275 A Case Study of Retinal Artery Occlusion Following Mechanical Thrombectomy via Direct Carotid Puncture.

Abstract Background This case study reviews the role of carotid puncture as arterial access in mechanical thrombectomy and an associated rare complication. Methods This case reviews the management of a 74-year-old gentleman who presented with a left MCA ischaemic stroke. On presentation NIHSS was 21 consistent with a left total anterior circulation stroke syndrome (TACS) with a very severe clinical deficit. He underwent IV thrombolysis and attempted mechanical thrombectomy via femoral puncture. However the intracranial middle cerebral artery (MCA) occlusion could not be reached as a near occlusion at the internal carotid artery (ICA) origin could not be passed. A carotid puncture was successfully attempted followed by mechanical thrombectomy with complete recanalization of occluded MCA. Despite carotid puncture occurring in the setting of IV thrombolysis there were no post procedure bleeding complications. On day 2 post-procedure, the NIHSS score was 1 (residual facial droop) representing remarkable neurological recovery. On day 4 post-procedure, acute left eye vision loss developed with subsequent diagnosis of left central retinal artery occlusion (CRAO). The mechanism of this retinal artery occlusion may have been a direct delayed complication of carotid artery puncture propagating clot into the ophthalmic artery, or may have been due to the underlying stroke mechanism such as new embolism from ICA origin or failure of collaterals. Results Persistent residual left eye blurred vision and right facial droop. Conclusion Proximal intracranial occlusion can effectively be treated with mechanical thrombectomy. Carotid puncture is a rarely used but effective alternative method of arterial access (11 out of 498 procedures between August 2016 and August 2018). Retinal artery occlusion is a possible complication from mechanical thrombectomy with carotid puncture.