Key result
Rescue stenting with tirofiban yields complete recanalization and lowers NIHSS ~9 points in MCA stenosis.
Why the study?
The timing of endovascular treatment in patients with large vessel occlusion and a low NIHSS is controversial, and an underlying intracranial stenosis may rarely be present.
Case Report (n=1)
No
Answers are grounded in this paper and cite their sources.
This case report highlights that underlying severe intracranial stenosis should be considered in patients presenting with large vessel occlusion and low NIHSS who subsequently deteriorate, and may require rescue angioplasty, stenting, and glycoprotein IIb/IIIa inhibition following mechanical thrombectomy.
Introduction: When to perform endovascular treatment (EVT) in a patient with large vessel occlusion (LVO) and a low NIHSS is a controversial issue. The general consensus on the approach to these patients is to perform EVT after deterioration occurs. Although rarely, an underlying intracranial stenosis may be found.Case: A 79-year-old woman with known hypertension and asthma presented to the emergency department with slurred speech and drooping of the mouth that began one day earlier. Neurological examination showed dysarthric speech, flattening of the right nasolabial fold, and 5-/5 strength in the right upper extremity. Brain CT showed no hemorrhage, and the ASPECTS was 10. CTA showed a left MCA M1 occlusion. Mechanical thrombectomy was not considered indicated because the NIHSS was <5. Antiplatelet treatment with acetylsalicylic acid 100 mg and clopidogrel 75 mg was started. On day 2 of ward follow-up, her neurological examination worsened. The current examination showed lethargy, global aphasia, and 1/5 strength in the right upper and lower extremities (NIHSS: 15). The follow-up brain CT showed no hemorrhage and an ASPECTS of 10, and she was taken to the angiography suite. Mechanical thrombectomy was performed for the left MCA M1 occlusion. After recanalization, a 90% stenosis was seen in the left MCA M1 segment. When the stenosis closed again after balloon angioplasty, a Pegasus 4.5x25 mm stent was placed in the left MCA M1 segment (Figure 1). Tirofiban infusion was started when in-stent thrombus formed. After the procedure, mTICI 3 recanalization of the left MCA was seen. The examination at 24 hours showed motor aphasia and 5-/5 strength in the right upper and 5-/5 in the right lower extremity (NIHSS: 6). The follow-up CT showed no hemorrhage. She was discharged on day 9 of admission with a completely normal examination.Discussion/Conclusion: An underlying intracranial stenosis, although rare, may be present in MCA occlusions. Because the stenosis progresses slowly, leptomeningeal collaterals may develop over time and compensate for it. However, any later condition that impairs cerebral perfusion (hypotension, etc.) can cause deterioration. Intracranial stenosis is therefore a condition to be kept in mind in LVO patients who present with a low NIHSS.Keywords:
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Öztürk et al. (2026) conducted a case report in Left MCA M1 occlusion with underlying 90% intracranial stenosis presenting with low NIHSS (<5) and subsequent neurological deterioration (NIHSS: 15) (n=1). Mechanical thrombectomy, balloon angioplasty, Pegasus 4.5x25 mm stent placement, and tirofiban infusion was evaluated on Vessel recanalization (mTICI score) and neurological recovery (NIHSS score). Mechanical thrombectomy with rescue Pegasus 4.5x25 mm stenting and tirofiban achieved mTICI 3 recanalization and lowered NIHSS from 15 to 6 at 24 hours in a 90% MCA M1 stenosis.
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