Another thing that came up in conference recently was whether, in the case of acute carotid and tandem M1 occlusions, it might be advisable to attempt recanalization via the non-occluded carotid. The rationale was that tunneling through the the occluded carotid can take a long time and is accompanied by heavier antithrombotic exposure, with its attendant bleeding risks, especially after IV tPA. Putting the guide wire up the non-occluded carotid and across the anterior communicator could allow faster access to the offending M1 occlusion with less antithrombotic exposure.
I asked one of our neuroendovascular colleagues about this option, and the reply was that such an approach has the disadvantage of putting the healthy brain hemisphere at risk (via thromboembolism, vessel perforation, etc.) In this person’s opinion, its better to keep the cerebral procedural risks confined to the infarcting hemisphere if possible.