Endovascular Reperfusion for Acute Isolated Cervical Carotid Occlusions: The Concept of “Hemodynamic Thrombectomy”

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Abstract

Background/Aims: Endovascular treatment improves the outcomes of patients presenting with acute large vessel occlusions. Isolated proximal carotid occlusions presenting with hemodynamic ischemic stroke may probably also benefit from endovascular treatment. We aimed to assess the clinical and radiological data findings on patients who underwent endovascular treatment for acute ischemic stroke related to an isolated cervical carotid artery occlusion. Methods: Of a consecutive series of 223 patients who were admitted with acute ischemic stroke and were treated by thrombectomy, we included 9 patients with isolated cervical internal carotid occlusions. Results: The mean baseline National Institutes of Health Stroke Scale (NIHSS) score was 11.8. Complete carotid recanalization was achieved in 5 of the 9 patients (55.5%). In 2 patients, vertebral angioplasty was performed to improve the collateral flow. All patients had a modified Thrombolysis in Cerebral Infarction (mTICI) score of 3 at the end of the procedures. A good neurological outcome, defined as a modified Rankin Scale score ≤2 at the 3-month follow-up, was observed in 6 patients (66.7%). No symptomatic intracranial hemorrhages or deaths occurred during the 3 months of follow-up. Conclusions: The endovascular recanalization of isolated cervical carotid occlusions presenting with acute ischemic stroke symptoms is feasible. Because isolated cervical carotid occlusions are associated with hemodynamic ischemic symptoms, if carotid recanalization cannot be achieved, stenting other cervical arteries’ stenoses, with a focus on intracranial flow improvement, appears to be a reasonable strategy. Large controlled studies are necessary to assess the safety and efficacy of recanalization of acute isolated cervical carotid occlusions.

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Most cited references 9

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Significance of large vessel intracranial occlusion causing acute ischemic stroke and TIA.

Wade S Smith, Michael H. Lev, Joey D English … (2009)

Acute ischemic stroke due to large vessel occlusion (LVO)-vertebral, basilar, carotid terminus, middle and anterior cerebral arteries-likely portends a worse prognosis than stroke unassociated with LVO. Because little prospective angiographic data have been reported on a cohort of unselected patients with stroke and with transient ischemic attack, the clinical impact of LVO has been difficult to quantify. The Screening Technology and Outcome Project in Stroke Study is a prospective imaging-based study of stroke outcomes performed at 2 academic medical centers. Patients with suspected acute stroke who presented within 24 hours of symptom onset and who underwent multimodality CT/CT angiography were approached for consent for collection of clinical data and 6-month assessment of outcome. Demographic and clinical variables and 6-month modified Rankin Scale scores were collected and combined with blinded interpretation of the CT angiography data. The OR of each variable, including occlusion of intracranial vascular segment in predicting good outcome and 6-month mortality, was calculated using univariate and multivariate logistic regression. Over a 33-month period, 735 patients with suspected stroke were enrolled. Of these, 578 were adjudicated as stroke and 97 as transient ischemic attack. Among patients with stroke, 267 (46%) had LVO accounting for the stroke and 13 (13%) of patients with transient ischemic attack had LVO accounting for transient ischemic attack symptoms. LVO predicted 6-month mortality (OR, 4.5; 95% CI, 2.7 to 7.3; P<0.001). Six-month good outcome (modified Rankin Scale score

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The benefits of intravenous thrombolysis relate to the site of baseline arterial occlusion in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET).

Christopher Bladin, Martin Ebinger, P Barber … (2010)

In ischemic stroke, the site of arterial obstruction has been shown to influence recanalization and clinical outcomes. However, this has not been studied in randomized controlled trials, nor has the impact of arterial obstruction site on reperfusion and infarct growth been assessed. We studied the influence of site and degree of arterial obstruction patients enrolled in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET). EPITHET was a prospective, randomized, placebo-controlled trial of intravenous tissue plasminogen activator (tPA) in the 3- to 6-hour time window. Arterial obstruction site and degree were rated on magnetic resonance angiography blinded to treatment allocation and outcomes. In 101 EPITHET patients, 87 had adequate quality magnetic resonance angiography, of whom 54 had baseline arterial obstruction. Infarct growth attenuation was greater in those with tPA treatment compared to placebo among patients with middle cerebral artery (MCA) obstruction (P=0.037). The treatment benefit of tPA over placebo in attenuating infarct growth was greater for MCA than internal carotid artery (ICA) obstruction (P=0.060). With tPA treatment, good clinical outcome was more likely with MCA than with ICA obstruction (P=0.005). Most patients with ICA obstruction did not achieve good clinical outcome, whether treated with tPA (100%) or placebo (77%). The study was underpowered to prove any treatment benefit of tPA among patients with any or severe degree of arterial obstruction. Arterial obstruction site strongly predicts outcomes. ICA obstruction carries a uniformly poor prognosis, whereas good outcomes with MCA obstruction are associated with tPA therapy.

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Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes.

Peter Kan, Travis M. Dumont, Kenneth V Snyder … (2012)

Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. The best treatment approach to acute stroke in this setting is unknown. We sought to determine clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intravenous (IV) systemic thrombolysis or intra-arterial endovascular therapy. Using the PubMed database, we searched for studies that included patients with acute ischemic stroke attributable to ICA occlusion who received treatment with IV thrombolysis or intra-arterial endovascular interventions. Studies providing data on functional outcomes beyond 30 days and mortality and symptomatic intracerebral hemorrhage (sICH) rates were included in our analysis. We compared the proportions of patients with favorable functional outcomes, sICH, and mortality rates in the 2 treatment groups by calculating χ(2) and confidence intervals for odds ratios. We identified 28 studies with 385 patients in the IV thrombolysis group and 584 in the endovascular group. Rates of favorable outcomes and sICH were significantly higher in the endovascular group than the IV thrombolysis-only group (33.6% vs 24.9%, P=0.004 and 11.1% vs 4.9%, P=0.001, respectively). No significant difference in mortality rate was found between the groups (27.3% in the IV thrombolysis group vs 32.0% in the endovascular group; P=0.12). According to our systematic review, endovascular treatment of acute ICA occlusion results in improved clinical outcomes. A higher rate of sICH after endovascular treatment does not result in increased overall mortality rate.

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Author and article information

Journal

Journal ID (publisher-id): INE

Journal ID (pmc): INE

Journal ID (doi): 10.1159/issn.1664-5545

Title: Interventional Neurology

Publisher: S. Karger AG

ISSN (Print): 1664-9737

ISSN (Electronic): 1664-5545

Publication date Subscription-year: 2019

Publication date (Print): February 2020

Publication date (Electronic): 27 September 2018

Volume: 8

Issue: 1

Pages: 27-37

Affiliations

[_a] _aDivision of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil

[_b] _bDivision of Neurology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil

Author notes

*Luís Henrique de Castro-Afonso, Division of Interventional Neuroradiology, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900, Monte Alegre, Ribeirão Preto, SP 14048-090 (Brazil), E-Mail castroafonsolh@yahoo.com.br

Article

Publisher ID: 493021 Other ID: Intervent Neurol 2019;8:27–37

DOI: 10.1159/000493021

PMC ID: 7098291

PubMed ID: 32231693

SO-VID: 122a24b8-3c48-47da-80a2-89baac1f65a5

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

History

Date received : 17 May 2018

Date accepted : 16 August 2018

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Figures: 4, Tables: 2, Pages: 11

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Endovascular Reperfusion for Acute Isolated Cervical Carotid Occlusions: The Concept of “Hemodynamic Thrombectomy”

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Abstract

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Karger: Neurology and Neuroscience

Most cited references 9

Significance of large vessel intracranial occlusion causing acute ischemic stroke and TIA.

The benefits of intravenous thrombolysis relate to the site of baseline arterial occlusion in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET).

Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes.

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