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Schlacter JA, Ratner M, Siracuse J, Patel V, Johnson W, Torres J, Chang H, Jacobowitz G, Rockman C, Garg K. Urgent Endarterectomy for Symptomatic Carotid Occlusion is Associated with a High Mortality. J Vasc Surg 2023:S0741-5214(23)01033-9. [PMID: 37076104 DOI: 10.1016/j.jvs.2023.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Interventions for carotid occlusions are infrequently undertaken and the outcomes are poorly defined. We sought to study patients undergoing urgent carotid revascularization for symptomatic occlusions. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was queried from 2003 to 2020 to identify patients with carotid occlusions undergoing carotid endarterectomy (CEA). Only symptomatic patients undergoing urgent interventions within 24 hours of presentation were included. Patients were identified based on CT and MRI imaging. This cohort was compared to symptomatic patients undergoing urgent intervention for severe stenosis (≥80%). Primary endpoints were perioperative stroke, death, myocardial infarction (MI) and composite outcomes as defined by the SVS reporting guidelines. Patient characteristics were analyzed to determine predictors of perioperative mortality and neurological events. RESULTS 390 patients who underwent urgent CEA for symptomatic occlusions were identified. The mean age was 67.4±10.2 years (range 39 to 90 years). The cohort was predominantly male (60%) with associated risk factors for cerebrovascular disease, including hypertension (87.4%), diabetes (34.4%), coronary artery disease (21.6%) and current smoking (38.7%). This population had high utilization of medications including statin (78.6%), P2Y12 inhibitor (32.0%), aspirin (77.9%) and renin-angiotensin inhibitor (43.7%) preoperatively. When compared to patients undergoing urgent endarterectomy for severe stenosis (≥80%), those with symptomatic occlusion were well matched with regards to risk factors, but the severe stenosis cohort appeared better medically managed and less likely to present with cortical stroke symptoms. Perioperative outcomes were significantly worse for the carotid occlusion cohort, primarily driven by higher perioperative mortality (2.8% vs 0.9%, P<.001). The composite endpoint of stroke/death/MI was also significantly worse in the occlusion cohort (7.7% vs 4.9%, P=.014). On multivariate analysis, carotid occlusion was associated with increased mortality (OR, 3.028; 95% CI, 1.362-6.730; P=.007) and composite outcome of stroke, death, or MI (OR, 1.790; 95% CI, 1.135-2.822, P=.012). CONCLUSIONS Revascularization for symptomatic carotid occlusion constitutes approximately 2% of carotid interventions captured in the VQI, affirming the rarity of this undertaking. These patients have acceptable rates of perioperative neurologic events but are at an elevated risk of overall perioperative adverse events, primarily driven by higher mortality, compared to those with severe stenosis. Carotid occlusion appears to be the most significant risk factor for the composite endpoint of perioperative stroke, death, or MI. While intervention for a symptomatic carotid occlusion may be performed with acceptable rate of perioperative complications, judicious patient selection is warranted in this high-risk cohort.
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Affiliation(s)
| | - Molly Ratner
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Jeffrey Siracuse
- Division of Vascular and Endovascular Surgery, Boston University, Boston, MA
| | - Virendra Patel
- Division of Vascular and Endovascular Surgery, Columbia University, New York, NY
| | - William Johnson
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Jose Torres
- Department of Neurology, New York University Langone Health, New York, NY
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Westchester Medical Center, Valhalla, NY
| | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY.
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2
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Mayer L, Grams A, Freyschlag CF, Gummerer M, Knoflach M. Management and prognosis of acute extracranial internal carotid artery occlusion. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1268. [PMID: 33178800 PMCID: PMC7607089 DOI: 10.21037/atm-20-3169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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.
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Affiliation(s)
- Lukas Mayer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Maria Gummerer
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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3
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Hause S, Oldag A, Breja A, Neumann J, Wilcke J, Schreiber S, Heinze HJ, Skalej M, Halloul Z, Goertler M. Acute symptomatic extracranial internal carotid occlusion - natural course and clinical impact. VASA 2019; 49:31-38. [PMID: 31621550 DOI: 10.1024/0301-1526/a000826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: To assess the vascular and clinical course of acute symptomatic extracranial internal carotid artery (ICA) occlusion. Patients and methods: Patients with an acute ischemic event in the anterior circulation and corresponding extracranial ICA occlusion at CT angiography and/or color-coded duplex sonography underwent recurrent duplex follow-up for detection of spontaneous recanalization. Stroke recurrence and functional outcome 4.5 months after the ischemic index event assessed by modified Rankin scale served as secondary outcome parameters. Results: 133 patients (91 men, mean age 62.3 years, SD 10.8) demonstrated symptomatic occlusion of the extracranial ICA with open intracranial ICA and open middle cerebral artery and were followed-up for spontaneous recanalization. Twenty-eight recanalized spontaneously, 25 to high-grade focal stenosis within 12 days, revealing an early cumulative recanalization rate of 23 %. Detection of recanalization was independently associated with de novo dual anti-platelet therapy (adjusted odds ratio [OR], 3.24; 95 % confidence interval [CI], 1.34 to 7.80). Ischemic recurrence occurred in 16 patients, of which 10 deemed to be embolic and 5 hemodynamic. Spontaneous ICA recanalization and an exhausted cerebrovascular reserve in the hemisphere distal to the occluded ICA were both independently associated with the occurrence of a recurrent ischemic event at Cox regression. An increasing NIHSS score at admission, a decreasing middle cerebral artery flow velocity and an ischemic recurrence independently predicted poor outcome (modified Rankin scale 3 to 6) in multivariate analysis. Conclusions: Acute symptomatic extracranial ICA occlusion is an unstable condition with frequent spontaneous recanalization to severe stenosis and early embolic stroke recurrence, demanding appropriate prevention especially in those patients with only mild deficit.
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Affiliation(s)
- Stephan Hause
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Andreas Oldag
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Andrea Breja
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Jens Neumann
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Juliane Wilcke
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Stefanie Schreiber
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Hans-Jochen Heinze
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Martin Skalej
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Institute of Neuroradiology, Magdeburg University Hospital, Magdeburg, Germany
| | - Zuhir Halloul
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of General, Abdominal and Vascular Surgery, Magdeburg University Hospital, Magdeburg, Germany
| | - Michael Goertler
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
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Beneš V, Bradáč O, Horváth D, Suchomel P, Beneš V. Surgery of acute occlusion of the extracranial internal carotid artery - a meta-analysis. VASA 2019; 49:6-16. [PMID: 31210589 DOI: 10.1024/0301-1526/a000801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acute occlusion of the extracranial internal carotid artery (eICA) is associated with poor prognosis. Surgical desobliteration has not received adequate attention in recent years. We therefore conducted a literature review and meta-analysis of surgical studies published after 2000 that treated eICA occlusion surgically in an emergency setting. The search identified 10 relevant articles that included a total of 175 patients. The outcomes analysed included rates of recanalization (93 %), early neurological improvement (66 %), modified Rankin Scale 0-2 (62 %), mortality (5 %), early reocclusion (4 %), in-hospital stroke (4 %) and symptomatic intracerebral haemorrhage (4 %). In conclusion, acute surgical desobliteration of eICA occlusion leads to high rates of recanalization and a majority of patients experience early neurological improvement and achieve favourable outcome. Rates of mortality, early reocclusion, in-hospital stroke and sICH are acceptable in the view of unfavourable natural history.
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Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery, Regional Hospital Liberec, Liberec, Czech Republic
| | - Ondřej Bradáč
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - David Horváth
- Institute of Scientific Information, Charles University, First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Petr Suchomel
- Department of Neurosurgery, Regional Hospital Liberec, Liberec, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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Lamanna A, Maingard J, Barras CD, Kok HK, Handelman G, Chandra RV, Thijs V, Brooks DM, Asadi H. Carotid artery stenting: Current state of evidence and future directions. Acta Neurol Scand 2019; 139:318-333. [PMID: 30613950 DOI: 10.1111/ane.13062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Julian Maingard
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Hong Kuan Kok
- Interventional Radiology ServiceNorthern Hospital Radiology Melbourne, Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
| | - Guy Handelman
- Education and Research CentreBeaumont Hospital Dublin Ireland
- Department of RadiologyRoyal Victoria Hospital Belfast UK
| | - Ronil V. Chandra
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience & Mental HealthUniversity of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
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Abstract
Introduction Acute internal carotid artery occlusion is a devastating form of ischemic accident with significant morbidity and possible mortality. The “threatened hemisphere” is allowed limited access to collateral circulation further worsening the ischemic burden and the overall prognosis. Methods We present the details of a case of a 38-year-old woman who suffered from an ischemic stroke. The clinical course of which showed a hemodynamic dependence to preserve her neurological function, prompting the use of the phosphodiesterase inhibitor milrinone to maintain her neurological function. Result This case represents the first case in the literature in which a medical therapy is used to salvage brain tissue in the site of acute symptomatic large vessel occlusion. This has spared the patient from a potential significant morbidity and even mortality if a revascularization procedure had been attempted. Conclusion This innovative use of milrinone, if applied in more captured patients with internal carotid occlusion or those with reversible hemodynamic failure, would improve our understanding of the ischemic thresholds and cerebral vascular reserves and would improve the clinical outcome of this significant ischemic insult.
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7
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Schubert J, Witte OW, Settmacher U, Mayer TE, Günther A, Zanow J, Klingner CM. Acute Stroke Treatment by Surgical Recanalization of Extracranial Internal Carotid Artery Occlusion: A Single Center Experience. Vasc Endovascular Surg 2018; 53:21-27. [PMID: 30301430 DOI: 10.1177/1538574418800131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Ischemic stroke due to an acute occlusion of the extracranial internal carotid artery (eICA) is associated with high morbidity and mortality. The best treatment option remains unclear. This study aims to increase the available therapeutic experience documented for surgical recanalization of acute eICA occlusions. We retrospectively reviewed all hospital records of the University Hospital Jena between 2006 and 2018 to identified patients with acute ischemic stroke due to an occlusion of the eICA who underwent emergent surgical recanalization. We analyzed clinical data, surgical reports, imaging data, and outpatient records. The primary outcome parameter was the modified Rankin Scale (mRS) at 3 months. During the survey, 12 patients (mean age: 62.3 ± 10.8 years; range: 35-87) underwent emergent surgical recanalization for an acutely symptomatic eICA occlusion. All patients presented with neurological deficits with a mean National Institutes of Health Stroke Scale score at admission of 15.0 ± 5.1 (range 2-23). Patients were selected for surgery mainly due to the extent of the perfusion mismatch, while stroke severity and age were also considered. The median time from symptom onset to surgery was 309 ± 122 minutes (range 112-650 minutes). Complete recanalization was obtained in all 12 patients. No patient deteriorated postoperatively, no intracranial hemorrhage was observed, and no patient died in the following 3 months. Favorable outcomes (mRS: 0-2) after 3 months were achieved in 7 of 12 patients. The current study adds support to previous findings that the surgical recanalization of acute eICA occlusions is a possible and safe treatment option. However, a critical patient selection based on mismatch size in perfusion imaging is crucially important for successful treatment.
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Affiliation(s)
- Julia Schubert
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Otto W Witte
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Utz Settmacher
- 2 Department of General, Visceral and Vascular Surgery, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Thomas E Mayer
- 3 Section Neuroradiology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Albrecht Günther
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Jürgen Zanow
- 2 Department of General, Visceral and Vascular Surgery, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Carsten M Klingner
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany.,4 Biomagnetic Center, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
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8
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Gunka I, Krajickova D, Lesko M, Jiska S, Raupach J, Lojik M, Maly R. Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery. Vasc Endovascular Surg 2017; 51:176-182. [DOI: 10.1177/1538574416674641] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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.
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Affiliation(s)
- Igor Gunka
- Department of Surgery, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Dagmar Krajickova
- Department of Neurology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Michal Lesko
- Department of Surgery, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Stanislav Jiska
- Department of Surgery, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Miroslav Lojik
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
| | - Radovan Maly
- 1st Department of Internal Medicine—Cardioangiology, University Hospital and Faculty of Medicine Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech Republic
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9
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Internal carotid artery occlusion should not exclude surgery. ACTA ACUST UNITED AC 2016; 1:e75-e77. [PMID: 28905025 PMCID: PMC5421529 DOI: 10.5114/amsad.2016.61495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/10/2016] [Indexed: 11/17/2022]
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10
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Lee JI, Jander S, Oberhuber A, Schelzig H, Hänggi D, Turowski B, Seitz RJ. Stroke in patients with occlusion of the internal carotid artery: options for treatment. Expert Rev Neurother 2014; 14:1153-67. [PMID: 25245575 DOI: 10.1586/14737175.2014.955477] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke may occur in patients in whom vascular imaging shows the ipsilateral internal carotid artery (ICA) to be occluded. In younger patients this is often due to carotid artery dissection, while in older people this most likely results from cardiac embolism or thrombosis secondary to high-grade stenosis at the carotid bifurcation. Interventional techniques aim at recanalization of the carotid artery for early restoration of cerebral blood flow and secondary prevention of future strokes. In chronic ICA occlusion the ischemic infarct may be related to hemodynamic compromise. In this situation, extracranial-intracranial bypass surgery was introduced, but its role remains still unclear. Ischemic stroke may also occur in patients with a chronic occlusion of the contralateral ICA. This situation demands the usual stroke treatment, but surgical and neuroradiological interventions face a higher risk than unilateral vascular pathology. Medical treatment supports stroke prevention in carotid artery occlusion.
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Affiliation(s)
- John Ih Lee
- LVR-Klinikum Düsseldorf, University Hospital Düsseldorf, Düsseldorf, Germany
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11
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Beneš V, Buchvald P, Klimošová S, Eichlová Z, Suchomel P. Acute extracranial occlusion of the internal carotid artery: emergent surgery remains a viable option. Acta Neurochir (Wien) 2014; 156:901-8; discussion 908-9. [PMID: 24584902 DOI: 10.1007/s00701-014-2036-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/10/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute symptomatic occlusion of extracranial internal carotid artery (eICA) can lead to a critical and potentially devastating stroke associated with high morbidity and mortality. Optimal treatment remains unclear. We analyzed our institutional experience with emergent surgical recanalization of acutely occluded eICA. METHODS Retrospective analysis of hospital records, surgical reports, imaging studies and outpatient records. Final outcome was assessed according to modified Rankin Scale (mRS). RESULTS Between January 2010 and September 2013, 22 patients underwent emergent surgical recanalization. There were 17 men and five women, mean age 65.4 years (range 37-85). Mean admission National Institute of Health Stroke Scale (NIHSS) was 12 (range 6-21). All patients had evidence of salvageable penumbra on perfusion computed tomography. Tandem intracranial lesion was present in nine patients. Surgical recanalization was successful in 16 patients (72.7 %). Twenty-four hours after surgery, 17 patients (77.2 %) improved by a minimum of 1 point on NIHSS, 14 patients (63.6 %) improved by three and more points; two patients deteriorated by two and five points, the latter treated initially with systemic thrombolysis due to intracranial hemorrhage. No other intracranial hematoma was observed. During 30 days following surgery, two patients died (9 % mortality rate) due to severity of initial stroke. On discharge, four patients were classified as mRS 0, five patients as mRS 1, five patients as mRS 2 and six patients as mRS 4. Favorable recovery (mRS 0-2) was achieved in 14 patients (63.6 %). No change in mRS was observed at three months. CONCLUSIONS Our results suggest that emergent surgical desobliteration of occluded eICA can lead to favorable recovery in a majority of patients. Patient selection based on penumbra imaging is crucial. Given the popularity and simplicity of carotid endarterectomy, the procedure should by no means be abandoned in the treatment of acute eICA occlusion.
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Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic,
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12
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Krylov VV, Luk'ianchikov VA. Cerebral revascularization for the treatment of patients with acute ischemic stroke. Zh Nevrol Psikhiatr Im S S Korsakova 2014; 114:46-52. [DOI: 10.17116/jnevro201411412246-52] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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13
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Weis-Müller BT, Spivak-Dats A, Turowski B, Siebler M, Balzer KM, Grabitz K, Godehardt E, Sandmann W. Time Is Brain? — Surgical Revascularization of Acute Symptomatic Occlusion of the Internal Carotid Artery up to One Week. Ann Vasc Surg 2013; 27:424-32. [DOI: 10.1016/j.avsg.2012.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 10/23/2011] [Accepted: 05/07/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Barbara Theresia Weis-Müller
- Department for Vascular Surgery and Kidney Transplantation, University Hospital of Düsseldorf, Heinrich-Heine-University of Düsseldorf, Düsseldorf, Germany.
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14
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Irace L, Gabrielli R, Rosati MS, Giannoni MF, Castiglione A, Laurito A, Gossetti B. Carotid artery free-floating thrombus caused by paradoxical embolization from greater saphenous vein ascending thrombophlebitis. Ann Vasc Surg 2013; 27:499.e13-7. [PMID: 23618593 DOI: 10.1016/j.avsg.2012.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 04/21/2012] [Accepted: 06/11/2012] [Indexed: 10/26/2022]
Abstract
Stroke of unknown origin in young patients is seen to be closely correlated with patent foramen ovale (PFO) than stroke in patients with established stroke mechanisms. We report a case of a young woman without cardiovascular risk factors who was admitted to our emergency department with listlessness and altered mental status. The clinical examination revealed right lower limb swelling. Magnetic resonance imaging and contrast-enhanced computed tomographic scans revealed a free floating thrombus of the left internal carotid artery (ICA) with a large bilateral frontal ischemic lesion. The diagnosis of a medium-sized PFO with moderate right-to-left contrast shunting was made after transesophageal echocardiography. No other cardiac sources for embolization were detected, while an ascending thrombophlebitis of the right greater saphenous vein was detected by venous Doppler ultrasonography. These findings support the diagnosis of ICA free-floating thrombus caused by paradoxical embolization (via the PFO) of clot from the greater saphenous vein. The patient underwent emergency saphenofemoral disconnection with femoral vein thrombectomy and subsequently carotid artery thrombectomy under general anesthesia. No carotid atheromatous wall lesions were detected at surgical exploration; no immunologic pathology, hypercoagulable status, or malignancy were recorded. No hemorrhagic cerebral complications were observed in the postoperative period, and the patient had an improvement of her neurologic status (a reduction of the National Institutes of Health Stroke Scale score from 7 to 3). Her recovery was uneventful. The patient was transferred for rehabilitation on postoperative day 5 with oral anticoagulation. Six-month ultrasound follow-up revealed deep and superficial venous system and carotid artery patency. The patient was asymptomatic and anticoagulation was discontinued. Paradoxical cerebral embolization through a PFO is a rare phenomenon that, in our patient, appeared to have resulted in stroke caused by a free-floating thrombus in the ICA. Accurate evaluation of carotid and lower limb veins by duplex scan is mandatory in cases of stroke of unknown origin, and urgent surgical repair can be useful in order to improve the clinical outcome.
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Affiliation(s)
- Luigi Irace
- Department of Emergency Policlinico Umberto I, Sapienza University of Rome, Rome Italy
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Hauck EF, Natarajan SK, Ohta H, Ogilvy CS, Hopkins LN, Siddiqui AH, Levy EI. Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke. Neurosurgery 2011; 69:899-907; discussion 907. [PMID: 21499144 DOI: 10.1227/neu.0b013e31821cfa52] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute proximal (cervical) internal carotid artery (ICA) occlusion may cause ischemia of an entire hemisphere or no ischemia at all, depending on the presence of intracranial collaterals. OBJECTIVE To retrospectively analyze the clinical results for emergent endovascular carotid recanalization in patients with acute proximal (cervical) ICA occlusion and to assess predictors of recanalization and clinical, neurological, and functional outcome. METHODS Emergent endovascular revascularization was attempted in 22 patients presenting with acute stroke secondary to complete cervical ICA occlusion. Patients with pseudo-occlusion were excluded. Recanalization was assessed with the Thrombolysis in Myocardial Ischemia (TIMI) system: grade 0 (no flow) to grade 3 (normal flow). RESULTS The median age of the patients was 65 years; mean admission National Institutes of Health Stroke Scale (NIHSS) score was 14. Recanalization (TIMI grade 2/3) occurred in 17 patients (77.3%). Ten patients (45.5%) demonstrated significant clinical improvement during hospitalization (NIHSS improved ≥4 points). Fifty percent of patients had good outcomes (modified Rankin Scale ≤2) after a median follow-up of 3 months. Patient age <70 years and successful recanalization (TIMI grade 2/3) predicted a good outcome (P ≤ .01). Presence of atrial fibrillation, admission NIHSS score ≥20, and complete ICA occlusion at all levels (cervical, petrocavernous, and intracranial) were associated with poor outcomes (P ≤ .05). Patients with complete cervical ICA occlusion but partial distal preservation of the vessel were most likely to benefit from the intervention (recanalization in 88.2%; good outcome in 64.7%). CONCLUSION Attempts at emergent endovascular carotid recanalization for acute stroke are encouraged, particularly in younger patients with partial distal preservation of the ICA.
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Affiliation(s)
- Erik F Hauck
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, NY, USA
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Sallustio F, Di Legge S, Marziali S, Ippoliti A, Stanzione P. Floating carotid thrombus treated by intravenous heparin and endarterectomy. J Vasc Surg 2011; 53:489-91. [DOI: 10.1016/j.jvs.2010.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Revised: 08/03/2010] [Accepted: 08/04/2010] [Indexed: 10/19/2022]
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Illoh K, Supsupin E, Shaltoni HM, Cacayorin ED. Case of “Slow” Stroke from Carotid Artery Occlusion Treated by Delayed but Cautious Endovascular Intervention. Stroke Res Treat 2011; 2011:974357. [PMID: 21603176 PMCID: PMC3095941 DOI: 10.4061/2011/974357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 02/22/2011] [Indexed: 11/20/2022] Open
Abstract
In a challenging case of carotid occlusion with slowly evolving stroke, we used brain imaging to facilitate endovascular revascularization resulting in the relief of the patient's symptoms. Patients with carotid occlusion and continued neurological worsening or fluctuations present enormous treatment challenges. These patients may present “slow” strokes with subacute infarcts that present significant challenges and risks during attempts at revascularization of the occluded artery. We present such a case in which we used multimodal imaging techniques, including MR-perfusion, to facilitate endovascular revascularization. Our approach of delayed but cautious intra-arterial thrombolytic therapy, guided by brain imaging, and followed by stent placement across the residual stenosis, enabled revascularization of the occluded artery without overt in-hospital complications.
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Affiliation(s)
- Kachi Illoh
- Division of Neurology Products, Center for Drug Evaluation and Research, U. S. Food and Drug Administration, Building 22, Room 5402, 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA
| | - Emilio Supsupin
- Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX 77030, USA
| | - Hashem M. Shaltoni
- Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Mail Stop BCM360, Houston, TX 77030, USA
| | - Edwin D. Cacayorin
- Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, 6431 Fannin Street, MSB 2.130B, Houston, TX 77030, USA
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Lin MS, Kao HL. Regarding "Symptomatic acute occlusion of the internal carotid artery: reappraisal of urgent vascular reconstruction based on current stroke imaging". J Vasc Surg 2009; 49:278; author reply 278-9. [PMID: 19174272 DOI: 10.1016/j.jvs.2008.08.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 08/14/2008] [Accepted: 08/14/2008] [Indexed: 10/21/2022]
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Weis-Müller BT, Sandmann W. Reply. J Vasc Surg 2009. [DOI: 10.1016/j.jvs.2008.08.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Patterson BO, Holt PJ, Hinchliffe RJ, Thompson MM, Loftus IM. Urgent Carotid Endarterectomy for Patients with Unstable Symptoms: Systematic Review and Meta-Analysis of Outcomes. Vascular 2009; 17:243-52. [DOI: 10.2310/6670.2009.00038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Current evidence suggests that carotid endarterectomy (CEA) performed within 2 weeks of symptoms produces better long-term results than if it is delayed. Urgent endarterectomy following unstable presentations such as crescendo transient ischemic attack (cTIA) or progressive stroke has been associated with variable results. The evidence for this treatment strategy required reviewing. A systematic review of articles related to urgent CEA between 1980 and 2008 was performed. For cTIA, there was an odds ratio of 5.6 (95% confidence interval 3.3–9.7, p ≤ .0001) for combined stroke or death compared with surgery for “standard” indications. For unstable stroke, the odds ratio was 5.5 (95% confidence interval 3.1–9.3, p ≤ .0001). Patients with unstable neurologic presentations are at higher risk of complications if operated on urgently. Clearer definitions would help more precise patient selection to avoid inadvertently operating on patients with an unacceptably high risk of poor outcome.
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Affiliation(s)
| | - Peter J. Holt
- *Department of Vascular Surgery, St George's Vascular Institute, London, UK
| | | | - Matt M. Thompson
- *Department of Vascular Surgery, St George's Vascular Institute, London, UK
| | - Ian M. Loftus
- *Department of Vascular Surgery, St George's Vascular Institute, London, UK
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Regarding "Symptomatic acute occlusion of the internal carotid artery: Reappraisal of urgent vascular reconstruction based on current stroke imaging". J Vasc Surg 2008; 48:1068; author reply 1069. [PMID: 18992447 DOI: 10.1016/j.jvs.2008.05.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 05/28/2008] [Accepted: 05/29/2008] [Indexed: 11/21/2022]
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Carotischirurgie reloaded. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2008. [DOI: 10.1007/s00398-008-0656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Update Thrombolyse des akuten ischämischen Schlaganfalls. Notf Rett Med 2008. [DOI: 10.1007/s10049-008-1043-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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