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Introduction Drug‐eluting stent (DES) use in symptomatic intracranial atherosclerosis disease (ICAD) has been described in the literature using different guiding and distal access catheters. We describe a case of deployment of a Xience Skypoint everolimus‐eluting stent (EES) (Abbott Vascular, Abbott Park, Illinois) into a symptomatic stenosed left M1 segment using Armadillo catheter (Q'Apel, Fremont, CA) with a successful result. Methods Case report and review of literature Results 67‐year‐old woman with type II diabetes mellitus, hypertension, hyperlipidemia, and recent admission for transient ischemic attack (resolving right hemiparesis and mild dysnomia in the setting of severe left M1 segment stenosis with discharge on Aspirin, Clopidogrel and Atorvastatin), presented with recurrence of symptoms, and MRI brain showing left basal ganglia acute infarction. No tPA was given low NIHSS and resolution of symptoms. Patient’s aphasia and hemiparesis worsened with segmental hypoperfusion which resolved by maintaining high blood pressures with norepinephrine drip. Decision was made to deploy a drug eluting stent into the stenosed M1 segment. Through femoral access, a 7F long destination sheath was inserted to the left common carotid origin. A 7F Armadillo catheter was then inserted into the left internal carotid artery (ICA) terminus. ASAHI Prowater coronary guidewire was inserted over which Xience Skypoint EES deployment was attempted but was unsuccessful given difficulty traversing the ICA ophthalmic segment. Ultimately, Armadillo catheter was advanced over a Phenom catheter (Medtronic) with good access into the distal M1 segment. The Phenom intermediate catheter was then removed, and the 2.25 mm x 12 mm stent was introduced through the Prowater guidewire into the segment and inflated to a pressure of 8 atm, with restoration of blood flow. Postoperatively, SBP was lowered to prevent reperfusion injury. Patient’s exam stabilized with mild dysnomia and right hemiparesis without any elevated blood pressure requirements. At 5‐months follow‐up, patient’s exam was non‐focal with NIHSS 0 and repeat DSA showed no evidence of stent occlusion and patent M1 segment. Conclusion Xience Skypoint EES can be successful in treating symptomatic MCA stenosis refractory to maximal medical therapy with good long term results.

Introduction Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in mechanical thrombectomies in adults but has not been described in pediatrics to our knowledge. We present two cases of a 14‐year‐old boy with acute right middle cerebral artery (MCA) syndrome and a 10‐year‐old boy with acute left MCA syndrome who underwent mechanical thrombectomy using Zoom Reperfusion System safely with TICI 2B and 3 recanalization respectively. Methods Case report and review of literature Results Case 1: 14‐year‐old previously healthy boy presented to our facility for acute right MCA syndrome secondary to right supraclinoid internal carotid artery (ICA) occlusion. After receiving alteplase, patient was taken for mechanical thrombectomy. After femoral access was obtained, an 8‐French sheath was introduced into the right femoral artery through which a Zoom 88 catheter and 5‐French BERN catheter (Terumo) were coaxially advanced over a Terumo Glidewire into the right common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the lacerum ICA segment with BERN catheter and Glidewire then removed. Angiogram demonstrated complete occlusion of the ICA just past the origin of the ophthalmic artery. Via Zoom 88 catheter, a Zoom 71 catheter was then navigated to the face of clot over a velocity microcatheter (Penumbra) and synchro 2 wire system (Stryker) which was then removed. The vacuum manifold was then attached to Zoom 71 catheter and allowed to engage with the clot for 3 minutes prior to withdrawal into the Zoom 88 catheter. TICI 2B recanalization was achieved with sub‐occlusive thrombus within the proximal M1 segment. Retrieval of the sub‐occlusive thrombus in the M1 segment was performed with TREVO stentriever (Stryker). Procedure was complicated by vasospasm in the A1 and M2 segments which resolved with milrinone and verapamil infused through the Zoom 88 catheter. Case 2: 10‐year‐old with left hypoplastic heart syndrome presented to our facility for acute left MCA syndrome due to left ICA terminus occlusion. Mechanical thrombectomy was performed after receiving alteplase. Femoral artery access was obtained with a 8‐French sheath, through which Zoom 88 catheter and 5‐French select catheter (Penumbra) were advanced over Terumo Glidewire into the left common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the ophthalmic segment of ICA with select catheter and Glidewire then removed. Angiogram demonstrated complete occlusion at the ICA terminus. Zoom 71 catheter was introduced through Zoom 88 catheter and navigated to the face of clot at the ICA terminus over velocity microcatheter (Penumbra) and synchro wire system (Stryker) which was then removed. Zoom 71 was then attached to a vacuum manifold to engage with the clot for 90 seconds. TICI 2A recanalization after first pass was achieved with flow restoration in anterior cerebral artery but none in the MCA.TICI 3 recanalization was achieved after second pass. Conclusion The use of Zoom reperfusion system potentially proves to be safe for use in the pediatric age group with good recanalization results and no intraoperative or postoperative complications.

Introduction Dolichoectasia is a term used to describe dilated, elongated and tortuous arteries due to defects within the medial layer of their walls secondary to loss of elasticity. Multiple pathophysiological processes might lead to the development of dolichoectatic vessels, and activation of metalloproteinases and irregular turbulent blood flow seem to cause irreversible disruption of the internal elastic lamina. Consequences often include mass effects and ischemic and hemorrhagic stroke. Blood flow within dolichoectatic arteries is turbulent predisposing to thrombus formation with resultant ischemic strokes. Ideally, with optimal anticoagulation therapy, such strokes can be prevented. However, in rare instances, they can still occur despite anticoagulation, likely due to direct compression of pontine perforators from dolichoectasias or persistent turbulent flow. Methods Case report Results A 66‐year‐old woman with hypertension, diabetes mellitus, atrial fibrillation (taking warfarin at home), and left‐sided trigeminal neuralgia due to compressive left vertebrobasilar dolichoectasia with a focal fusiform aneurysm, presented with transient dysarthria and lightheadedness lasting for less than an hour. MRI brain did not show any acute pathology. CTA head showed worsening left vertebrobasilar dolichoectasia with transitional fusiform aneurysm (24 mm in diameter) with mass effect on the anterior part of the pons and lower midbrain. Next day, the patient developed dysarthria and right‐sided weakness, and a repeat MRI brain showed a left acute paramedian pontine infarct. Warfarin was discontinued, and the patient was started on a heparin drip and later transitioned to Apixaban. Eventually, a diagnostic cerebral angiogram and surpass stent placement within the aneurysm were attempted which went uneventful and the flow through the aneurysm regularized. The patient was eventually discharged home on Apixaban and Prasugrel with interval follow‐up. Conclusions Compression of perforating vessels supplying brainstem structures, branching off the pathologic vertebrobasilar dolichoectasia is a rare etiology of acute pontine ischemic stroke, not with standing the anticoagulation. It warrants immediate neurosurgical intervention to optimize blood flow and prevent a recurrence.