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Objective We sought to assess preliminary technical and clinical outcomes of Catalyst 5 (CAT 5) as front-line aspiration treatment for M2-M3 occlusion in acute ischemic stroke. Methods Patients with symptomatic stroke and distal M2 or M3 occlusions were enrolled retrospectively. A direct aspiration first-pass technique was used as the first treatment option for absolute contraindication to intravenous fibrinolytic therapy. Time to recanalization, first attempt recanalization, and number of attempts were recorded. Successful recanalization was defined as a modified thrombolysis in cerebral infarction score ≥2b; incidence of procedure-related complications was recorded. National Institutes of Health Stroke Scale at discharge and modified Rankin Scale score at 90 days were evaluated by a dedicated neurologist. Results A total of 11 acute occlusions of distal M2-M3 segment were treated with a direct aspiration first-pass technique using CAT 5 (mean age 69.3 years). Tandem occlusion was present in 2 cases. Intracranial preocclusive mean vessel diameter was 1.9 mm. Overall modified thrombolysis in cerebral infarction score ≥2b was obtained in 72.7% of patients with mean time to recanalization of 36.4 minutes and a mean of 1.9 attempts. First-attempt recanalization with CAT 5 was obtained in 54% of patients with a mean time to recanalization of 29.2 minutes. A stent retriever with proximal aspiration was incorporated as a rescue device in 2 cases. Embolization of new territories was reported after CAT 5 aspiration in 1 patient. No intracranial hemorrhage was detected on follow-up computed tomography. The median National Institutes of Health Stroke Scale score at discharge was 3. At 90 days, a modified Rankin Scale score of 0–2 was achieved in 90.9% of patients. Conclusions Preliminary experience using CAT 5 in distal occlusions demonstrates that it may be safe and effective in acute stroke treatment.

Background Contrast-induced encephalopathy (CIE) is a rare and misdiagnosed complication of intravascular injection of contrast, responsible for arterial vasospasm and neurologic effects. Conventional radiologic findings are not in themselves specific for cerebral vasospasm diagnosis. We present a case in which arterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) was useful in early diagnosis of CIE. Case Description A 56-year-old woman was admitted for elective flow-diverter embolization of a recanalized left supra-ophthalmic internal carotid artery aneurysm; at 4 hours postprocedure, she acutely developed sensitive aphasia and right arm paresis. Although no-contrast computed tomography and MRI with fluid-attenuated inversion recovery and diffusion-weighted imaging sequences did not demonstrate acute ischemic/hemorrhagic cerebral foci or cortical edema, ASL showed decreased cerebral blood flow (CBF) in the insular-temporal-parietal anterior lobe, suspected for hypoperfusion due to vasospasm, which was not confirmed by subsequent emergent digital subtraction angiography. At 16 hours, because of worsening symptoms, patient underwent an additional MRI, which showed slight insular cortical edema on fluid-attenuated inversion recovery and corresponding slight restricted diffusion-weighted imaging with a severe reduction in CBF value; at this time, emergent digital subtraction angiography demonstrated distal arterial vasospasm of left middle cerebral artery, and vasospasm therapy was started. Within 48 hours of symptom onset, the patient gradually improved to a complete neurologic recovery, with normalization of CBF values in the concerning cerebral region. Conclusions CIE should always be considered in patients with focal neurologic deficits after iodinate contrast exposure. ASL perfusion MRI with CBF maps could be a promising tool for prompt, early confirmation of underlying vasospasm, as cortical edema and distal vasospasm could not be detected on conventional radiologic imaging.