J Korean Neurosurg Soc.  2014 Jun;55(6):313-320. 10.3340/jkns.2014.55.6.313.

Emergent Recanalization with Stenting for Acute Stroke due to Athero-Thrombotic Occlusion of the Cervical Internal Carotid Artery : A Single Center Experience

• Choi JY
• Lee JI
• Lee TH
• Sung SM
• Cho HJ
• Ko JK

• KMID: 2191110
• DOI: http://doi.org/10.3340/jkns.2014.55.6.313

Abstract

OBJECTIVE
The purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting (CAS) for acute stroke due to athero-thrombotic occlusion of the cervical internal carotid artery (ICA).
METHODS
Review of medical records identified 17 patients who underwent emergent CAS for treatment of athero-thrombotic occlusion of the cervical ICA with acute stroke between 2009 and 2013. Eleven patients (64.7%) presented with concomitant intracranial artery occlusion, which was treated primarily by mechanical thrombectomy after CAS.
RESULTS
Successful revascularization of the cervical ICA with emergent CAS was achieved in all patients. After CAS, intracranial recanalization with Thrombolysis in Cerebral Infarction > or =2b flow was achieved in four of the 11 patients (36.4%). The overall recanalization rate (cervical ICA and intracranial artery) was 10 of 17 patients (58.8%). Symptomatic intracranial hemorrhage occurred in two patients (11.8%), resulting in death. Ten patients (58.8%) showed improvement (decrease in NIHSS score of > or =4 points) at seven days after recanalization. Nine patients (52.9%) showed a favorable outcome (mRS < or =2) at the last follow-up. A favorable outcome (mRS < or =2) was obtained in four of the six patients with isolated cervical ICA occlusion (4/6, 66.7%) and five of 11 patients with intracranial tandem occlusion (5/11, 45.5%).
CONCLUSION
Emergent CAS for acute stroke due to athero-thrombotic occusion of the cervical ICA showed a good technical feasibility and favorable clinical outcome.

Keyword

Carotid stent; Stroke; Carotid occlusion; Thrombolysis

MeSH Terms

Angioplasty
Arteries
Carotid Artery, Internal*
Cerebral Infarction
Follow-Up Studies
Humans
Intracranial Hemorrhages
Medical Records
Stents*
Stroke*
Thrombectomy

Figure

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  Fig. 1 Patient 4. Acute cervical internal carotid artery (ICA) occlusion without intracranial tandem occlusion. A : Initial diffusion-weighted image reveal small infarction areas in the right hemisphere. B : Computed tomography perfusion scan with mean transit time obtained before intervention. There is significant hypoperfusion of the entire right middle cerebral artery (MCA) territory, indicating widespread mismatch. C : Diagnostic angiography shows complete occlusion of the right cervical ICA. D and E : Anteroposterior and lateral views of the right ICA angiogram show that the intracranial segment of the right ICA and MCA is visualized with poor contrast via the collateral vessels of the external carotid artery and the ophthalmic artery (arrowheads). F : There is no collateralization of the right MCA territory via the left ICA. G : After passing the ICA occlusion using a 0.014-inch microwire, partial recanalization of the ICA showing a high-grade arteriosclerotic stenosis. H : Unsubtracted images acquired immediately after stent deployment show recanalization and residual stenosis. I : After balloon angioplasty, normal ICA outflow is visible. J : Intracranial control angiogram shows normal flow in the intracranial ICA and MCA.

• 

  Fig. 2 Patient 8. Acute cervical internal carotid artery (ICA) occlusion with intracranial tandem occlusion. A and B : Initial images demonstrate widespread mismatch between extent of lesion on diffusion-weighted image (A) and computed tomography perfusion scan with mean transit time (B). C : Diagnostic angiography shows acute occlusion just beyond the origin of the right ICA. D : After passing the ICA occlusion using a 0.014-inch microwire, partial recanalization of the ICA showing a high-grade arteriosclerotic stenosis. E : After stent placement and balloon angioplasty, normal ICA outflow is visible. F : There is an additional distal M1 occlusion in the anteroposterior view of the right ICA angiogram. G : Digital subtraction angiogram after deployment of the Solitaire stent shows partial restoration of vessel flow; distal stent markers (arrow) are visible. H : After stent withdrawal, the vessel is fully recanalized to a Thrombolysis In Cerebral Infarction 3 state.

Reference

1. Adams HP Jr, Bendixen BH, Leira E, Chang KC, Davis PH, Woolson RF, et al. Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery : A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999; 53:122–125. PMID: 10408547.

2. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1998; 339:1415–1425. PMID: 9811916.

3. Brandl R, Brauer RB, Maurer PC. Urgent carotid endarterectomy for stroke in evolution. Vasa. 2001; 30:115–121. PMID: 11417281.

4. Christou I, Felberg RA, Demchuk AM, Burgin WS, Malkoff M, Grotta JC, et al. Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. J Neuroimaging. 2002; 12:119–123. PMID: 11977905.

5. Dabitz R, Triebe S, Leppmeier U, Ochs G, Vorwerk D. Percutaneous recanalization of acute internal carotid artery occlusions in patients with severe stroke. Cardiovasc Intervent Radiol. 2007; 30:34–41. PMID: 17122887.

6. Dalyai RT, Chalouhi N, Singhal S, Jabbour P, Gonzalez LF, Dumont AS, et al. Stent-assisted endovascular recanalization of extracranial internal carotid artery occlusion in acute ischemic stroke. World Neurosurg. 2013; 79:143–148. PMID: 23022651.

7. Du Mesnil De Rochemont R, Sitzer M, Neumann-Haefelin T, Harmjanz A, Berkefeld J. Endovascular recanalization of acute atherothrombotic carotid artery occlusion holds up progressive stroke. Neuroradiology. 2004; 46:583–586. PMID: 15168098.

8. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001; 357:1729–1737. PMID: 11403808.

9. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008; 359:1317–1329. PMID: 18815396.

10. Hauck EF, Natarajan SK, Ohta H, Ogilvy CS, Hopkins LN, Siddiqui AH, et al. Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke. Neurosurgery. 2011; 69:899–907. discussion 907. PMID: 21499144.

11. Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J, et al. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke. 2003; 34:e109–e137. PMID: 12869717.

12. Horiuchi T, Nitta J, Ishizaka S, Kanaya K, Yanagawa T, Hongo K. Emergency EC-IC bypass for symptomatic atherosclerotic ischemic stroke. Neurosurg Rev. 2013; 36:559–564. discussion 564-565. PMID: 23821132.

13. Imai K, Mori T, Izumoto H, Watanabe M, Majima K. Emergency carotid artery stent placement in patients with acute ischemic stroke. AJNR Am J Neuroradiol. 2005; 26:1249–1258. PMID: 15891193.

14. Iwata T, Mori T, Tajiri H, Miyazaki Y, Nakazaki M. Safety and effectiveness of emergency carotid artery stenting for a high-grade carotid stenosis with intraluminal thrombus under proximal flow control in hyperacute and acute stroke. J Neurointerv Surg. 2013; 5:40–44. PMID: 22170821.

15. Jovin TG, Gupta R, Uchino K, Jungreis CA, Wechsler LR, Hammer MD, et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke. 2005; 36:2426–2430. PMID: 16224082.

16. Le May MR, Labinaz M, Davies RF, Marquis JF, Laramée LA, O'Brien ER, et al. Stenting versus thrombolysis in acute myocardial infarction trial (STAT). J Am Coll Cardiol. 2001; 37:985–991. PMID: 11263625.

17. Linfante I, Llinas RH, Selim M, Chaves C, Kumar S, Parker RA, et al. Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke. 2002; 33:2066–2071. PMID: 12154264.

18. Meyer FB, Sundt TM Jr, Piepgras DG, Sandok BA, Forbes G. Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits. Ann Surg. 1986; 203:82–89. PMID: 3942424.

19. Miyamoto N, Naito I, Takatama S, Shimizu T, Iwai T, Shimaguchi H. Urgent stenting for patients with acute stroke due to atherosclerotic occlusive lesions of the cervical internal carotid artery. Neurol Med Chir (Tokyo). 2008; 48:49–55. discussion 55-56. PMID: 18296872.

20. Nedeltchev K, Brekenfeld C, Remonda L, Ozdoba C, Do DD, Arnold M, et al. Internal carotid artery stent implantation in 25 patients with acute stroke : preliminary results. Radiology. 2005; 237:1029–1037. PMID: 16237137.

21. Papanagiotou P, Roth C, Walter S, Behnke S, Grunwald IQ, Viera J, et al. Carotid artery stenting in acute stroke. J Am Coll Cardiol. 2011; 58:2363–2369. PMID: 22115640.

22. Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia : the Carotid Occlusion Surgery Study randomized trial. JAMA. 2011; 306:1983–1992. PMID: 22068990.

23. Qureshi AI. Endovascular revascularization of symptomatic acute extracranial internal carotid artery occlusion. Stroke. 2005; 36:2335–2336. PMID: 16239628.

24. Qureshi AI, Luft AR, Sharma M, Guterman LR, Hopkins LN. Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures : Part II--Clinical aspects and recommendations. Neurosurgery. 2000; 46:1360–1375. PMID: 10834641.

25. Randomised trial of endarterectomy for recently symptomatic carotid stenosis : final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998; 351:1379–1387. discussion 1375-1376. PMID: 9593407.

26. Rubiera M, Ribo M, Delgado-Mederos R, Santamarina E, Delgado P, Montaner J, et al. Tandem internal carotid artery/middle cerebral artery occlusion : an independent predictor of poor outcome after systemic thrombolysis. Stroke. 2006; 37:2301–2305. PMID: 16888266.

27. Shawl FA. Emergency percutaneous carotid stenting during stroke. Lancet. 1995; 346:1223. PMID: 7475670.

28. Stampfl S, Ringleb PA, Möhlenbruch M, Hametner C, Herweh C, Pham M, et al. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol. 2014; 35:741–746. PMID: 24157733.

29. Wholey MH, Wholey M, Mathias K, Roubin GS, Diethrich EB, Henry M, et al. Global experience in cervical carotid artery stent placement. Catheter Cardiovasc Interv. 2000; 50:160–167. PMID: 10842380.

30. Zaidat OO, Alexander MJ, Suarez JI, Tarr RW, Selman WR, Enterline DS, et al. Early carotid artery stenting and angioplasty in patients with acute ischemic stroke. Neurosurgery. 2004; 55:1237–1242. discussion 1242-1243. PMID: 15574205.

31. Zhu MM, Feit A, Chadow H, Alam M, Kwan T, Clark LT. Primary stent implantation compared with primary balloon angioplasty for acute myocardial infarction : a meta-analysis of randomized clinical trials. Am J Cardiol. 2001; 88:297–301. PMID: 11472712.