title: Embolic protection devices and the Penumbra 054 catheter: utility in tandem occlusions in acute ischemic stroke.
abstract: BACKGROUND
  Tandem proximal and distal occlusions in the setting of an acute stroke are therapeutic challenges. Treating either lesion first has its respective shortcomings. An approach is described which may lessen the probability of distal embolic events during emergency carotid angioplasty and stenting during an acute stroke, and simplify access to both a distal and proximal lesion.
  
  
  METHODS
  A 58-year-old man presented with waxing and waning neurological examination with an NIH Stroke Scale varying from 4 to 21. CT angiography demonstrated a left internal carotid artery occlusion at its origin and a left middle cerebral artery occlusion. The CT scan failed to demonstrate significant ischemic changes so the patient was brought to angiography for treatment under conscious sedation.
  
  
  METHODS
  Triaxial access into the distal middle cerebral artery was achieved followed by brief aspiration and clot maceration by opening the vessel completely. An embolic protection device was deployed through the intermediate catheter which was subsequently removed. Stenting and angioplasty were then performed, followed by removal of the embolic protection device which had visibly trapped debris.
  
  
  CONCLUSIONS
  Embolic protection devices may have a role in the emergency treatment of proximal occlusions in the setting of an acute ischemic stroke. Safe deployment through an occluded vessel may be assisted by use of an intermediate catheter. The Penumbra 054 catheter may be used both to aspirate the distal thrombus and to house the embolic protection device as it is advanced past a proximal occlusion.
authors: Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. huif@ccf.org
authors: Ferdinand K
authors: FK
authors: Hui
authors: Muhammad S
authors: MS
authors: Hussain
authors: Mohamed H
authors: MH
authors: Elgabaly
authors: Thinesh
authors: T
authors: Sivapatham
authors: Irene L
authors: IL
authors: Katzan
authors: Alejandro M
authors: AM
authors: Spiotta
mesh_terms: D017130:Angioplasty / Q000295:instrumentation* / Q000379:methods*; D002341:Carotid Artery Thrombosis / Q000000981:diagnostic imaging / Q000601:surgery*; D002404:Catheterization / Q000295:instrumentation* / Q000379:methods; D057505:Embolic Protection Devices; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000000981:diagnostic imaging / Q000601:surgery*