A Case of Acute Ischemic Stroke due to Tandem Lesion Treated with Endovascular Thrombectomy by Internal Carotid Artery Direct Puncture

Objective: Endovascular thrombectomy is widely performed for acute ischemic stroke due to proximal intracranial artery occlusion. The femoral artery is often selected for puncture. However, common carotid artery puncture may be considered in more challenging cases. When the internal carotid artery is occluded or obstructed by atherosclerosis, puncturing the distal internal carotid artery becomes necessary. This is rare and was reported in only 2 cases. We report here a case of endovascular thrombectomy using direct puncture of the internal carotid artery.Case Presentation: A 76-year-old male presented with sudden-onset right upper limb hemiparesis and mild dysarthria. Hospital admittance 1 hour later. Diffusion-weighted imaging (DWI) on head MRI revealed a hyperintense area in the left basal ganglia and corona radiata. MRA showed occlusion of the left internal carotid artery and the M2 segment of the left middle cerebral artery. Intravenous tissue plasminogen activator (tPA) was initiated, and endovascular thrombectomy was attempted. However, navigating the occluded left internal carotid artery was impossible. Symptomatic improvement was observed with tPA therapy causing recanalization of the M2 segment. Thus, further treatment was halted. Two days later, aphasia and complete right hemiparesis developed. MRA revealed no left anterior circulation flow. Under general anesthesia, an incision parallel to the left sternocleidomastoid muscle was made, and a direct puncture of the left internal carotid artery was performed to complete thrombectomy.Conclusion: In difficult-to-access cases, especially when considering puncturing the cervical vessels, our report suggests that exposing the cervical vessels first can improve the hemostasis and puncture performance.