Reperfusion strategies in stroke due to isolated cervical internal carotid artery occlusion: systematic review and treatment comparison

Abstract

Introduction Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there are still no conclusive data to guide treatment in stroke due to cervical internal carotid artery (ICA) occlusion. We systematically reviewed available literature to compare IVT, EVT, and bridging (IVT + EVT) and define optimal treatment. Methods Systematic review followed predefined protocol (Open-Science-Framework osf.io/bfykj). MEDLINE, EMBASE, and Cochrane CENTRAL were searched. Results were restricted to studies in English, with sample size ≥ 10 and follow-up ≥30 days. Primary outcomes were favorable outcome (mRS ≤ 2), mortality, and symptomatic intracerebral hemorrhage(sICH), defined according to study original report. Newcastle-Ottawa scale was used for bias assessment. Results Seven records of 930 screened were included in meta-analysis. Quality of studies was low-to-fair in 5, good in 2. IVT (n = 450) did not differ for favorable outcome and mortality compared to EVT (n = 150), though having lower rate of sICH (OR = 0.4, 95% CI 0.2–0.8). Compared to IVT, bridging (IVT + EVT) was associated with higher rate of favorable outcome (OR = 2.2, 95% CI 1.3–3.7). Compared to EVT, bridging (IVT + EVT) provided higher rate of favorable outcome (OR = 1.9, 95% CI 1.1–3.4), with a marginally increased risk of sICH (OR = 2.1, 95% CI 1–4.4) but similar mortality rates. Conclusions Our systematic review highlights that, in acute ischemic stroke associated with isolated cervical ICA occlusion, bridging (IVT + EVT) might lead to higher rate of functional independence at follow-up, without increasing mortality. The low quality of available studies prevents from drawing firm conclusions, and randomized-controlled clinical trials are critically needed to define optimal treatment in this AIS subgroup.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

“…Despite a consistent amount of evidence on the benefit of MT in AIS due to LVO,1 65 there is still substantial uncertainty about the treatment of TO. Controversies are focused on the treatment of the extracranial ICA stenosis or occlusion,66 since evidence suggests that the eCAS may reduce the risk of early recurrent ischemic events, despite the need for an antiplatelet regimen in the acute settings.…”

Study on the correlation between the circle of Willis structure and collateral circulation in bilateral carotid artery occlusion

“…Previous studies on bilateral severe carotid artery stenosis/ occlusion mainly focused on the analysis of the therapeutic effect of carotid endarterectomy and carotid artery stent placement [13][14][15]. Few studies have performed collateral circulation assessment of bilateral severe carotid artery stenosis/occlusion, and its hemodynamic characteristics are still unclear.…”

Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review

“…Successful recanalization was calculated at surprisingly high rates of 14.6%. 51 However, only 5 of the 7 studies reported rates of successful recanalization, the definition of successful recanalization differed between studies, whereas in the largest study that reported rates of successful recanalization these were at 24 h post-treatment and at rates of 54%, suggesting probably an overestimation of the effect of systemic thrombolysis. 52 Collectively, although IVT for pICAOs appears to be beneficial and should be offered to all eligible patients, the rates of successful recanalization are low, while the rates of sICH are not neglectable.…”