ABSTRACT NUMBER: ESOC2026A225 TWO FOR THE PRICE OF ONE: CONCURRENT TREATMENT OF LARGE VESSEL OCCLUSION AND ACUTE ON CHRONIC SUBDURAL HAEMORRHAGE

Abstract Background and aims We present the novel case of an 84-year-old female who presented with a large vessel occlusion (LVO, proximal M1) after collapsing with headache and speech difficulty. Past medical history included hypercholesterolaemia, hypertension and chronic renal disease. Pre-morbid MRS was 0. Admission NIHSS was 7. Initial CT head also revealed an incidental finding of an acute on chronic right subdural haemorrhage (SDH) measuring 13 mm at its maximum width. ECG confirmed new atrial fibrillation as the most likely cause of the infarction. Methods The patient underwent mechanical thrombectomy for the LVO, TICI 2 a. In the same sitting, the decision was made to embolise her right medial meningeal artery (MMA) in line with current emerging best practice (Siddiq et al 2025). The rationale for this was to allow early use of antiplatelets and, in due course, anticoagulation despite the SDH. Results Post procedure NIHSS was 24 with persistent right sided weakness and aphasia. Repeat CT/CTA head confirmed stable appearance of the right SDH with no new bleeding along with maturation of the left MCA territory infarction. After collaboration with neurosurgical and geriatrician colleagues, a decision was made to start Aspirin 75 mg OD acutely, anticoagulation was started a fortnight later after serial CT scanning to ensure stability of the SDH. Conclusions Stroke patients may present with conditions which demand conflicting treatment approaches. The emergence of MMA embolization as treatment for chronic SDH allows earlier use of evidence-based stroke treatments when these conditions co-exist, which may improve clinical outcomes in this patient group. Conflict of interest Barbara Madigan: nothing to disclose, Timothy Raffan-Burnett: nothing to disclose, Hannah McCoubrie: nothing to disclose, Gopinath Ramadurai: nothing to disclose, James Dodd: nothing to disclose, James Choulerton: nothing to disclose