Carotid Intervention in Acute Stroke

Abstract

With advances in acute stroke management, patients with symptomatic severe carotid stenosis are frequently evaluated in the acute stage (ie, within the first few hours) after onset of symptoms. Patients with severe extracranial carotid artery stenosis presenting with acute stroke often have associated intracranial occlusive lesions. When invasive intra-arterial therapy is indicated, both revascularization of the extracranial and of the intracranial occlusive lesion is warranted to achieve a good functional outcome. In patients presenting with acute stroke, revascularization of severe extracranial carotid stenosis and even frank occlusion is possible; it improves distal flow and allows easier access to the often coexistent intracranial occlusion. In this article, the authors review the indications, techniques, and results of acute carotid interventions for acute stroke.

Emergent extracranial internal carotid artery stenting and mechanical thrombectomy in acute ischaemic stroke

“…However, only 8% of acute strokes are caused solely by carotid disease, and they are more frequently associated with ipsilateral intracranial occlusions. 2 These can be distal emboli of associated atheromatous ICA occlusions. Extracranial carotid disease is even more significant in ischaemic stroke patients of ages 16–45 years, with spontaneous carotid dissection causing 10–25% of such cases.…”

“…Occlusion of the extracranial ICA can also be a significant complication in the setting of AIS, and is most likely due to pre-existing atherosclerotic disease or vascular dissection. Although the combination of cervical ICA occlusion with synchronous intracranial thrombus represents only 8% of all strokes, 2 such occlusions are shown to be strongly associated with poor patient outcomes; Meyer et al. 3 reported a good clinical outcome in only 17% of these types of cases, with a death rate as high as 55%.…”

Endovascular treatment in patients with acute ischemic stroke and apparent occlusion of the extracranial internal carotid artery on CTA

“…Once the blood flow in the ICA is restored, the patient's thrombolytic system may be more effective and the often coexisting embolus in the MCA can be reached and treated more easily 14. Revascularization of a distal occlusion in the intracranial ICA, MCA or anterior cerebral artery is critical to maximize the chance of a good functional outcome 13–15…”

Parallel guidewire technique in acute ischemic stroke secondary to carotid artery dissection

“…These patients have a low recanalization rate upon intravenous thrombolysis with rt-PA (only 31%). Most patients with middle cerebral artery occlusion have a poor prognosis (5,10). There were 11 patients in our study who received intravenous thrombolysis but whose blood vessels were not recanalized.…”