Accepted Manuscript Distal Thrombectomy for Acute Anterior Circulation Stroke with Chronic Large Vessel Occlusion Jun Zhang, Xiao Zhang, Jinping Zhang, Yun Song, Ju Han PII: S1878-8750(18)32797-9 DOI: https://doi.org/10.1016/j.wneu.2018.11.236 Reference: WNEU 10920 To appear in: World Neurosurgery Received Date: 16 October 2018 Revised Date: 29 November 2018 Accepted Date: 30 November 2018 Please cite this article as: Zhang J, Zhang X, Zhang J, Song Y, Han J, Distal Thrombectomy for Acute Anterior Circulation Stroke with Chronic Large Vessel Occlusion, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2018.11.236. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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ACCEPTED MANUSCRIPT Title Distal Thrombectomy for Acute Anterior Circulation Stroke with Chronic Large RI PT Vessel Occlusion Running head SC Chronic occlusion: the trap during thrombectomy M AN U Authors and Affiliations Jun Zhang, Xiao Zhang, Jinping Zhang, Yun Song, Ju Han Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong TE D University, Jinan, 250014, Shandong, China Declarations of interest EP None AC C Address for Correspondence and Reprints Ju Han, Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, 250014, Shandong, China Tel: +86 0531 89269312 Fax: +86 0531 82963647 E-mail: hanjujack@163.com ACCEPTED MANUSCRIPT Abstract Background: Endovascular therapy has been increasingly recommended for the treatment of acute ischemic stroke with large vessel occlusion of the anterior circulation. However, occlusions of the distal cerebral artery are not uncommon and RI PT may cause clinical deficits, especially when combined with ipsilateral chronic large vessel occlusion. Therefore, in this patient population, the recognition of chronic occlusion and recanalization of the distal occlusive artery might be of great value for SC flow compensation. Case description: A 59-year-old male with a history of stroke was transferred to the M AN U emergency room with a severe right hemiplegia and aphasia syndrome. Head computed tomography demonstrated an old infarction focus of the left basal ganglia, and digital subtraction angiography revealed an occlusion of the left middle cerebral artery (MCA). After careful attempts, the microguidewire could not pass through the TE D left MCA. Upon consideration of the patient’s previous stroke history and the angiographic neovascularization, the left MCA was recognized as a chronic occlusion and its territory was supposed to be partly compensated by the ipsilateral anterior EP cerebral artery (ACA). A super-selective angiography of the left ACA demonstrated AC C an occlusion of the callosomarginal artery. After a mechanical thrombectomy with a stent retriever, an angiogram showed complete recanalization and good antegrade reperfusion of the ACA supplying the partial MCA territory. The patient had a positive prognosis. Conclusions: The recognition of chronic occlusion is crucial during acute mechanical thrombectomy, and distal thrombectomy may be beneficial after a careful full-scale assessment. Keywords: ischemic stroke; mechanical thrombectomy; distal occlusion; chronic ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT occlusion ACCEPTED MANUSCRIPT Introduction Growing evidence has demonstrated the efficacy of mechanical thrombectomy with stent retrievers for acute stroke patients with large vessel occlusion in the anterior circulation.1-5 However, few reports are available for thrombectomy of distal cerebral RI PT artery occlusions, which have highly pleomorphic clinical presentations. When specific branches of the primary or supplementary motor areas are affected, they can lead to severe clinical deficits.6 The effect is magnified when combined with SC ipsilateral chronic large vessel occlusion, which is attributed to a significant compromise in the collateral flow. However, the recognition of chronic occlusion is M AN U sometimes difficult, especially when it is located in the same territory as the culprit vessel. For this patient population, the selective recanalization of distal artery occlusion may be critical for a good prognosis. This study presents a case of acute ischemic stroke successfully treated with mechanical thrombectomy of the TE D callosomarginal artery with ipsilateral chronic middle cerebral artery (MCA) Case report EP occlusion and a good outcome. AC C A 59-year-old male with a history of atrial fibrillation, mitral valve replacement, and ischemic stroke (modified Rankin Scale [mRS] 1) was transferred to the emergency room with a severe right hemiplegia and aphasia syndrome. His National Institutes of Health Stroke Scale (NIHSS) score was 15. A non-contrast computed tomography (CT) demonstrated an old infarction focus of the left basal ganglia and no hemorrhage (Figure 1A). The time from symptom onset to emergency room admittance was nearly 5 hours. Under local anesthesia, an angiogram demonstrated an occlusion of the left middle cerebral artery (MCA) and a slow antegrade flow of the ipsilateral anterior ACCEPTED MANUSCRIPT cerebral artery (ACA) with the presence of the anterior communicating artery (ACoA) (Figure 1B). After careful attempts, the microguidewire could not pass through the left MCA. Considering the patient’s previous stroke history, the old infarction focus on the CT, and the angiographic neovascularization, the left MCA was recognized as a RI PT chronic occlusion and its territory was supposed to be partly compensated via the ipsilateral ACA. After a super-selective angiography, the callosomarginal artery of the left ACA was found to be occluded (Figures 1C and D). Therefore, for this patient, the SC recanalization of the callosomarginal artery was of vital importance for flow compensation. A 4 × 15 mm Solitaire AB stent retriever (Covidien, Irvine, CA, USA) M AN U was exactly positioned through a Rebar-18 microcatheter (EV3, Irvine, CA, USA) (Figure 1E). After a mechanical thrombectomy, an angiogram showed the complete recanalization and good antegrade reperfusion of the ACA (TICI grade 3), which as expected supplied the partial MCA territory (Figures 1F-H). The post-procedure TE D NIHSS was 3, and no parenchymal hemorrhage was observed via follow-up CT scanning. With subsequent medication therapy, the patient completely recovered to AC C Discussion EP pre-stroke at discharge. His 90-day mRS was 1. Mechanical thrombectomy has become the first-line treatment for acute large vessel occlusion stroke of the anterior circulation.1-5 In fact, distal smaller cerebral artery occlusions are not uncommon. They can be categorized as primary occlusions or secondary embolic occlusions that either migrate spontaneously or as a consequence of endovascular treatment for proximal large vessel occlusion with a frequency between 3.5% and 11.4%.7-9 When specific branches of the primary or supplementary motor areas are affected, they can lead to severe clinical deficits.6 The effect is ACCEPTED MANUSCRIPT magnified when combined with ipsilateral chronic large vessel occlusion, which is attributed to a significant compromise in the collateral flow. For this patient, the left MCA was supposed to be chronically occlusive according to his previous history and imaging presentation, and the ipsilateral ACA branches played a significant role in RI PT flow compensation. Therefore, the recanalization of the distal ACA branch was vital and may have been beneficial. More importantly, the recognition of chronic occlusion is crucial during acute SC mechanical thrombectomy, especially when it is located in the same territory as the culprit vessel, which can effectively shorten the recanalization time and increase the mechanical thrombectomy. Conclusion M AN U success rate. Therefore, a careful full-scale assessment should be performed in TE D The recognition of chronic occlusion is crucial during acute mechanical thrombectomy, and distal thrombectomy may be beneficial after a careful full-scale AC C EP assessment. ACCEPTED MANUSCRIPT Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 1 RI PT References Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11-20. 2 Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic 3 SC stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-1018. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid 4 M AN U endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-1030. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015; 372:2285-2295. 5 Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306. Alonso A, Gass A, Rossmanith C, et al. Clinical and MRI patterns of pericallosal TE D 6 artery infarctions: the significance of supplementary motor area lesions. J Neurol. 2012;259:944-951. Chalumeau V, Blanc R, Redjem H, et al. Anterior cerebral artery embolism EP 7 during thrombectomy increases disability and mortality. J Neurointerv Surg. 8 AC C 2018. Grossberg JA, Rebello LC, Haussen DC, et al. Beyond Large Vessel Occlusion Strokes: Distal Occlusion Thrombectomy. Stroke. 2018;49:1662-1668. 9 Pfaff J, Herweh C, Pham M, et al. Mechanical Thrombectomy of Distal Occlusions in the Anterior Cerebral Artery: Recanalization Rates, Periprocedural Complications, and Clinical Outcome. AJNR Am J Neuroradiol. 2016;37:673-678. ACCEPTED MANUSCRIPT Figure legend Figure 1. Cerebral imaging of the mechanical thrombectomy (A) CT showing the old infarction focus of the left basal ganglia. (B) Cerebral angiogram demonstrating the occlusion of the left MCA and the slow antegrade flow RI PT of the ipsilateral ACA. (C-D) Cerebral angiogram showing the occlusion of the ipsilateral callosomarginal artery of the ACA. (E) The thrombectomy device was placed at the occlusion site. (F-H) Cerebral angiogram showing the complete AC C EP TE D M AN U SC recanalization after thrombectomy and good compensatory perfusion. AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT Abbreviations list ACA= anterior cerebral artery; ACoA=anterior communicating artery; CT=computed tomography; MCA=middle cerebral artery; mRS=modified Rankin Scale; AC C EP TE D M AN U SC RI PT NIHSS=National Institutes of Health Stroke Scale.