Acute Stroke Treatment by Surgical Recanalization of Extracranial Internal Carotid Artery Occlusion: A Single Center Experience

Abstract

Ischemic stroke due to an acute occlusion of the extracranial internal carotid artery (eICA) is associated with high morbidity and mortality. The best treatment option remains unclear. This study aims to increase the available therapeutic experience documented for surgical recanalization of acute eICA occlusions. We retrospectively reviewed all hospital records of the University Hospital Jena between 2006 and 2018 to identified patients with acute ischemic stroke due to an occlusion of the eICA who underwent emergent surgical recanalization. We analyzed clinical data, surgical reports, imaging data, and outpatient records. The primary outcome parameter was the modified Rankin Scale (mRS) at 3 months. During the survey, 12 patients (mean age: 62.3 ± 10.8 years; range: 35-87) underwent emergent surgical recanalization for an acutely symptomatic eICA occlusion. All patients presented with neurological deficits with a mean National Institutes of Health Stroke Scale score at admission of 15.0 ± 5.1 (range 2-23). Patients were selected for surgery mainly due to the extent of the perfusion mismatch, while stroke severity and age were also considered. The median time from symptom onset to surgery was 309 ± 122 minutes (range 112-650 minutes). Complete recanalization was obtained in all 12 patients. No patient deteriorated postoperatively, no intracranial hemorrhage was observed, and no patient died in the following 3 months. Favorable outcomes (mRS: 0-2) after 3 months were achieved in 7 of 12 patients. The current study adds support to previous findings that the surgical recanalization of acute eICA occlusions is a possible and safe treatment option. However, a critical patient selection based on mismatch size in perfusion imaging is crucially important for successful treatment.

Surgery of acute occlusion of the extracranial internal carotid artery – a meta-analysis

“…After applying the described quality assessment (ESM 2), the mean number of points scored was 20.1 (range 16-25). Altogether, 4 studies reached 20 or more points [15,19,25,29].…”

“…Clinical presentation included whole range of neurological deficits from simple transient ischemic attacks to complete hemiplegia (with or without aphasia). Preoperative scoring system included Rankin scale [25,30], modified Rankin scale [27,28], National Institute of Health Stroke Scale (NIHSS) [15,[18][19][20]29] or no scale at all [31]. Timing of surgery ranged from hours [15,[18][19][20][27][28][29][30] up to two weeks [31] (see ESM 3).…”

“…Preoperative scoring system included Rankin scale [25,30], modified Rankin scale [27,28], National Institute of Health Stroke Scale (NIHSS) [15,[18][19][20]29] or no scale at all [31]. Timing of surgery ranged from hours [15,[18][19][20][27][28][29][30] up to two weeks [31] (see ESM 3).…”

“…Early neurological improvement was reported in 6 studies [15,25,27,28,29,30] and was reached in 66 % of patients (95 % CI: 51-79). Modified Rankin scale as the outcome measure was reported in 7 articles [15,18,19,20,25,28,29] and 62 % of patients (95 % CI: 51-72) achieved favourable outcome (mRS 0-2) at last follow-up (Tables III and IV).…”

“…CEA has been shown to be safe and effective even in the acute setting of symptomatic stenosis and CEA within days of stroke can be performed with very acceptable rates of complications [16,17]. Given rapid advances in interventional radiology seen in the last three decades, surgical therapy of eICA occlusion has been overlooked with only anecdotal case series reported in the last decade [15,[18][19][20]. In order to draw attention of the neurosurgical community to the possibility of a rapid, effective and popular CEA in the setting of eICA occlusion, we performed a literature review of studies focusing on this potentially devastating cause of stroke to gauge its surgical treatment outcomes.…”