: A 69-year-old man with coronary artery disease and hypertension was found unconscious and brought to the emergency department at 15:33; examination revealed right hemiplegia, gaze deviation (Vulpian’s sign), and aphasia. Imaging showed diffusion restriction in the left middle cerebral artery (MCA) territory, intravenous thrombolytic therapy was started at 17:20, and he was referred to our center for endovascular treatment. Arterial puncture was performed at 18:40. The patient was alert, with forced leftward gaze, aphasia, and 1/5 strength in the right upper and lower extremities. On DSA, left common carotid artery (CCA) injection showed an intraluminal thrombus on an atherosclerotic plaque causing 98% stenosis of the proximal ICA. Distal ICA flow was reduced, and left MCA filling was severely diminished. A long sheath was seated in the CCA, and the intraluminal thrombus was aspirated with a 6 French (6F) aspiration catheter. Because the critical ICA stenosis could not be crossed with the distal access catheter, it was dilated with balloon angioplasty. The subsequent image showed that left MCA flow had returned to normal, and the lateral DSA view showed modified Thrombolysis in Cerebral Infarction (mTICI) 2c, with a very distal appearance that could be consistent with microembolism. Because the ICA stenosis was at a flow-limiting level, and given the risk of plaque rupture and a tendency to thrombosis, a decision was made for emergency stenting. A 7×40 mm Wallstent was placed from the proximal ICA to the CCA so as to cover the bulb, and balloon angioplasty was repeated for residual in-stent stenosis. At the end of the procedure, ICA flow had returned to normal, and recanalization was achieved at 19:40. On the second day of admission, strength in the right upper and lower extremities rose to 4/5, and the gaze limitation and speech improved.Discussion/Conclusion: An intraluminal thrombus accompanying critical carotid stenosis can pose an important treatment problem in acute ischemic stroke because of distal embolization. Although a “head first” approach can be used in tandem occlusions and in proximal ICA occlusions and severe stenoses, a “neck first” approach was preferred in this case because of the critical cervical stenosis and the intraluminal thrombus. The absence of distal embolism in the intracranial MCA segment after ICA flow was restored, and recanalization achieved without the need for intracranial endovascular treatment, show that deciding at what stage to end endovascular treatment is also important in such a case.Keywords: