Intermediate catheter injections in closed segments during acute stroke intervention: a cautionary note

Area of Science:

• Neurology
• Interventional Radiology
• Vascular Surgery

Background:

• Mechanical thrombectomy is a key treatment for acute ischemic stroke.
• Angiographic visualization of vasculature distal to an occlusion is crucial for intervention planning.
• Microcatheters and intermediate catheters are used for contrast injection in these procedures.

Observation:

• Two patients with acute ischemic stroke underwent mechanical thrombectomy using the Penumbra 054 system.
• Both patients presented with complex occlusions involving the internal carotid artery (ICA).
• Contrast injections through the 054 catheter in occluded segments led to contrast extravasation.

Findings:

• Rapid, large-volume contrast injections in impeded vessels created significant pressure gradients.
• This resulted in vessel injury and contrast extravasation in both cases.
• The procedures were terminated, leading to completed infarcts.

Implications:

• Performing contrast injections through large-lumen catheters in proximally and distally impeded vessels carries a high risk of injury.
• Careful consideration of injection dynamics is necessary during endovascular stroke treatment.
• Modified techniques may be required to safely visualize distal vasculature in acute stroke interventions.