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The examination remained unchanged despite the intravenous thrombolysis. The patient was taken for thrombectomy after discussion of risks and benefits with the family. Figure?3 Case example. Axial cut of CT perfusion image displays areas of increased time-to-peak contrast material opacification (small arrows) with preserved volume (large arrow), consistent with ischemic penumbra. Treatment Angiography confirmed occlusion (TICI grade 0) of the superior trunk of the right MCA (figure 4). The diagnostic catheter was exchanged for a 6?Fr Cook shuttle which was placed within the proximal internal carotid artery. A Trevo Pro 18 microcatheter (0.021?inch inner diameter) was directed into position over a flow-directed 0.016?inch microwire SB431542 through a Penumbra 054 catheter. Upon confirming the position distal to the site of occlusion, the Trevo device was deployed and the microcatheter subsequently removed. Thrombectomy was performed with continuous aspiration through the Penumbra 054 catheter, which was brought into position just proximal to the deployed Trevo stent at the site of occlusion. Two thrombectomy attempts were made, with return of thick thromboembolic material on both passes. After two thrombectomy attempts, TICI grade 2b flow was achieved (figure 5). There was an area of delayed flow in the distal frontal lobe that was thought to be clinically insignificant, and the procedure was completed with removal of the catheters and arteriotomy closure. Figure?4 Same case as figure 3. Angiography, right internal carotid artery injection with anteroposterior (left) and lateral (right) views showing occlusion of the superior trunk of the middle cerebral artery (arrows). Figure?5 Same case as figure 3. Angiography, right internal carotid artery injection with anteroposterior (left) and lateral (right) views showing Thrombolysis in Cerebral Infarction grade 2b flow of the middle cerebral artery after thrombectomy. Postoperative course Postoperative MRI displayed a small infarction (figure 6). The patient's neurological examination returned to near baseline level with subtle hemiparesis (NIHSS score 2). Figure?6 Same case as figure 3. Axial sections of diffusion-weighted imaging 24?h postoperatively showing punctuate areas of restricted diffusion within the middle cerebral artery distribution (arrow) consistent with areas of infarction. The majority of ... Discussion Stentrievers are the newest tool in the arsenal of the endovascular surgeon for the treatment of acute ischemic stroke. Although the results of the SWIFT1 and TREVO 22 studies are promising, it is our hope that thromboaspiration at the site of the occlusion in addition to thrombectomy will further improve outcomes with more efficient and complete thrombectomy.