Management and prognosis of acute extracranial internal carotid artery occlusion

Abstract

Acute occlusion of the internal carotid artery is the underlying etiology in 4 to 15% of all ischemic strokes. The clinical presentation varies considerably ranging from asymptomatic occlusion to severe ischemic strokes. Substantial differences in the acute management of acute symptomatic internal carotid artery occlusions (ICAO) exists between centers. Thusly, we comprised a narrative review of the natural course of acute ICAO and of available treatment options [i.v. thrombolysis, endovascular thrombectomy and stenting, bypass between the superficial temporal and the middle cerebral arteries (MCA) and carotid endarterectomy (CEA)]. We found that very few randomized treatment trials have been performed in patients acute symptomatic ICAO. Most evidence stems from case series and observational studies. Especially in older studies the intracranial vessel status has rarely been considered. After revision of these studies we concluded that the mainstay of the acute management of acute symptomatic ICAO is i.v. thrombolysis when applied within the label and in combination with mechanical thrombectomy in case of intracranial large vessel occlusion. In cases without intracranial large vessel occlusion mechanical thrombectomy of acute ICAO is associated with a risk of distal embolization. More research on prognostic parameters is needed to better characterize the risk of decompensation of collateral flow and to better define the time-window of intervention. When mechanical thrombectomy fails or is not available, surgical approaches are an alternative in selected patients.

When Can an Emergency CTA Be Dispensed with for TIA Patients?

“…Consistently with other studies, we were able to confirm that gender, duration of TIA symptoms, known hypertension, known coronary artery disease, a history of myocardial ischemia, and antiplatelet medication were significantly associated with relevant pathologies in the CTA, and these could therefore be used to select patients for CTA [ 4 , 21 , 23 , 24 , 25 , 26 ].…”

Mechanical Thrombectomy for Bihemispheric Infarction Caused by Acute Unilateral Internal Carotid Artery Occlusion in a Patient with Contralateral Chronic Carotid Occlusion: A Case Report

“…Although we did not find any cases of tandem occlusion in the series, it also should be kept in mind. 20) In the present study, we performed thrombectomy with a stent retriever for acute occlusion of the ICA that served the bilateral anterior circulation in a patient with asymptomatic chronic CA occlusion on the contralateral side. To our knowledge, this is the first case who underwent thrombectomy for such hemodynamic condition.…”

Carotid artery stenosis and stroke: controversies in prevention and treatment

“…Another controversial issue is the management of internal carotid artery occlusion (7)(8)(9). Although it was previously thought that internal carotid artery occlusion is a benign condition, this issue has been challenged by recent evidence that some carotidrelated strokes may occur in the presence of an ipsilateral carotid artery occlusion (7)(8)(9). Stenosis progression or plaque rupture with secondary thrombosis is thought to be the most common cause of acute internal carotid occlusion (10,11).…”

“…Importantly, when considering the optimal management of extracranial internal carotid artery occlusion, it is essential to differentiate patients with vs. without intracranial large vessel occlusion (8). In the presence of a concomitant intracranial vessel occlusion, early thrombolysis of the intracranial lesion is the single most important parameter contributing to a favorable outcome of the ischemic stroke (8). In the absence of a concomitant intracranial artery occlusion, the management is not clear as there are no randomized trials on the topic ( 8).…”

“…In the absence of a concomitant intracranial artery occlusion, the management is not clear as there are no randomized trials on the topic ( 8). An intervention is probably warranted in patients at high risk of progressive clinical worsening, as well as in those with significant neurologic deficits and a large penumbra (8).…”