Cross-circulation thrombectomy for acute middle cerebral artery occlusion through a posterior communicating artery: a case report

Two concurrent instances of acute large vessel occlusion identified in two circulation systems is rare and associated with poor clinical outcomes. The complex vascular anatomy and chronic lesions involving extracranial or intracranial vessels may make classical anterograde approaches through parent vessels quite challenging. Besides, the effective treatment is required complicated and risky endovascular techniques. The cross-circulation approach, which consists of primary catheterization of the target artery from the contralateral side or the opposite cerebral circulation system, provides an alternative endovascular route when anterograde intervention is not feasible. This approach helps to save time, enhance the efficiency, and improve the clinical prognosis of the patient. However, cross-circulation approaches are also associated with potential risks, such as long procedure times (puncture to recanalization), hemorrhagic complications, and thromboembolic events in unaffected arterial territories. We report the rare clinical case resolved by applying a posterior-to-anterior mechanical thrombectomy technique with intermediate catheter assistance. A 67-year-old woman presented with basilar artery and right middle cerebral artery occlusion and underwent simultaneous mechanical thrombectomy of both occluded intracranial arteries. Antegrade access to the right middle cerebral artery thrombus was prevented by the discovery of a chronic occlusion in the right carotid artery. Cross-circulation thrombectomy via the right posterior communicating artery was performed successfully. Our findings indicate that cross-circulation stroke treatment may be beneficial in cases with chronic occlusion or complex vascular anatomies.