A 72-year-old female who presented initial NIHSS of 22 for gaze preference, complete honomynous hemanopsia, facial droop, hemiparesis, sensory deficit, and aphasia. Imaging revealed left M1 total occlusion for which she received IV tPA. She was brought to the angiography suite for mechanical thrombectomy. The procedure was complicated by difficulty accessing the right femoral, left femoral, and right radial arteries due to significant peripheral artery disease and our options were limited to a trans-carotid approach.
It was expected that hemostasis would be diffculty to achieve in a post-tPA patient and we requested vascular surgery to assist in a carotid cutdown procedure for carotid puncture under direct vision. Forty-five minutes elapsed before access could be secured due to hospital-logistics and prepping appropriate sterile field. Aspiration thrombectomy was subsequently performed and TICI3 reperfusion was achieved. Deep and superficial fascia were closed.
Our patient required 1 unit of packed red blood cells for blood loss during the procedure, however, no other complications occurred. Follow up MRI showed signal changes consistent with ischemic stroke at the left parietotemporal lobe, basal ganglia, and internal capsule. On discharge, her NIHSS was 9 due to level of consciousness, hemianopia, facial palsy, right upper extremity weakness, and aphasia; overall mRS 3. She was released to an inpatient rehabilitation facility.