Rescue Revascularisation in Acute Internal Carotid Artery Occlusion with a Super Extended Time Window of More than 48 hours

Background and Aim. Mechanical thrombectomy (MT) and intravenous thrombolysis are the gold standard treatment for large vessel occlusion (LVO) strokes. 10-20% of LVO patients present as "minor strokes " with a National Institutes of Health Stroke Scale (NIHSS) <= 5 points. Therefore, MT is often not primarily performed. These patients rely on collateral blood flow but are prone to clinical deterioration and unfavourable outcome. MT is performed after clinical deterioration, often in an extended time window within 24 hours. No scores identify patients at risk for clinical deterioration. Methods. We present the case of a 71-year-old Caucasian male "minor stroke " patient with LVO, good collateral flow via the ophthalmic artery, receiving rescue MT following clinical deterioration after > 48 hours. NIHSS and modified Rankin scale (mRS) were used for follow-up and modified treatment in cerebral infarction (mTICI) score for angiographic results. Results. Excellent angiographic result (mTICI 3) and clinical improvement were achieved (NIHSS preintervention 18, on discharge 2 points). 90-day follow-up showed excellent outcome (mRS 1). Conclusions. Late intervention MT should be encouraged when clinical deficit exceeds infarct demarcation. Standardized identification based on clinical and imaging data is required to target critical patients with LVO and low NIHSS, favouring a primary intervention.