Stent-Assisted Endovascular Recanalization of Extracranial Internal Carotid Artery Occlusion in Acute Ischemic Stroke

doi:10.1016/j.wneu.2012.08.017

World Neurosurgery

Volume 79, Issue 1, January 2013, Pages 143-148

https://doi.org/10.1016/j.wneu.2012.08.017 Get rights and content

Objective

Carotid artery occlusions traditionally have extremely poor outcomes with intravenous tissue plasminogen activator treatment or emergent thromboendarterectomy. We retrospectively reviewed our institutional experience with acute carotid occlusions using internal carotid artery endovascular thrombolysis and stent placement.

Methods

We studied the radiographic and clinical characteristics of 17 patients with an acute cervical internal carotid artery occlusion treated with stent-assisted endovascular thrombolysis. Clinical outcomes were assessed by using National Institute of Health Stroke Scale (NIHSS) scores, which were obtained on admission and discharge. Inclusion criteria were an NIHSS score of at least 6 and the presence of significant penumbra on computed tomographic perfusion. Morbidity and mortality data were collected and analyzed.

Results

Seventeen candidates met our inclusion criteria, 16 (94%) of whom had successful immediate recanalization of the internal carotid artery. On admission, the mean NIHSS score was 16.5 and the mean modified Rankin Scale score was 4.8. The mean NIHSS score improved to 6.9 on discharge, with a mean modified Rankin Scale score of 2.88. Eight (47%) patients recovered ambulatory function on discharge. The overall mortality rate of our series was 17%.

Conclusions

In the setting of acute ischemic stroke, emergent carotid artery thrombolysis and stenting is a promising treatment for acute carotid occlusions with excellent recanalization rates and favorable clinical outcomes.

Introduction

Acute carotid occlusions are severely debilitating lesions that can lead to extensive hemispheric infarction. As a subtype of ischemic strokes, extracranial internal carotid artery (ICA) occlusions carry an extremely poor prognosis, with a 16%–55% associated mortality and 40%–69% severe neurologic disability, whereas only 2%–12% achieve favorable clinical outcome (14). In the majority of acute carotid occlusions, the underlying etiology is a preexisting atherosclerotic plaque with a superimposed acute thrombus. This process is similar to vessel occlusion in myocardial infarction, where studies have shown superior treatment outcomes with recanalization and stent placement. In addition, acute carotid occlusions are a particularly poignant health care issue affecting a young patient population with acute carotid dissections. ICA dissections presenting as an acute occlusion or intramural thrombus are responsible for approximately 14%–20% of ischemic strokes in patients younger than 45 years (7).

Therapeutic interventions with emergent thromboendarterectomy or intravenous (IV) tissue plasminogen activator (tPA) have not been encouraging thus far (14, 19). Rubiera et al. (19) found that 73% of patients with a proximal occlusion treated by IV tPA for acute ICA occlusions had not achieved lasting recanalization of their occluded vessels. Similarly, with emergent carotid thromboendarterectomy, only 26.5% of cases achieved favorable clinical outcomes. Recent results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) proved that non-emergent carotid artery stenting is comparable to endarterectomy in perioperative and long-term outcomes (3). Specifically, the incidence of periprocedural neurologic or cardiac complications including ipsilateral stroke within 2.5 years was 7.2% in the endovascular group and 6.8% in the surgical group (P = 0.51) (11). There are limited data on endovascular interventions of the extracranial carotid artery in the setting of acute ischemic stroke. We report our series of 17 patients with acute cervical carotid occlusions who underwent revascularization by balloon angioplasty and the off-label use of stenting.

Section snippets

Methods

A retrospective analysis was performed of 17 patients who presented to Jefferson Hospital for Neuroscience with acute symptomatic carotid occlusions in the setting of acute ischemic stroke between 2006 and 2011. All patients were assessed using the National Institute of Health Stroke Scale (NIHSS) on admission and discharge.

Preoperative evaluation included a noncontrast head computed tomography (CT), which provided a baseline, and excluded patients with intracranial hemorrhage or completed

Results

Table 1 summarizes patient characteristics and demographics. Acute cervical ICA occlusions were found in 17 patients. There were 10 males (59%) and 7 females (41%), with a mean age of 62. Nine patients (53%) were being actively treated for hypertension and three patients were treated for diabetes (18%). Three patients (18%) had a prior history of ischemic stroke and four patients (24%) were on antiplatelet medications on admission. Five patients had a significant history of tobacco use (29%).

Discussion

Acute ischemic stroke is the most prevalent neurologic diagnosis and the fourth leading cause of death in the United States. The annual incidence of ischemic stroke in the United States is roughly 800,000, which leads to an estimated cost of $74 billion (17). The standard of care mandates administration of IV tPA in all patients with no contraindications presenting within 4.5 hours of symptom onset. Based on results from the National Institute of Neurological Disorders and Stroke (NINDS) trial,

Conclusion

In conclusion, urgent carotid artery angioplasty and stenting is a feasible intervention with successful recanalization rates, as well as clinical outcomes that are superior to the use of IV tPA and medical management alone.

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Feasibility and efficiency of a new classification based on high-resolution MRI for carotid artery pseudo-occlusion and occlusion: Hybrid revascularization pilot study
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Studies on changes in the distal internal carotid artery based on high resolution magnetic resonance imaging (HRMRI) are scarce. Herein, we propose a histological classification system for patients with carotid artery pseudo-occlusion or occlusion based on preoperative HRMRI, for which we evaluated the feasibility and clinical implications.
From January 2017 to June 2021, 40 patients with Doppler ultrasound, CTA or MRA suggesting carotid artery occlusion were enrolled in this study. A new classification system based on HRMRI was established and subsequently verified by postoperative specimens. We recorded and analyzed patient characteristics, HRMRI data, recanalization rate, requirements of additional endovascular procedures, complications, and outcomes.
Four histological classifications (type Ⅰ–Ⅳ) were identified. According to our classification system, 20 patients (50.00%) were type I, nine (22.50%) were type II, 7 (17.50%) were type III, and four (10.00%) were type Ⅳ. The success rate of recanalization was 88.89% (32/36) in type I–III patients. Four (44.44%) type Ⅱ patients and five (71.43%) type Ⅲ patients suffered from intraoperative dissection.
Patients identified as types I (pseudo-occlusion) and II (thrombotic-occlusion) were able to be treated via hybrid revascularization with relatively low risk, while patients identified as type III (fibrous-occlusion) required more careful treatment. Recanalization is not suitable for patients identified as type Ⅳ. Our proposed classification system based on HRMRI data can be used as an adjunctive guide to predict the technical feasibility and success of revascularization via a hybrid technique.
Concurrent Cardio-Cerebral Infarctions in COVID-19: A Systematic Review of Published Case Reports/Series
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Twelve CCI patients were studied with confirmed or suspected COVID-19 infection. The majority of these patients were males (83.3%) with a median age of 55 years from three geographical locations, constituting the Middle East (7), Spain (3), and the USA (1). In 6 patients, IgG/IgM was positive for COVID-19, 4 with high pretest probability and 2 with positive RT-PCR. Type 2 DM, hyperlipidemia, and smoking were the primary risk factors. Right-sided neurological impairments and verbal impairment were the most common symptoms. Our analysis found 8 (66%) synchronous occurrences. In 58.3% of cases, neuroimaging showed left Middle Cerebral Artery (MCA) infarct and 33.3% right. Carotid artery thrombosis (16.6%), tandem occlusion (8.3%), and carotid stenosis (1%) were also reported in imaging. Dual antiplatelet therapy (DAPT) and anticoagulants were conservative therapies (10). Two AMI patients had aspiration thrombectomy, while three AIS patients had intravenous thrombolysis/tissue plasminogen activator (IVT-tPA), 2 had mechanical thrombectomy (MT), and 1 had decompressive craniotomy. Five had COVID-19-positive chest X-rays, whereas 4 were normal. four of 8 STEMI and 3 NSTEMI/UA patients complained chest pain. LV, ICA, and pulmonary embolism were further complications (2). Upon discharge, 7 patients (70%) had residual deficits while 1 patient unfortunately died.
Multimodal Recanalization for Subacute Symptomatic Internal Carotid Artery Occlusion Due to Atherosclerosis: Outcomes and Notes on Hybrid Techniques
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Citation Excerpt :
However, due to the inability to reach the distal ICA, the success rate of CEA alone in recanalizing ICAO is as low as 34%.11 ET with which the distal ICAO can be reached and managed interventionally has been reported to be an effective method for ICAO recanalization in recent years,5,6,8,12,13 with a recanalization rate close to 70%, which is higher than that of CEA alone.4,9,13,14 However, its potential complications, such as vessel dissection, pseudoaneurysm formation, and vessel perforation, may be hazardous and even life-threatening.15,16
Subacute internal carotid artery occlusion (ICAO) is associated with ipsilateral recurrent stroke, and successful recanalization of ICAO can improve cerebral blood perfusion (CBP) and prevent stroke. However, the optimal treatment remains controversial.
We conducted a retrospective analysis of patients with subacute symptomatic ICAO due to atherosclerosis treated at our center. The hybrid surgical procedures included carotid endarterectomy, Fogarty balloon catheter embolectomy, aspiration thrombectomy, and percutaneous transluminal angioplasty/stenting. Recanalization rates, CBP improvement, stroke recurrence, and restenosis/reocclusion were investigated.
Fourteen symptomatic atherosclerotic ICAO patients (type A, 4; type C, 10; men, 11; women, 3; average age, 68.1 ± 7.9 years) in the subacute phase were treated with a multimodal recanalization technique. Symptoms included mild cerebral infarction, transient ischemic attack (TIA), and amaurosis fugax. The average onset-to-treatment time was 18.1 ± 4.8 days. The successful recanalization (thrombolysis in cerebral ischemia grade 2 or 3) rate was 100%. The ipsilateral-to-contralateral mean transit time ratio was significantly lower at the 1-year follow-up than preoperatively (1.01 ± 0.05 vs. 1.26 ± 0.09, P < 0.0001). There was one case of restenosis detected 1 year after surgery and no cases of reocclusion. During the 28.3 ± 10.0 months of follow-up, only two cases of TIA occurred. The average modified Rankin Scale score and National Institute of Health Stroke Scale score were significantly lower at the most recent follow-up than before recanalization (1.21 ± 0.89 vs. 1.86 ± 0.66, P = 0.0003; 1.36 ± 1.55 vs. 2.00 ± 1.88, P = 0.0066).
Multimodal recanalization techniques performed in a hybrid operation theater can safely achieve high recanalization rates in atherosclerotic ICAO patients in the subacute phase, which can be beneficial for recovering CBP and preventing stroke.
Recanalization of symptomatic chronic internal carotid artery occlusions by hybrid treatment
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Citation Excerpt :
Another procedure for recanalization is carotid artery stenting (CAS), with accumulating data suggesting its safety and efficacy [12]. CAS is less invasive than CEA but could carry a slightly increased risk of distal vessel embolization by the dislodged thrombus [13,14]. Hybrid surgery in which CEA for a proximal ICAO is combined with endovascular intervention (EI) for a distal ICAO simultaneously is reportedly a feasible and effective procedure with a higher success rate [8,15,16].
To evaluate the efficacy and safety of hybrid revascularization by carotid endarterectomy and endovascular intervention in the treatment of chronic internal carotid artery occlusion (ICAO).
We performed a retrospective analysis of patients who received hybrid treatment for symptomatic chronic ICAO between December 2016 and December 2018. Fifty-six patients with long-segment ICAO were enrolled and divided into the short duration (1–3 months) and long ICAO duration (>3 months) groups, and their clinical and angiographic data were analyzed.
The mean duration was 106.8 ± 36.1 days from the date of ICAO diagnosis to revascularization. Totally, 10 patients (17.8%, n = 56) in the short duration group while no patients in the long duration group failed recanalization (n = 7). Perioperative complications included intraoperative thromboembolism in 1 (1.8%) patient and subarachnoid hemorrhage in 2 (3.6%) patients. Early phase postoperative hypertension was noted in 11 (19.6%) patients and cervical hemorrhage in 1 (1.8%) patient. No severe neurological deficits occurred. Overall, the 6-month modified Rankin score, Mini-mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in patients with successful recanalization significantly improved versus the baseline (P < 0.05). After successful recanalization, the long duration group demonstrated more stents for revascularization compared with the short duration group (P < 0.05). Five (10.8%) patients had recurrent transient ischemic attack, and 1 (2.2%) patient developed stroke in the successful revascularization group during 6 months of follow-up. ICA restenosis occurred in 5 (8.9%) patients and re-occlusion was noted in 1 (1.8%) patient.
Hybrid operation may be feasible and effective for patients with symptomatic chronic complete ICAO according to our limited data. The original occlusion site from the carotid bifurcation and the duration of ICAO should be considered as independent indicators for successful recanalization as well as perioperative outcomes.
Emergency embolectomy for acute middle cerebral artery occlusion with chronic common carotid artery occlusion
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Citation Excerpt :
Endovascular embolectomy is considered the standard treatment for acute MCA occlusion; however, endovascular treatment may not be indicated for various reasons, such as the presence of chronic ipsilateral CCA occlusion. Several studies have reported endovascular treatment for acute MCA occlusion with severe stenosis of cervical ICA [3,4]. However, in cases of acute MCA occlusion with chronic carotid artery occlusion, the approach route to the occlusion site is complicated and endovascular treatment thus becomes difficult.
Occurrence of acute middle cerebral artery occlusion with common carotid artery occlusion is rare, and its treatment may be complicated. If the approach route cannot be secured because of carotid artery occlusion, endovascular embolectomy may not be indicated. The best treatment approach for such cases remains controversial. A woman in her 70s was transferred to our hospital in ambulance following a sudden onset of dysarthria and left hemiparesis. Magnetic resonance imaging revealed an ischemic lesion in the right basal ganglia and occlusion of the right common carotid and intracranial middle cerebral arteries. Emergency embolectomy was performed for acute middle cerebral artery occlusion. Postoperative magnetic resonance imaging revealed complete recovery of the right middle cerebral artery blood flow. Emergency embolectomy can effectively treat acute middle cerebral artery occlusion with common carotid artery occlusion.
Treatment Strategy for Progressive Cervical Internal Carotid Artery Stenosis Under Restriction of the Use of Antiplatelet Drugs
2019, World Neurosurgery
Citation Excerpt :
Considering this report, we believe that it is safe to perform PTA only immediately during the acute phase. Dalyai et al.12 reported a similar case of progressive ICS in which PTA was performed without the use of antiplatelet drugs. A strong point in favor of this method is that, along with our treatment strategy, it is able to reduce the risk of intracranial hemorrhage by avoiding antiplatelet drugs.
Acute ischemic stroke caused by cervical internal carotid artery stenosis (ICS) with altered consciousness and progressive paralysis leads to a poor neurologic prognosis. When such a patient is brought to the hospital in the hyperacute phase, intravenous tissue plasminogen activator is first administered. However, when an indwelling carotid artery stent is required after administration, physicians often hesitate to use antithrombotic drugs. In this report, we propose performing staged angioplasty (SAP) for such cases.
Four patients were retrospectively investigated. In all 4 patients, we immediately performed only percutaneous transluminal angioplasty (PTA) without antiplatelet drugs. If both cerebral perfusion on angiography and neurologic findings improved, no additional treatment was provided; otherwise, emergency carotid artery stenting (eCAS) was performed. In PTA-successful cases, eCAS or carotid endarterectomy (CEA) was performed with single or dual antiplatelet drugs at a later date.
The success rate of PTA was 50% (2 of 4), and the overall treatment success rate was 100% (4 of 4). Three patients had favorable outcomes (modified Rankin Scale [mRS] score 0–2), but unfortunately, 1 patient had severe disability (mRS score >3) on discharge. The PTA-successful patients had no perioperative complications. On the other hand, 1 of the 2 patients who underwent eCAS experienced embolic complications, including distal embolization.
In this investigation, both eCAS and SAP could be performed safety. However, performing SAP first without antiplatelet drugs to avoid hemorrhagic complications and cerebral hyperperfusion syndrome appears to have considerable validity.

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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Peer-Review ReportStent-Assisted Endovascular Recanalization of Extracranial Internal Carotid Artery Occlusion in Acute Ischemic Stroke

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Lancet

Ultrasound identification and lysis of clots

Stroke

Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion

Stroke

Stenting versus endarterectomy for treatment of carotid-artery stenosis

N Engl J Med

Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion

J Neuroimaging

Cerebral hemodynamic impairment: methods of measurement and association with stroke risk

Neurology

Intravenous tPA in acute ischemic stroke related to internal carotid artery dissection

Neurology

Cerebral ischemic accidents in young subjectsA prospective study of 296 patients aged 16 to 45 years

Rev Neurol (Paris)

Mechanical thrombectomy of intracranial internal carotid occlusion: pooled results of the MERCI and Multi MERCI Part I trials

Stroke

Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion

Stroke

Stent-assisted endovascular thrombolysis versus intravenous thrombolysis in internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion

Stroke

Peer-Review Report
Stent-Assisted Endovascular Recanalization of Extracranial Internal Carotid Artery Occlusion in Acute Ischemic Stroke