Abstract

Background: Terminal internal carotid artery (ICA) occlusion is a frequent cause of acute ischemic stroke due to large vessel occlusion (LVO). Mechanical thrombectomy using a single stent retriever achieves high recanalization rates but may fail in cases of long, stiff thrombi or underlying intracranial atherosclerosis (ICAS). The double stent retriever (double SR) technique is a rescue option. We report a case of double SR combined with Tigertriever angioplasty in the absence of a dedicated intracranial balloon.

Case presentation: A 70-year-old male presented 4 hours after symptom onset with left hemiparesis and aphasia; NIHSS score was 20. CT angiography showed right C1 ICA occlusion. Time from onset to arterial puncture was 270 minutes. After four failed single stent retriever passes (Solitaire X 4×40 mm), we performed the double SR technique using two parallel Solitaire stents combined with aspiration via a React catheter. Successful recanalization (TICI 3) was achieved after two retrieval attempts. However, severe reocclusion of the M1 segment due to underlying ICAS occurred after 10 minutes. In the absence of a dedicated intracranial angioplasty balloon, we deployed a Tigertriever with maximal active expansion for 15 minutes together with a 1000 IU heparin bolus, which significantly improved the stenosis. No hemorrhagic complications, dissection, or vasospasm were observed. The NIHSS score improved to 6 at 24 hours, and the discharge mRS was 2.

Conclusion: This case suggests that the double SR technique may be a useful rescue strategy for refractory terminal ICA occlusions that fail single-device thrombectomy. In settings where an intracranial angioplasty balloon is unavailable, the Tigertriever might be considered as a temporary dilator, although the risk of endothelial injury should be carefully weighed.