Diagnostic and therapeutic aspects of neuroradiology in acute ischemic stroke affecting the anterior circulation

Abstract

Acute ischemic stroke (AIS) is a cerebrovascular accident resulting from insufficient focal cerebral blood flow. Stroke is the second leading cause of death and is a leading cause of serious long-term disability. Tandem occlusion (TO) of the cervical ICA and a distal large vessel is responsible for up to 20% of AIS cases, responds poorly to intravenous thrombolysis and is associated with poor prognosis without timely and successful recanalization. Although there is a rapid expansion in the literature on the treatment of tandem occlusions in AIS recently, key aspects including distal-to-proximal versus proximal-to-distal recanalization approach, placement versus non-placement of a stent in the acute setting, perioperative and postoperative antithrombotic medication and the role of embolic protection devices are still debated. We introduced a novel method the balloon-assisted tracking (BAT) technique in the treatment of tandem large vessel occlusive lesions in AIS cases and a detailed description of this novel recanalization technique has been illustrated with precise drawings and examples. In our cohort the successful recanalization rate was 93%. Intraprocedural stenting was required in 37% due to high grade residual stenosis, floating thrombus or flow limiting dissection of the cervical ICA segment. Good functional outcome (mRS 0–2) at 3 months was observed in 50%. Hence the applicability, feasibility, efficacy and safety of this novel method in the endovascular recanalization of tandem ICA occlusion in AIS has been demonstrated. Besides we presented a case of an adolescent with hemiplegic migraine to highlight the role of acute non-invasive vascular imaging in the differential diagnosis of acute diseases with severe neurological symptoms in childhood or adulthood to diagnose or rule out stroke mimics. At last, we compared the effectiveness of CT angiography after supra-aortic stenting as a modality of choice for follow up.