Intra-arterial thrombolysis for tandem cervical internal carotid artery/middle cerebral artery occlusion approached from the contralateral side

Despite the widespread use of intravenous (IV) thrombolysis for acute stroke, patients with occlusion of the internal carotid artery (ICA) are often refractory to the intervention. Recent studies suggest that intra-arterial (IA) thrombolysis may be more efficacious than IV thrombolysis for ICA occlusion. Tandem occlusion of the ICA and middle cerebral artery (MCA) is particularly challenging, because of difficulty in achieving recanalization due to long-segment thrombus. The use of new endovascular devices to mechanically remove clots may be promising, but they are neither universally available nor evidence-based. We present a case of tandem left ICA/MCA occlusion treated by IA thrombolysis through the anatomical collateral pathway. The MCA occlusion was approached from the contralateral ICA through the anterior communicating artery. The recanalization of both the MCA and ICA was accomplished, followed by prompt clinical improvement. This may be a useful IA thrombolysis technique for selected patients with tandem ICA/MCA occlusion in whom collateral circulation is developed enough to be catheterized.