Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery

Abstract

Background:

Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke.

Methods:

A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding.

Results:

During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2).

Conclusion:

Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.

Keywords

acute ischemic stroke carotid artery occlusion internal carotid artery carotid endarterectomy outcome penumbra

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References

Bhatia

Hill

Shobha

. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010;41(10):2254–2258.

Christou

Felberg

Demchuk

. Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. J Neuroimaging. 2002;12(2):119–123.

Paciaroni

Inzitari

Agnelli

. Intravenous thrombolysis or endovascular therapy for acute ischemic stroke associated with cervical internal carotid artery occlusion: the ICARO-3 study. J Neurol. 2015;262(2):459–468.

Mokin

Kass-Hout

. Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes. Stroke. 2012;43(9):2362–2368.

Brott

Halperin

Abbara

; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Stroke Association; American Association of Neuroscience Nurses; American Association of Neurological Surgeons; American College of Radiology; American Society of Neuroradiology; Congress of Neurological Surgeons; Society of Atherosclerosis Imaging and Prevention; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Neurointerventional Surgery; Society for Vascular Medicine; Society for Vascular Surgery; American Academy of Neurology and Society of Cardiovascular Computed Tomography. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke. 2011;42(8):e464–e540.

Beneš

III Buchvald

Klimošová

Eichlová

Suchomel

. Acute extracranial occlusion of the internal carotid artery: emergent surgery remains a viable option. Acta Neurochir. 2014;156(5):901–908.

Cho

Kwon

Chae

Kim

. Carotid endarterectomy for symptomatic complete occlusion of the internal carotid artery. Acta Med Okayama. 2011;65(4):239–245.

Weis-Müller

Huber

Spivak-Dats

Turowski

Siebler

Sandmann

. Symptomatic acute occlusion of the internal carotid artery: reappraisal of urgent vascular reconstruction based on current stroke imaging. J Vasc Surg. 2008;47(4):752–759.

Kiyofuji

Inoue

Tamura

Saito

. Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion. Acta Neurochir. 2015;157(8):1313–1318.

10.

Mandavia

Qureshi

Dharmarajah

Head

Davies

. Safety of carotid intervention following thrombolysis in acute ischaemic stroke. Eur J Vasc Endovasc Surg. 2014;48(5):505–512.

11.

Rathenborg

Venermo

Troëng

. Safety of carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke: a case-controlled multicentre registry study. Eur J Vasc Endovasc Surg. 2014;48(6):620–625.

12.

Rathenborg

Jensen

Baekgaard

Schroeder

. Carotid endarterectomy after intravenous thrombolysis for acute cerebral ischaemic attack: is it safe? Eur J Vasc Endovasc Surg. 2013;45(6):573–577.

13.

Bartoli

Squarcioni

Nicoli

. Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke. Eur J Vasc Endovasc Surg. 2009;37(5):512–518.

14.

Koraen-Smith

Troëng

Björck

Kragsterman

Wahlgren

; Swedish Vascular Registry and the Riks-Stroke Collaboration. Urgent carotid surgery and stenting may be safe after systemic thrombolysis for stroke. Stroke. 2014;45(3):776–780.

15.

Crozier

Reid

Welch

Muir

Stuart

. Early carotid endarterectomy following thrombolysis in the hyperacute treatment of stroke. Br J Surg. 2011;98(2):235–238.

16.

Klijn

van Buren

Kappelle

. Outcome in patients with symptomatic occlusion of the internal carotid artery. Eur J Vasc Endovasc Surg. 2000;19(6):579–586.

17.

Berkhemer

Fransen

Beumer

. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.

18.

Campbell

Mitchell

Kleinig

; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–1018.

19.

Goyal

Demchuk

Menon

; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–1030.

20.

Saver

Goyal

Bonafe

; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–2295.

21.

Jovin

Chamorro

Cobo

; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–2306.

22.

Berthet

Marty-Ané

Picard

. Acute carotid artery thrombosis: description of 12 surgically treated cases. Ann Vasc Surg. 2005;19(1):11–18.

23.

Kappelhof

Marquering

Berkhemer

Majoie

. Intra-arterial treatment of patients with acute ischemic stroke and internal carotid artery occlusion: a literature review. J Neurointerv Surg. 2015;7(1):8–15.

24.

Wylie

Hein

Adams

. Intracranial hemorrhage following surgical revascularization for treatment of acute strokes. J Neurosurg. 1964;21:212–215.

25.

Devlin

Phade

Hutson

. Computed tomography perfusion imaging in the selection of acute stroke patients to undergo emergent carotid endarterectomy. Ann Vasc Surg. 2015;29(1):125.e1–e11.

26.

Kasper

Wladis

Lohr

. Carotid thromboendarterectomy for recent total occlusion of the internal carotid artery. J Vasc Surg. 2001;33(2):242–249.

27.

Paty

Adeniyi

Mehta

. Surgical treatment of internal carotid artery occlusion. J Vasc Surg. 2003;37(4):785–788.

28.

Bhatia

Shobha

Menon

. Combined full-dose IV and endovascular thrombolysis in acute ischaemic stroke. Int J Stroke. 2014;9(8):974–979.

29.

Fassbender

Dempfle

Mielke

. Changes in coagulation and fibrinolysis markers in acute ischemic stroke treated with recombinant tissue plasminogen activator. Stroke. 1999;30(10):2101–2104.

30.

Vivien

Gauberti

Montagne

Defer

Touzé

. Impact of tissue plasminogen activator on the neurovascular unit: from clinical data to experimental evidence. J Cereb Blood Flow Metab. 2011;31(11):2119–2134.