Objective: Marfan's syndrome (MFS) is a systemic connective tissue disorder with autosomal dominant inheritance.Cardiovascular complications of MFS such as aortic root or valve disease and aortic aneurysm or dissection are potential cause of access route problems of mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Here, we report a case of a patient with MFS who underwent MT for AIS.Case Presentation: A 58-year-old woman with MFS presented with a sudden onset of consciousness disturbance and right hemiparesis, and was referred to our hospital. After the infusion of tissue plasminogen activator, CTA showed a type III arch in the aortic arch and severe tortuosity of the thoracoabdominal aorta; thus, angiography was performed using the transbrachial approach. Left common carotid angiogram showed complete recanalization of the left middle cerebral artery. On the sixth day, the patient presented a sudden consciousness disturbance and left hemiparesis. MRA showed right internal carotid artery occlusion. MT was performed by the transbrachial approach, and complete recanalization was achieved on the first pass. Conclusion:MT via the transbrachial approach is a treatment option that should be considered, especially in MFS, where the transfemoral approach is difficult due to anatomical problems.

Objective: Complications of mechanical thrombectomy (MT) should be identified and managed because they often worsen clinical outcomes. Here we present a case of post-MT embolization of the artery supplying the oculomotor nerve, which has not previously been reported as a complication of MT.Case Presentation: An 81-year-old woman visited our hospital within 2 hours of the sudden onset of left hemiparesis and impaired awareness. MRA showed right middle cerebral artery (MCA) M1 segment occlusion and a possibly salvageable penumbra. We performed thrombectomy for right MCA occlusion with successful recanalization. In the final angiography view, the marginal tentorial artery was almost invisible. Ten hours after thrombectomy, the patient developed complete right oculomotor nerve palsy. Subsequent MRI showed ischemic lesions, but none in the oculomotor nucleus, and there were no lesions compressing the oculomotor nerve. We presume that embolization of the marginal tentorial artery caused oculomotor nerve palsy. The intracranial middle and distal portions of the oculomotor nerve are supplied by the superior branches of the inferolateral trunk and by the marginal tentorial artery. Conclusion:Occlusion of the marginal tentorial artery can cause oculomotor nerve palsy, although this has not previously been reported. Our case suggests that neurointerventional surgeons should evaluate patency of branches of the inferolateral trunk and the meningohypophyseal trunk during the procedure of MT.

Mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) of the internal carotid artery and the M1 segment of the middle cerebral artery can improve patient prognosis compared to medical therapy alone. Although a high recanalization rate of approximately 90% has been reported for MT using a stent retriever (SR) or aspiration catheter (AC), in actual clinical practice, we sometimes encounter complex cases that require recanalization using conventional MT techniques due to anatomical factors and the complexity of the lesion. This article presents several complex cases of MT, describing the following six typical conditions that are likely to be encountered clinically and discussing the therapeutic strategies and techniques for these complicated lesions in the literature: (1) difficulty accessing the lesion due to tortuous vessel anatomy, (2) carotid artery and intracranial tandem lesion, (3) distal lesions beyond the M2 segment of the middle cerebral artery, (4) vertebra-basilar artery occlusion, (5) intracranial atherosclerotic stenosis (ICAS), and (6) cerebral artery dissection. We generally adopted a combined technique with SR and AC as the first choice for these procedures. The advantages of this combined technique are as follows: (1) embolization in a new territory (ENT) is reduced by tightly catching the thrombus with both the SR and AC; (2) because the axis of the AC is aligned with the axis of the parent artery due to the distally placed stent, there is less vascular damage due to branch vessel withdrawal during SR retraction; and (3) distal advancement of the AC is facilitated by anchoring the SR distally. To improve patient outcomes, surgeons should aim to achieve complete recanalization at one pass (FPE: first-pass effect) using various treatment strategies and techniques adapted to the situation.