Acute Mirror M1 Occlusions Treated With Endovascular First-Pass Contact Aspiration Technique

Abstract

Patients with acute bilateral M1 occlusion are usually comatose at presentation and have a grave prognosis. There have been few reports of emergent treatment using endovascular reperfusion therapy (ERT). We describe a patient treated with simultaneous first-pass contact aspiration and review the literature for cases describing the successful use of ERT in patients with bilateral anterior circulation proximal large-vessel occlusion (LVO). A functionally independent 95-year-old woman with history of atrial fibrillation (AF) presented with altered mentation, aphasia, and weakness in all extremities. Her National Institutes of Health Stroke Scale (NIHSS) score was 13. CT angiogram and perfusion demonstrated acute mirror M1 occlusions with extensive bilateral middle cerebral artery (MCA) territory penumbra, respectively. Emergent ERT was performed with simultaneous contact aspiration within the bilateral M1s under concomitant flow arrest with a balloon guide catheter. Modified Thrombolysis in Cerebral Infarction (mTICI) grades 3 and 2c were achieved on the left and right, respectively. By postoperative day 1 (POD1), the patient had improved motor function, mentation, and communication.The technical feasibility of simultaneous contact aspiration thrombectomies for acute bilateral M1 occlusions was demonstrated with successful reperfusion of both vascular territories in a single pass lasting 28 minutes. Simultaneous thrombectomies yielded rapid recanalization and reperfusion and minimized radiation exposure. Previous cases demonstrating this technique utilized stent-retriever techniques in successive fashion, with a consequent increase in the patient’s total ischemic time. The technical success of our aggressive approach suggests it may have utility in the treatment of acute multivessel occlusions (MVOs).