Intracranial Angioplasty Utilizing the Comaneci Device As Bailout in Very Late Thrombectomy for Ischemic Stroke.

Abstract

Endovascular management of ischemic stroke has been established as an effective treatment option. Nevertheless, restrictive selection criteria and limited device availability may delay recanalization in certain cases, particularly in developing countries. This report describes a resource-driven, off-label use of the Comaneci device in a patient with ischemic stroke presenting beyond the 24-hour window. A 61-year-old male arrived 28 hours after last known well (LKW). Despite initial clinical improvement with medical therapy alone, neurological deterioration occurred 2 days after onset. Primary aspiration thrombectomy achieved incomplete recanalization (mTICI 1, antegrade reperfusion but limited distal branch filling), revealing underlying intracranial atherosclerosis. Due to a lack of standard angioplasty tools, mechanical angioplasty with a Comaneci petit device was performed, improving perfusion to mTICI 2c (near complete perfusion except for slow flow or distal emboli). At 3-month follow-up, the patient had no residual symptoms and achieved full recovery (National Institutes of Health Stroke Scale (NIHSS) 0, mRS 0). Endovascular management remains a critical component of stroke care. Further exploration of alternative and adaptable strategies may help expand treatment access in challenging clinical settings.