Management of patients with atherosclerotic carotid occlusion

Hemodynamic Changes in Patients with Chronic Internal Carotid Artery Occlusion After Recanalization

Objective

This study aimed to investigate the feasibility and clinical efficacy of endovascular recanalization in patients with chronic internal carotid artery occlusion (CICAO) and explore the application value of computed tomography perfusion (CTP) in endovascular recanalization.

Methods

This non-randomized controlled study included 41 patients with CICAO. All patients received active medical treatment. In this study, patients with successful endovascular recanalization and those who refused endovascular recanalization were included in the recanalization and medication groups, respectively. Before and 90 days after treatment, cognitive function was evaluated using the Montreal Cognitive Function Assessment, and neurological function was evaluated using the National Institutes of Health Stroke Scale and modified Rankin scale. For patients with successful endovascular recanalization, brain CTP imaging was performed to evaluate hemodynamic changes in patients with CICAO before and three days after treatment.

Results

Overall, 41 symptomatic patients with CICAO were included, and 20 patients received endovascular recanalization therapy, with a success rate of 60% (12/20). The perioperative complication rate was 15% (3/20); there were no events such as hyperperfusion, distal embolism, vascular rupture, or cerebral hemorrhage, and no stroke-related or death-related events. Patients were divided into a medication group (n=21) and recanalization group (n=12). After 90 days of follow-up, patients in the recanalization group showed greater improvement in overall cognitive and neurological function. In addition, successful endovascular recanalization significantly improved cerebral blood perfusion on the occluded side of patients with CICAO.

Conclusion

Successful recanalization can effectively improve the overall cognitive and neurological functions of patients in the short term. CTP can be used to quantitatively evaluate not only the cerebral hemodynamic changes after internal carotid artery occlusion but also the improvement of cerebral blood perfusion after successful endovascular recanalization, which provides a reliable method for postoperative follow-up.

Carotid-Carotid Artery Crossover Bypass with a Synthetic Vascular Graft for Symptomatic Type 1A Common Carotid Artery Occlusion

OBJECTIVE

To investigate the effect of carotid-carotid artery crossover bypass with a synthetic vascular graft for symptomatic type 1A common carotid artery occlusion (CCAO).

METHODS

A retrospective analysis was conducted of patients with symptomatic type 1A CCAO who underwent carotid-carotid artery crossover bypass surgery via a retropharyngeal route with a synthetic vascular graft in the Department of Neurosurgery at our hospital. Preoperative demographic data, surgical complications, incidence of stroke during follow-up, and other clinical data were summarized.

RESULTS

Between 2011 and 2016, carotid-carotid artery crossover bypass was performed with a synthetic vascular graft in 4 patients with type 1A CCAO. The mean patient age was 63.3 years (range, 49-69 years). Clinical symptoms included dizziness, amaurosis fugax, persistent limb numbness, and transient ischemic attack. In all 4 patients, postoperative computed tomography angiography showed internal carotid artery thickening due to successful bypass, whereas computed tomography perfusion showed improved postoperative cerebral perfusion on the side of the lesion. The sole perioperative complication was a complaint of foreign body sensation on swallowing in 1 patient. The mean duration of follow-up was 40.3 months (range, 14-77 months), during which no newly occurred cerebral ischemia or synthetic vascular graft occlusion was observed.

CONCLUSIONS

Carotid-carotid artery crossover bypass with a synthetic vascular graft is a safe and effective therapeutic approach for patients with symptomatic type 1A CCAO. However, studies with larger series are needed to enable more precise conclusions.

Prognosis of Asymptomatic Carotid Artery Occlusion

Background and Purpose—

The aim of this systematic review was to quantify the risk of ipsilateral stroke in patients with asymptomatic carotid artery occlusion (ACAO).

Methods—

Studies reporting ipsilateral stroke risk in ACAO were identified by a search of MEDLINE, EMBASE, and study bibliographies. Study estimates were pooled using a random effects model, and heterogeneity was quantified using the I 2 statistic. The primary outcome was the annual rate of ipsilateral stroke.

Results—

Thirteen studies were identified, encompassing 718 patients with ACAO who were followed up for a median of 2.8 years. The annual rate of ipsilateral stroke was 1.3% (95% confidence interval, 0.4–2.1; I 2 =53%). The annual rate of ipsilateral transient ischemic attack was 1.0% (95% confidence interval, 0.3–1.8; I 2 =40%). The annual rate of death was substantially higher at 7.7% (95% confidence interval, 4.3–11.2; I 2 =83%). Correction for possible publication bias for the primary outcome suggested a lower risk of ipsilateral stroke (0.3% per year; 95% confidence interval, –0.4 to 1.1).

Conclusions—

Stroke in ACAO is relatively infrequent, but patients face high mortality rates. This suggests the need for intensified medical therapy in ACAO.

Management of Bilateral Carotid Occlusive Disease

BACKGROUND

Symptomatic bilateral internal carotid occlusive disease is a rare but potentially devastating entity. Medical therapy alone is associated with high rates of mortality and recurrent stroke. The optimal management of this disease remains poorly understood.

METHODS

A retrospective review of a prospectively maintained database was conducted for patients who presented with an acute stroke in the setting of bilateral carotid occlusive disease between May and October 2013.

RESULTS

We identified 3 patients. The admission National Institutes of Health Stroke Scale score ranged from 4 to 7. All patients had small- to moderate-sized infarcts in the anterior circulation on presentation. Angiography confirmed bilateral internal carotid occlusions with collateral filling via the posterior communicating artery and retrograde filling via external carotid artery supply to the ophthalmic artery. All patients were initially managed with permissive hypertension and anticoagulation followed by carotid angioplasty and stenting. At 1-year follow-up, all patients demonstrated a modified Rankin scale score of 0-1.

CONCLUSIONS

Carotid stenting may be a safe and effective therapy for patients presenting with symptomatic bilateral carotid occlusions.

Ipsilateral Infarct in Newly Diagnosed Cervical Internal Carotid Artery Atherosclerotic Occlusion

OBJECTIVE

We aimed to determine factors associated with recent infarct (RI) in patients with newly identified atherosclerotic cervical internal carotid artery occlusion (CICAO).

METHODS

This was a retrospective review of consecutive patients who underwent cervical CT angiography from 2002 to 2006 at a single tertiary center. RI was defined by positive diffusion-weighted imaging/apparent diffusion coefficient magnetic resonance imaging (MRI) in the correspondent CICAO territory. Subjects were dichotomized into those with a RI versus patients with no RI (No-RI).

RESULTS

Of 2,459 patients with cervical CT angiograms in the study period, 108 (4.4%) had complete medical records and brain MRI and were included. The mean age was 64 ± 13 years, 58% were men, and 62 (57%) had a RI. The demographics of the RI and No-RI patients were comparable, with the exception that those with RI had a lower frequency of coronary artery disease (CAD, 13 vs. 54%; p < 0.01) and dyslipidemia (38 vs. 69%; p < 0.01). The use of antiplatelets was not statistically different between the groups (56 vs. 71%; p = 0.1). Subjects with RI were less likely on statins (21 vs. 56%; p < 0.01) and antihypertensives (9 vs. 71%; p < 0.01). Multivariate regression revealed that CAD, the use of statins, and the use of antihypertensives were associated with No-RI CICAO presentation.

CONCLUSION

The use of statins and antihypertensives is associated with a decreased risk of RI atherosclerotic CICAO.

Lower stroke risk with lower blood pressure in hemodynamic cerebral ischemia

OBJECTIVE

To determine whether strict blood pressure (BP) control is the best medical management for patients with symptomatic carotid artery occlusion and hemodynamic cerebral ischemia.

METHODS

In this prospective observational cohort study, we analyzed data from 91 participants in the nonsurgical group of the Carotid Occlusion Surgery Study (COSS) who had recent symptomatic internal carotid artery occlusion and hemodynamic cerebral ischemia manifested by ipsilateral increased oxygen extraction fraction. The target BP goal in COSS was ≤130/85 mm Hg. We compared the occurrence of ipsilateral ischemic stroke during follow-up in the 41 participants with mean BP ≤130/85 mm Hg to the remaining 50 with higher BP.

RESULTS

Of 16 total ipsilateral ischemic strokes that occurred during follow-up, 3 occurred in the 41 participants with mean follow-up BP of ≤130/85 mm Hg, compared to 13 in the remaining 50 participants with mean follow-up BP >130/85 mm Hg (hazard ratio 3.742, 95% confidence interval 1.065-13.152, log-rank p = 0.027).

CONCLUSION

BPs ≤130/85 mm Hg were associated with lower subsequent stroke risk in these patients.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that control of hypertension ≤130/85 mm Hg is associated with a reduced risk of subsequent ipsilateral ischemic stroke in patients with recently symptomatic carotid occlusion and hemodynamic cerebral ischemia (increased oxygen extraction fraction).

Common carotid artery occlusion: a case series

Subjects and Methods. We analysed 5000 cerebrovascular ultrasound records. A total of 0.4% of the patients had common carotid artery occlusion (CCAO). Results. The mean age was 59.8 ± 14.2 years, and the male/female ratio was 2.33. The most frequent risk factors were hypertension, ischaemic heart disease, dyslipidemia, diabetes mellitus, and smoking. Right-sided and left-sided CCAO occurred in 65% and 30% of the cases, respectively, and bilateral occlusion was detected in one case (5%). Patent bifurcation was observed in 10 cases of CCAO in which the anterograde flow in the ICA was maintained from the external carotid artery with reversed flow. In two of the cases, the occluded CCA was hypoplastic. The aetiology of CCAO in the majority of cases was the atherosclerosis (15 cases). The male/female ratio was higher in the patients with occluded distal vessels, and the short-term outcome was poorer. Only two cases from this series underwent revascularisation surgery. Spontaneous recanalisation was observed in one case. Conclusions. The most frequent cause of CCAO was atherosclerosis. The outcome is improved in the cases with patent distal vessels, and spontaneous recanalisation is possible. Treatment methods have not been standardised. Surgical revascularisation is possible in cases of patent distal vessels, but the indications are debatable.