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Percutaneous Recanalization of Acute Internal Carotid Artery Occlusions in Patients with Severe Stroke

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Abstract

Background

Sudden symptomatic occlusions of the proximal internal carotid artery (ICA) resulting in severe middle cerebral artery (MCA) ischemia and stroke are usually not accessible by rt-PA thrombolysis and the prognosis is usually very poor. Mechanical recanalization of the proximal ICA combined with intravenous and intra-arterial thrombolysis was therefore used as a rescue procedure.

Methods

Ten patients (9 men, 1 woman; mean age 56.1 years) were treated with emergency recanalization of the proximal carotid artery by using stents and/or balloon angioplasty as a rescue procedure. Three patients showed dissection, and 7 had atherothrombotic occlusions. Nine of 10 presented with an initial modified Rankin Scale (mRS) of 5, the remaining patient with mRS 4 (average NIHSS 21.4). After sonographic confirmation of ICA with associated MCA/distal ICA occlusion and bridging with rt-PA (without abciximab) an emergency angiography was performed with subsequent mechanical recanalization by percutaneous transluminal angioplasty (PTA) (n = 1) or primary stenting (n = 9) using self-expanding stents. Distal protection was used in 1 of 10 patients.

Results

Recanalization of the proximal ICA was achieved in all. At least partial recanalization of the intracerebral arteries was achieved in all, and complete recanalization in 5. In 4 of 10 patients limited hemorrhage was detected during CT controls. Major complications included 2 patients who had to undergo hemicraniectomy. One patient died from malignant infarction. At the time of discharge from the stroke unit 9 of 10 patients had improved markedly, 5 patients having an mRS of ≤2, and 3 patients a mRS of 3. At control after a mean of 20 weeks, 7 of 8 (88%) patients had a mRS ≤2, and 1 a mRS of 3.

Conclusions

Primary mechanical recanalization of ICA occlusions by stent and PTA combined with fibrinolysis and/or GPIIb/IIIa-receptor antagonists seems to be feasible to improve patient outcome significantly.

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References

  1. Meves SH, Muhs A, Federlein J, Buttner T, Przuntek H, Postert T (2002) Recanalization of acute symptomatic occlusions of the internal carotid artery. J Neurol 249:188–192

    Article  PubMed  CAS  Google Scholar 

  2. Kim YS, Garami Z, Mikulik R, Molina CA, Alexandrov AV (2005) Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke Mar 36:869–871

    Article  Google Scholar 

  3. Christou I, Felberg RA, Demchuk AM, Burgin WS, Malkoff M, Grotta JC, Alexandrov AV (2002) Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. J Neuroimaging 12:119–123

    Article  PubMed  Google Scholar 

  4. Milhaud D, de Freitas GR, van Melle G, Bogousslavsky J (2002) Occlusion due to carotid artery dissection: A more severe disease than previously suggested. Arch Neurol 59:557–161

    Article  PubMed  Google Scholar 

  5. Georgiadis D, Oehler J, Schwarz S, Rousson V, Hartmann M, Schwab S (2004) Does acute occlusion of the carotid T invariably have a poor outcome? Neurology 63:22–226

    PubMed  CAS  Google Scholar 

  6. Linfante I, Llinas RH, Selim M, Chaves C, Kumar S, Parker RA, Caplan LR, Schlaug G (2002) Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke 33:2066–2071

    Article  PubMed  Google Scholar 

  7. Gonner F, Remonda L, Mattle H, Sturzenegger M, Ozdoba C, Lovblad KO, Baumgartner R, Bassetti C, Schroth G (1998) Local intra-arterial thrombolysis in acute ischemic stroke. Stroke 29:1894–1900

    PubMed  CAS  Google Scholar 

  8. Suarez JI, Sunshine JL, Tarr R, Zaidat O, Selman WR, Kernich C, Landis DM (1999) Predictors of clinical improvement, angiographic recanalization, and intracranial hemorrhage after intra-arterial thrombolysis for acute ischemic stroke. Stroke 30:2094–2100

    PubMed  CAS  Google Scholar 

  9. Zaidat OO, Suarez JI, Santillan C, Sunshine JL, Tarr RW, Paras VH, Selman WR, Landis DM (2002) Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion. Stroke 33:1821–1826

    Article  PubMed  CAS  Google Scholar 

  10. IMS Study Investigators (2004) Combined intravenous and intra-arterial recanalization for acute ischemic stroke: The Interventional Management of Stroke Study. Stroke 35:904–911 [Epub Mar 11, 2004]

    Article  Google Scholar 

  11. Beletsky V, Nadareishvili Z, Lynch J, Shuaib A, Woolfenden A, Norris JW; Canadian Stroke Consortium (2003) Cervical arterial dissection: Time for a therapeutic trial? Stroke 34:2856–2860 [Epub Nov 6, 2003]

    Article  PubMed  Google Scholar 

  12. Kremer C, Mosso M, Georgiadis D, Stockli E, Benninger D, Arnold M, Baumgartner RW (2003) Carotid dissection with permanent and transient occlusion or severe stenosis: Long-term outcome. Neurology 60:271–275

    PubMed  CAS  Google Scholar 

  13. Yamashita K, Okamoto S, Kim C, Nakatsu S, Miyasaki A, Hojo M (1997) Emergent treatment of iatrogenic dissection of the internal carotid artery with the Palmaz-Schatz stent: Case report. Neurol Med Chir (Tokyo) 37:336–339

    CAS  Google Scholar 

  14. Guterman LR, Budny JL, Gibbons KJ, Hopkins LN (1996) Thrombolysis of the cervical internal carotid artery before balloon angioplasty and stent placement: Report of two cases. Neurosurgery 38:620–623

    Article  PubMed  CAS  Google Scholar 

  15. Nesbit GM, Clark WM, O’Neill OR, Barnwell SL (1996) Intracranial intraarterial thrombolysis facilitated by microcatheter navigation through an occluded cervical internal carotid artery. J Neurosurg 84:387–392

    Article  PubMed  CAS  Google Scholar 

  16. Komiyama M, Nishio A, Nishijima Y (1994) Endovascular treatment of acute thrombotic occlusion of the cervical internal carotid artery associated with embolic occlusion of the middle cerebral artery: Case report. Neurosurgery 34:359–363

    PubMed  CAS  Google Scholar 

  17. Spearman MP, Jungreis CA, Wechsler LR (1995) Angioplasty of the occluded internal carotid artery. AJNR Am J Neuroradiol 16:1791–1796

    PubMed  CAS  Google Scholar 

  18. Eckstein HH, Schumacher H, Dorfler A, Forsting M, Jansen O, Ringleb P, Allenberg JR (1999) Carotid endarterectomy and intracranial thrombolysis: Simultaneous and staged procedures in ischemic stroke. J Vasc Surg 29:459–471

    Article  PubMed  CAS  Google Scholar 

  19. Berthet JP, Marty-Ane CH, Picard E, Branchereau P, Mary H, Veerapen R, Alric P (2005) Acute carotid artery thrombosis: Description of 12 surgically treated cases. Ann Vasc Surg 19:11–18

    Article  PubMed  Google Scholar 

  20. Cohen JE, Ben-Hur T, Rajz G, Umansky F, Gomori JM (2005) Endovascular stent-assisted angioplasty in the management of traumatic internal carotid artery dissections. Stroke Mar 3 [Epub ahead of print]

  21. Malek AM, Higashida RT, Phatouros CC, Lempert TE, Meyers PM, Smith WS, Dowd CF, Halbach VV (2000) Endovascular management of extracranial carotid artery dissection achieved using stent angioplasty. AJNR Am J Neuroradiol 21:1280–1292

    PubMed  CAS  Google Scholar 

  22. Ciftci E, Efendi H, Kanko M, Kutluay P (2004) Acute occlusion of internal carotid artery: Thrombolysis and stent placement. Neurol India 52:516–517

    PubMed  Google Scholar 

  23. Jovin TG, Gupta R, Uchino K, Jungreis CA, Wechsler LR, Hammer MD, Tayal A, Horowitz MB (2005) Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke 36:2426–2430

    Article  PubMed  Google Scholar 

  24. Nedeltchev K, Brekenfeld C, Remonda L, Ozdoba C, Do DD, Arnold M, Mattle HP, Schroth G (2005) Internal carotid artery stent implantation in 25 patients with acute stroke: Preliminary results. Radiology 237:1029–1037

    PubMed  Google Scholar 

  25. The Abciximab in Ischemic Stroke Investigators (2000) Abciximab in acute ischemic stroke: A randomized, double-blind, placebo-controlled, dose-escalation study. Presented at the International Stroke Conference. Stroke 31:601–609

    Google Scholar 

  26. Morris DC (2003) Abciximab and rt-PA in acute ischemic stroke treatment. Presented at the 28th International Stroke Conference (February 2003)

  27. Haerten K, Krabbe C, Raiber M (2004) Efficacy and safety of treatment of acute ischemic stroke with glycoprotein IIb/IIIa receptor blocker in routine clinical praxis. Dtsch Med Wochenschr 129:607–610

    Article  PubMed  CAS  Google Scholar 

  28. Seitz RJ, Meisel S, Moll M, Wittsack HJ, Junghans U, Siebler M (2004) The effect of combined thrombolysis with rtPA and tirofiban on ischemic brain lesions. Neurology 62:2110–2112

    PubMed  CAS  Google Scholar 

  29. Straub S, Junghans U, Jovanovic V, Wittsack HJ, Seitz RJ, Siebler M (2004) Systemic thrombolysis with recombinant tissue plasminogen activator and tirofiban in acute middle cerebral artery occlusion. Stroke 35:705–709

    Article  PubMed  CAS  Google Scholar 

  30. Wholey MH, Wholey MH, Eles G, Toursakissian B, Bailey S, Jarmolowski C, Tan WA (2003) Evaluation of glycoprotein IIb/IIIa inhibitors in carotid angioplasty and stenting. J Endovasc Ther 10:33–41

    Article  PubMed  Google Scholar 

  31. Neumann-Haefelin T, du Mesnil de Rochemont R, Fiebach JB, Gass A, Nolte C, Kucinski T, Rother J, Siebler M, Singer OC, Szabo K, Villringer A, Schellinger PD, Kompetenznetz Schlaganfall Study Group (2004) Effect of incomplete (spontaneous and postthrombolytic) recanalization after middle cerebral artery occlusion: A magnetic resonance imaging study. Stroke 35:109–14 [Epub Dec 11, 2003]

    Article  PubMed  CAS  Google Scholar 

  32. Vorwerk D, Gunther RW, Keulers P, Wendt G (1991) Surgical and percutaneous management of contralateral thrombus dislodgement following stent placement and dilatation of iliac artery occlusions: Technical note. Cardiovasc Intervent Radiol 14:134–136

    Article  PubMed  CAS  Google Scholar 

  33. Vorwerk D, Guenther RW, Schurmann K (1997) Stent placement on fresh venous thrombosis. Cardiovasc Intervent Radiol 20:359–363

    Article  PubMed  CAS  Google Scholar 

  34. Bolia A, Miles KA, Brennan J, Bell PR (1990) Percutaneous transluminal angioplasty of occlusions of the femoral and popliteal arteries by subintimal dissection. Cardiovasc Intervent Radiol 13:357–363

    PubMed  CAS  Google Scholar 

Download references

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Correspondence to Dierk Vorwerk.

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Dabitz, R., Triebe, S., Leppmeier, U. et al. Percutaneous Recanalization of Acute Internal Carotid Artery Occlusions in Patients with Severe Stroke. Cardiovasc Intervent Radiol 30, 34–41 (2007). https://doi.org/10.1007/s00270-005-0286-7

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  • DOI: https://doi.org/10.1007/s00270-005-0286-7

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