![]() The rate of subarachnoid hemorrhage caused by vessel perforation that occurs during thrombectomy has been well established by multiple observational studies and retrospective analyses. Broadly, these risks can be divided into two categories: (1) subarachnoid hemorrhage due to vessel perforation and (2) distal territory emboli caused by clot fragmentation. To do so, one usually maneuvers a microwire through the occlusion into the distal vasculature, but there is inherent risk associated with blindly crossing these occlusions. With direct aspiration, the catheter can be advanced to the proximal edge of the clot without ever needing to cross it, but for physicians who opt for a stent retriever, crossing the clot with a microcatheter first is a necessary maneuver to facilitate stent retriever deployment. Informal polling at recent neurointerventional society meetings in the United States suggests a relatively even split between direct aspiration and stent retriever as a first-choice tool for mechanical thrombectomy. We hope to provide some insight into crossing acute LVOs and suggest how best to approach these lesions, emphasizing successful revascularization and avoiding complications. This article focuses on one of these technical steps-crossing the clot. In even the most straightforward case, numerous actions must be executed, and countless decisions must be made when performing successful endovascular thrombectomy. Within this simplicity, however, hide many subtle complexities, controversies, and unanswered questions. When encountering a large vessel occlusion (LVO) stroke, the goal is undeniably simple: open the vessel. As rapidly as our understanding of acute ischemic stroke evolves, so do the nuances of its safe and effective treatment. ![]()
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