Endovascular Therapy Versus Medical Therapy for Acute Stroke Attributable to Isolated Cervical Internal Carotid Artery Occlusion Without Intracranial Large Vessel Occlusion

Abstract

Background The optimal treatment for acute stroke attributable to isolated cervical internal carotid artery occlusion without intracranial target is unclear. The purpose of our study was to examine whether endovascular therapy for acute stroke attributable to isolated cervical internal carotid artery occlusion was associated with improved clinical outcome. Methods We identified patients from 2 comprehensive stroke centers during the period January 2009 to December 2019, with acute ischemic stroke attributable to cervical internal carotid artery occlusion without an intracranial occlusion. We categorized patients into 2 groups: endovascular therapy and medical therapy. Clinical outcome (modified Rankin scale score at 90 days poststroke) was compared between the 2 groups. Results Seventy‐three patients were included (26 women [36%]; median age, 69 [interquartile range (IQR), 60–80] years; median National Institutes of Health Stroke Scale score, 11 [IQR, 5–16]). Of these, 40 patients received endovascular therapy, and 33 patients were managed with medical therapy alone. The endovascular therapy group had a significantly higher median National Institutes of Health Stroke Scale score on presentation (13 versus 3; P <0.0001). Rates of thrombolysis were also significantly higher in the endovascular group (50% versus 15%; P =0.002). There were no other significant differences in baseline characteristics between the 2 groups. Good clinical outcome (modified Rankin scale score 0–2 at 90 days or no decline in modified Rankin scale score from baseline at 90 days) was seen in 73% of the endovascular therapy group compared with the 61% of the medical management group (odds ratio [OR] for good outcome, 1.7 [95% CI, 0.64–4.6]), despite the large discrepancy in baseline stroke severity. When restricted to patients with presenting National Institutes of Health Stroke Scale score ≥6, endovascular therapy was associated with higher rates of good clinical outcome (66% versus 18%; OR for good outcome, 9.0 [95% CI, 1.65–49.0]). Conclusions Endovascular therapy in isolated cervical internal carotid artery occlusion may be associated with improved outcome when compared with medical therapy. However, the significant differences in baseline characteristics between the groups limit interpretation. Randomized controlled trials are necessary.

Accuracy of Computed Tomography Angiography for Diagnosing Extracranial Mural Lesions in Patients with Acute Internal Carotid Artery Occlusion: Correlation with Digital Subtraction Angiography

“…However, in the absence of these CML, a thromboembolic cause should be considered. In such cases, treatment options may include mechanical thrombectomy using aspiration and stent retrievers or aspiration alone for thrombus removal [12,13]. Therefore, a correct diagnosis is necessary for careful procedure preparation and for the selection of suitable devices [12,21,[33][34][35][36][37].…”

“…Atherosclerosis is the leading cause of extracranial or tandem ICA occlusions, whereas thromboembolism more often causes intracranial occlusion [5,11]. Nevertheless, oversized thromboembolisms can affect the cervical segment or the origin of the ICA [13,14]. Dissections, on the other hand, predominantly impact the distal cervical segment of the ICA near the base of the skull [5,11].…”

Endovascular Treatment for Acute Isolated Internal Carotid Artery Occlusion

“…Recently, an analysis of the MR CLEAN registry and MR CLEAN trial showed favorable outcomes in 54% of EVT-treated and 10% of non-EVT-treated patients with isolated distal ICA occlusion [ 9 ]; however, due to the low number of patients ( n = 41 EVT and n = 10 non-EVT), no regression analyses or statistical tests were performed. Another recent study showed a good clinical outcome in 73% of patients treated with EVT compared with 61% of patients treated with BMT in a cohort of 73 patients (OR 1.7; 95% CI 0.64–4.6) [ 10 ]; however, only patients with isolated cervical ICA occlusion were included and the differences in baseline characteristics between treatment groups limited interpretation. Other studies focused only on one treatment strategy.…”

“…Studies comparing EVT + BMT versus BMT in these patients are scarce or imbalanced [ 8 – 10 ]. Recently, one study investigated the benefit of initial BMT in patients with isolated ICA occlusion and reported a favorable outcome in 69% [ 11 ].…”

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

“…2 As revascularization of acute carotid occlusion gained acceptance as a treatment option, other groups reported their results. 3 A 2022 meta-analysis comparing acute CAS in patients with a tandem lesion, reported higher functional outcome with acute CAS (90-day modified Rankin Scale score ≤2, odds ratio, 1.52 [95% CI, 1.19–1.95]) but increased risk of symptomatic intracranial hemorrhage (odds ratio, 1.97 [95% CI, 1.23–3.15]). 4 However, this meta-analysis did not differentiate the pathophysiology of the tandem lesion by atherosclerotic versus dissection etiologies.…”