Managing Medically Refractory Acute Stroke: Clinical Decision Logic for Combined Thrombectomy and Stenting

🩺 [Clinical Profiling]
A 68-year-old female with chronic hypertension and prior stroke presented with fluctuating Middle Cerebral Artery (MCA) occlusion. Clinical status evolved from incomplete to total occlusion. Despite medical management, the patient’s NIHSS score increased, progressing to complete right-side hemiplegia, indicating exhausted collateral compensation.

⚖️ [Management Strategy]
For M1 segment in-situ atherosclerotic occlusion (ICAS-O), medical therapy often fails to stabilize hemodynamics. The Expert Team at Beijing Fuwai Hospital transitioned from conservative therapy to emergency Endovascular Treatment (EVT) following progressive neurological deterioration, aiming for immediate TICI 3 reperfusion.

🛠️ [Granular Surgical Steps]

Step 1 Access: Femoral approach with 6F guiding catheter support; micro-guidewire navigated through the occluded segment.

Step 2 Thrombectomy: Initial pass using a Solitaire stent retriever to remove acute thrombus.

Step 3 Evaluation: Post-thrombectomy angiography revealed severe in-situ stenosis (> 90%) with elastic recoil, confirming an atherosclerotic lesion.

Step 4 Intervention: A 2.0 mm x 15 mm compliant balloon was utilized for pre-dilation at 6 atm.

Step 5 Stenting: Deployment of a self-expanding intracranial stent to maintain luminal patency and hemodynamic stability.

✅ [Technical Summary]
This case illustrates the standardized protocol at Beijing Fuwai Hospital for ICAS-related acute stroke: a stepwise approach of "Thrombectomy + Balloon Angioplasty + Stenting" to address both acute embolism and long-term re-occlusion risks.