Tandem middle cerebral artery–internal carotid artery occlusions: reduced occlusion-to-revascularization time using a trans–anterior communicating artery approach with a Penumbra device

Report of 2 cases

Restricted access

Rapid revascularization of tandem extracranial and intracranial acute thromboembolic occlusions can be challenging and can delay restoration of blood flow to the cerebral circulation. Taking advantage of collateral pathways in the circle of Willis for thrombectomy can reduce the occlusion-to-revascularization time significantly, thereby protecting brain tissue from ischemic injury. The authors report using the trans–anterior communicating artery (ACoA) approach by using the Penumbra microcatheter to rapidly restore blood flow to the middle cerebral artery (MCA) territory prior to treating the ipsilateral internal carotid artery (ICA) occlusion. Two patients with acute onset of tandem ipsilateral ICA and MCA occlusions and a competent ACoA underwent rapid revascularization of the MCA using a trans-ACoA approach for pharmaceutical and mechanical thrombolysis with the 0.026-in Penumbra microcatheter. Subsequently, once blood flow was reestablished in the MCA territory via cross-filling from the contralateral ICA, the proximally occluded ICA dissection was revascularized with a stent. Both patients had rapid revascularization of the MCA territory (both Thrombolysis in Myocardial Infarction Grade 3) with the trans-ACoA approach (19 and 36 minutes) followed by treatment of the ipsilateral proximal ICA occlusion. This prevented prolonged MCA ischemia time (72 and 47 minutes for ICA revascularization time saved) that would have otherwise occurred if the dissections were treated prior to revascularization of the MCA. Both patients had improved NIH Stroke Scale scores after the procedure. No adverse events from crossing the ACoA with the Penumbra microcatheter were encountered during the revascularization procedure. The trans-ACoA approach with the Penumbra microcatheter for rapid revascularization of an acutely thrombosed MCA in the setting of a simultaneous ipsilateral proximal ICA occlusion is feasible in patients with a competent ACoA. This technique can significantly minimize ischemic injury by reducing the occlusion-to-revascularization time and allow for MCA perfusion via collateral circulation while treating a proximal occlusion. To the best of the authors' knowledge, this is the first reported trans-ACoA approach with the Penumbra microcatheter and the first to report the utilization of the collateral intracranial circulation to reduce occlusion-to-revascularization time.

Abbreviations used in this paper: ACoA = anterior communicating artery; ASPECTS = Alberta Stroke Program Early CT Score; CCA = common carotid artery; ICA = internal carotid artery; MCA = middle cerebral artery; NIHSS = NIH Stroke Scale; TIMI = Thrombolysis in Myocardial Infarction.

Article Information

Address correspondence to: Eric M. Deshaies, M.D., Department of Neurosurgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, New York 13210. email: deshaiee@upstate.edu.

Please include this information when citing this paper: published online December 23, 2011; DOI: 10.3171/2011.10.JNS111516.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Case 1. A: Axial CT angiogram of the head showing acute left M1 occlusion (arrow). B: Sagittal reconstructed CT angiogram of the neck showing acute occlusion of the left ICA at the origin (arrow). C: Native anteroposterior (AP) fluoroscopic image showing the 0.026-in Penumbra microcatheter traversing from the right ICA through the ACoA and into the left M1 thrombus (arrows). D: Subtracted AP angiogram showing the microcatheter injection (arrows) with retrograde reflux of contrast into the distal ICA. E: Pretreatment right ICA injection AP angiogram showing filling across the ACoA and occlusion of the left M1 segment. F: Posttreatment left CCA injection AP angiogram showing reconstitution of flow to the left hemisphere.

  • View in gallery

    Case 1. Postrevascularization axial MR imaging study (diffusion-weighted imaging sequence) demonstrating an acute infarction in the left basal ganglia with some involvement of the left anterior cerebral artery (ACA) and MCA territories, with sparing of some brain tissue in the MCA and ACA territories that had been completely occluded at presentation.

  • View in gallery

    Case 2. A: Left CCA injection lateral cervical angiogram showing left cervical ICA origin occlusion (arrow) secondary to the dissection. B: Coronal reconstruction CTA head showing a left M1 thromboembolic occlusion (arrow). C: Microcatheter injection AP cerebral angiogram showing the 0.026-in Penumbra microcatheter passing through the right ICA, crossing through ACoA into the left M1 just proximal to the thromboembolic occlusion (arrows). D: Same view angiogram as in panel C, now after revascularization of the left MCA with abciximab and 0.026-in Penumbra catheter aspiration of the clot. E: Left CCA injection lateral cervical angiogram showing the stented left cervical ICA dissection with complete revascularization and normal distal luminal diameter. F: Internal carotid artery injection AP cerebral angiogram showing complete intracranial revascularization of the left hemisphere after treatment.

  • View in gallery

    Case 2. Postrevascularization axial MR imaging study (diffusion-weighted imaging sequence) demonstrating an acute infarction in the left basal ganglia and no large infarction of the left hemisphere seen, showing sparing of most brain tissue in the MCA and ACA distributions that had been completely occluded at presentation.


  • 1

    Hui FKNarayanan SCawley CM: Posterior-to-anterior circulation access using the Penumbra Stroke System for mechanical thrombectomy of a right middle cerebral artery thrombus. World Neurosurg 73:17212010

  • 2

    Khatri PAbruzzo TYeatts SDNichols CBroderick JPTomsick TA: Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology 73:106610722009

  • 3

    Kulcsár ZBonvin CPereira VMAltrichter SYilmaz HLövblad KO: Penumbra system: a novel mechanical thrombectomy device for large-vessel occlusions in acute stroke. AJNR Am J Neuroradiol 31:6286332010

  • 4

    Lavallée PCMazighi MSaint-Maurice JPMeseguer EAbboud HKlein IF: Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion. Stroke 38:227022742007

  • 5

    Marks MPOlivot JMKemp SLansberg MGBammer RWechsler LR: Patients with acute stroke treated with intravenous tPA 3–6 hours after stroke onset: correlations between MR angiography findings and perfusion- and diffusion-weighted imaging in the DEFUSE study. Radiology 249:6146232008

  • 6

    Ozdemir OBussière MLeung AGulka ILee DChan R: Intra-arterial thrombolysis of occluded middle cerebral artery by use of collateral pathways in patients with tandem cervical carotid artery/middle cerebral artery occlusion. AJNR Am J Neuroradiol 29:159616002008

  • 7

    Rubiera MRibo MDelgado-Mederos RSantamarina EDelgado PMontaner J: Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke 37:230123052006

  • 8

    Thomalla GKruetzelmann ASiemonsen SGerloff CRosenkranz MRöther J: Clinical and tissue response to intravenous thrombolysis in tandem internal carotid artery/middle cerebral artery occlusion: an MRI study. Stroke 39:161616182008




All Time Past Year Past 30 Days
Abstract Views 127 127 23
Full Text Views 157 157 1
PDF Downloads 111 111 1
EPUB Downloads 0 0 0


Google Scholar