A 67-year-old man with a history of hypertension, hyperlipidemia, and diabetes acutely developed dizziness with nausea and vomiting. His neurological exam progressively worsened, and the patient required intubation for altered mental status and respiratory compromise. He underwent a CT angiogram that demonstrated occlusion of the basilar and extracranial left vertebral arteries. The patient underwent a cerebral angiogram that confirmed basilar thrombosis. A 6-French guiding catheter was advanced into the right vertebral artery. With the aid of a microwire, a microcatheter was successfully navigated through the basilar thrombosis. Distal positioning of the microcatheter tip was confirmed with a super-selective injection. A Solitaire device was then successfully deployed across the basilar thrombus and immediately improved flow. After a 5-min deployment, the Solitaire device was removed. Subsequent imaging demonstrated patency of the basilar artery with an unintended branch occlusion of the right posterior inferior cerebellar artery (Fig. 7.2).

A 42-year-old man with recently diagnosed renal infarct presented with the acute onset of aphasia and right-sided weakness. He was administered IV thrombolytics and his symptoms transiently improved but then returned. CT angiogram and perfusion studies were performed that demonstrated a left intracranial ICA occlusion with significant penumbra in the left hemisphere. A cerebral angiogram was then performed which demonstrated a left carotid-T occlusion with no flow beyond the posterior communicating artery segment. A Penumbra reperfusion catheter was advanced into the occluded intracranial carotid, and a thrombectomy was performed with continuous aspiration and a separator wire. After recanalization of the left ICA, the reperfusion catheter was advanced into the distal left MCA, and an additional thrombectomy was performed with continuous aspiration and a separator wire. Subsequent angiographic imaging from the guide sheath demonstrated recanalization of the left MCA. There was unintended branch occlusion of the ipsilateral anterior cerebral artery that resolved spontaneously. The stroke evaluation also included an echocardiogram that demonstrated severe stenosis of the aortic valve with left atrial enlargement secondary to childhood rheumatic heart disease (Fig. 7.3).

A 52-year-old man without significant past medical history acutely developed vision loss in the right eye and left hemiparesis. He received intravenous thrombolytics in the emergency room, but his deficits persisted. A subsequent cerebral angiogram demonstrated a flame-shaped taper of the right ICA most consistent with a dissection. A Penumbra reperfusion catheter was successfully navigated distal to the carotid dissection. Subsequent super-selective angiographic imaging demonstrated complete occlusion of the right MCA at its origin. A carotid stent was deployed across the dissected segment of the cervical ICA. We did not administer heparin or antiplatelet agents since IV thrombolytics had been administered. A Penumbra reperfusion catheter was then advanced into the right MCA, and the thrombectomy was performed with continuous aspiration and a separator wire (Fig. 7.4).