between november 2009 and march 2011 , we performed endovascular revascularization therapy in 87 cases of acute ischemic stroke due to a major intracranial arterial occlusion . a 67-year - old right - handed man was admitted to our hospital complaining of left extremity weakness after 70 minutes from stroke onset . the initial neurological examination revealed drowsiness , global aphasia , left homonymous hemianopia , and left hemiparesis including facial palsy with an nih stroke scale ( nihss ) score of 19 . a 72-year - old right - handed man was admitted to our hospital within 3 hours after experiencing acute left - side weakness and dysarthria . the neurological examination showed moderate dysarthria , left hemiparesis including facial palsy , and neglect syndrome with an nihss score of 10 . a 76-year - old right - handed man was transferred to our hospital following ct revealing an acute sdh 6 hours after symptom onset . the neurological examination revealed stupor , quadriparesis , and decreased brainstem reflex with an nihss score of 27 . also , he presented with a laceration to the right forehead with perilesional swelling . at baseline ct , we found an acute sdh in cases 1 and 3 , which were associated with head trauma during stroke onset , and incidentally found a chronic sdh in case 2 without evidence of early ischemic changes ( fig . diffusion - weighted imaging ( dwi ) showed small fuzzy hyperintensities in the right mca territory accompanied by decreased perfusion on perfusion - weighted imaging and right mca occlusion on mr angiography ( mra ) ( fig . 1 g , h , j , and k ) . in case 3 , dwi showed fuzzy hyperintensites on the bilateral thalamus accompanied by a distal basilar artery ( ba ) occlusion on mra ( fig . the above findings necessitated endovascular therapy to rescue salvageable brain tissue . under local anesthesia , mechanical thrombectomy ( mt ) , with no adjuvant thrombolytics , was performed according to our previously published protocol . forced arterial suction thrombectomy ( fast ) using the penumbra reperfusion catheter was successfully done in all cases without any procedure - related complications ( fig . the final recanalization status using the thrombolysis in cerebral infarction ( tici ) score was 2a in case 1 , 3 in case 2 , and 2b in case 3 . the use of antiplatelet or anticoagulant agents was prohibited during the acute stage of stroke because of the concomitant presence of intracranial bleeding . one day after mt , all three patients were given follow - up brain ct to confirm the safety of mt in the presence of concomitant bleeding ( fig . , there was a small increase in hemorrhage and subdural fluid collection on the contralateral side . in case 2 , there was a significant increase in infarct volume in the right mca territory . in cases 2 and 3 , the signal change was insignificant . in case 1 , despite tici 2a recanalization , there was a decline in the patient 's neurological status during hospitalization , and he was transferred to a rehabilitation center for further recovery . he was completely dependent on others for daily living at three months , and his modified rankin scale ( mrs ) score was 5 . in case 2 , he recovered from his neurological def icit completely ( nihss score of 0 ) . the mrs at three months was also 0 . in case 3 , with timely recanalization , his neurological status improved from a baseline nihss score of 27 to a 7-day nihss score of 11 . however , he suffered from aspiration pneumonia , which prolonged his hospitalization , delaying rehabilitation and recovery . the summaries of the clinical and angiographic findings are shown in the table , and the brain ct , mri , and angiographic findings are shown in the figure . case 1 . a 67-year - old right - handed man was admitted to our hospital complaining of left extremity weakness after 70 minutes from stroke onset . the initial neurological examination revealed drowsiness , global aphasia , left homonymous hemianopia , and left hemiparesis including facial palsy with an nih stroke scale ( nihss ) score of 19 . a 72-year - old right - handed man was admitted to our hospital within 3 hours after experiencing acute left - side weakness and dysarthria . the neurological examination showed moderate dysarthria , left hemiparesis including facial palsy , and neglect syndrome with an nihss score of 10 . a 76-year - old right - handed man was transferred to our hospital following ct revealing an acute sdh 6 hours after symptom onset . the neurological examination revealed stupor , quadriparesis , and decreased brainstem reflex with an nihss score of 27 . at baseline ct , we found an acute sdh in cases 1 and 3 , which were associated with head trauma during stroke onset , and incidentally found a chronic sdh in case 2 without evidence of early ischemic changes ( fig . diffusion - weighted imaging ( dwi ) showed small fuzzy hyperintensities in the right mca territory accompanied by decreased perfusion on perfusion - weighted imaging and right mca occlusion on mr angiography ( mra ) ( fig . 1 g , h , j , and k ) . in case 3 , dwi showed fuzzy hyperintensites on the bilateral thalamus accompanied by a distal basilar artery ( ba ) occlusion on mra ( fig . the above findings necessitated endovascular therapy to rescue salvageable brain tissue . under local anesthesia , mechanical thrombectomy ( mt ) , with no adjuvant thrombolytics , was performed according to our previously published protocol . forced arterial suction thrombectomy ( fast ) using the penumbra reperfusion catheter was successfully done in all cases without any procedure - related complications ( fig . the final recanalization status using the thrombolysis in cerebral infarction ( tici ) score was 2a in case 1 , 3 in case 2 , and 2b in case 3 . the use of antiplatelet or anticoagulant agents was prohibited during the acute stage of stroke because of the concomitant presence of intracranial bleeding . one day after mt , all three patients were given follow - up brain ct to confirm the safety of mt in the presence of concomitant bleeding ( fig . , there was a small increase in hemorrhage and subdural fluid collection on the contralateral side . in case 2 , there was a significant increase in infarct volume in the right mca territory . in cases 2 and 3 , in case 1 , despite tici 2a recanalization , there was a decline in the patient 's neurological status during hospitalization , and he was transferred to a rehabilitation center for further recovery . he was completely dependent on others for daily living at three months , and his modified rankin scale ( mrs ) score was 5 . in case 2 , he recovered from his neurological def icit completely ( nihss score of 0 ) . the mrs at three months was also 0 . in case 3 , with timely recanalization , his neurological status improved from a baseline nihss score of 27 to a 7-day nihss score of 11 . however , he suffered from aspiration pneumonia , which prolonged his hospitalization , delaying rehabilitation and recovery . the summaries of the clinical and angiographic findings are shown in the table , and the brain ct , mri , and angiographic findings are shown in the figure . timely recanalization of the target vessel in an acute ischemic stroke is associated with a 4- to 5-fold increase in the odds of a good clinical functional outcome and a 4- to 5-fold reduction in the odds of death . although endovascular therapy is a useful treatment option , the presence of a bleeding risk , such as intracranial hemorrhage or abnormal hemostasis , has been an exclusion criterion in decision - making regarding the use of chemical thrombolytics [ 2 , 5 ] . however , the use of mt alone in patients at risk of bleeding may seem feasible and safe . yet , recently , in an mt trial comparing stent retrievers and merci devices , imaging exclusion criteria included the presence of intracranial bleeding at baseline [ 6 , 7 ] . and a current set of guidelines for endovascular revascularization therapy proposed by a joint panel had exclusion criteria that included intracranial hemorrhage , specifically subdural hematoma . in real clinical practice , we sometimes see patients presenting with ais and concomitant sdh . according to many published mt trials , these patients are excluded from mt despite a chance of recovery with timely recanalization . in general , sdh is due to bleeding from the cortical bridging veins that drain into the superior sagittal sinus or other dural sinuses . the cortical bridging veins are vulnerable to venous hypertension or tearing in the subdural space following trauma . theoretically , recanalization using mt devices does not directly affect venous pressure but rather impacts the arterial pressure of affected distal tributaries . so , our case series offers some evidence of safely performing mt in ais patients with sdh . the main findings of this case report are as follows : 1 ) the size of the concomitant sdh was not significantly affected by recanalization with mt ; 2 ) the outcomes seem not to be much affected by the presence of the concomitant sdh , rather by the recanalization status and resultant infarct volume expansion ; and 3 ) mt alone in the three cases was safely implemented in our clinical practice , relative to the presence of sdh . however , more convincing data about mt for patients at risk of bleeding are needed , and a clear guideline indicating circumstances when mt with sdh is safe is desirable .
mechanical thrombectomy ( mt ) alone in cases of large - vessel acute ischemic stroke ( ais ) with a concomitant subdural hematoma ( sdh ) seems feasible and safe , but there 's still a lack of evidence in the clinical literature . 
 we report three cases of ais with sdh , of which mt was performed with successful recanalization and no major changes in sdh : two elderly men with acute traumatic sdh and one man with incidental chronic sdh . 
 ( 1 ) a 67-year - old man with acute traumatic sdh in the right side developed right middle cerebral artery ( mca ) stroke , ( 2 ) a 72-year - old man with chronic sdh in the left side developed right mca stroke , and ( 3 ) a 76-year - old - man with acute traumatic sdh in the right side developed top - of - basilar artery syndrome . as for ais patients with a sdh 
 , mt may be the only feasible and safe treatment option .