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Ischemic Stroke
Original research
Angioplasty and stenting for symptomatic extracranial non-tandem internal carotid artery occlusion
  1. Ashutosh Jadhav1,2,
  2. David Panczykowski2,
  3. Mouhammad Jumaa3,
  4. Amin Aghaebrahim4,
  5. Manasa Ranginani1,
  6. Felix Nguyen2,
  7. Shashvat M Desai1,
  8. Ramesh Grandhi5,
  9. Andrew Ducruet6,
  10. Bradley A Gross1,2,
  11. Brian Thomas Jankowitz1,2,
  12. Tudor G Jovin1,2
  1. 1 Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  2. 2 Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  3. 3 Department of Neurology, University of Toledo, Toledo, Ohio, USA
  4. 4 Baptist Neurological Institute, Jacksonville, Florida, USA
  5. 5 Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA
  6. 6 Barrow Neurological Institute, Phoenix, Arizona, USA
  1. Correspondence to Dr Tudor G Jovin, Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, USA; jovitg{at}upmc.edu

Abstract

Introduction Symptomatic internal carotid artery occlusion (ICAO) can lead to neurologic decline, recurrent stroke, and mortality.

Objective We sought to evaluate the safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO).

Design, setting, and participants This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO.

Main outcome(s) and measure(s) Study endpoints included discharge neurologic examination, post-procedural infarct burden, 3-month functional outcomes, and treatment durability.

Results A total of 107 patients with symptomatic angiographically-confirmed cervical ICAO without tandem LVO were identified. Median admission NIH Stroke Scale (NIHSS) score was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical imaging mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable/improved NIHSS score, while at 3 months 65% achieved independence (modified Rankin Scale score ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1 year.

Conclusions Stenting in selected patients at risk of neurologic deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach.

  • acute stroke
  • carotid occlusive disease
  • angioplasty and stenting
  • cerebral revascularization

https://doi.org/10.1136/neurintsurg-2018-013810

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    Footnotes

    • Contributors Conception and design: TGJ, AJ, MJ. Acquisition of data: All. Analysis and interpretation of data: All. Drafting the article: AJ, DP. Critically revising the article: All. Administrative/technical/material support: DP, SMD. Study supervision: TGJ.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests TGJ has the following disclosures: Consultant, Neuravi (steering committee -modest), Codman Neurovascular (DSMB - modest), Stryker Neurovascular (PI DAWN - unpaid), Fundacio Ictus (PI REVASCAT unpaid); stock, Anaconda, Silk Road, Blockade Medical (modest). AFD has the following disclosure: Consultant, Medtronic (device proctor - modest).

    • Patient consent Not required.

    • Ethics approval Institutional review board of University of Pittsburgh.

    • Provenance and peer review Not commissioned; externally peer reviewed.