Carotid occlusion is associated with more frequent neurovascular events than moderately severe carotid stenosis

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.

Imaging Predictors for Endovascular Recanalization of Non-acute Occlusion of Internal Carotid Artery Based on 3D T1-SPACE MRI and DSA

Objectives: To investigate the predictive factors for successful recanalization based on digital subtraction angiography and three-dimensional T1W sampling perfection with application-optimized contrasts using different flip angle evolutions (3D T1-SPACE) high-resolution magnetic resonance imaging (MRI) signal features.

Methods: Consecutive internal carotid artery occlusion cases with ipsilateral ischemic stroke refractory to therapy who visited our institution between February 2017 and August 2020 were retrospectively analyzed. Epidemiology, symptomatology, imaging morphology on angiography and MRI, peri-procedural complications, technical success rate, and follow-up results were summarized. Factors related to technical success were analyzed using univariate and multivariate analyses.

Results: In total, 75 cases (53 men, mean age 57.51 ± 9.71 years) were included. The total successful recanalization rate was 72.00% (54/75), with a complication rate of 13.33% (9/75). Through multivariate analysis, first ischemic stroke in <3 months (OR: 2.57; 95% CI: 1.13–4.58), tapered stump (OR: 4.31; 95% CI: 1.37–13.55), reversed flow of the ophthalmic artery (OR: 2.99; 95% CI: 1.06–8.49), high intraluminal signal on unenhanced T1-SPACE sequence (OR: 16.15; 95% CI: 3.40–76.72), no vessel wall collapse (OR: 17.00; 95% CI: 3.57–81.02), short occlusion length (OR: 9.87; 95% CI: 2.09–46.64), and primary occlusion site at the cervical internal carotid artery (OR: 8.42; 95% CI: 1.04–68.19) were associated with successful recanalization.

Conclusion: Besides traditional features such as short ischemic event time, tapered stump, and distal ICA reconstitution by the ophthalmic artery, our study demonstrates that luminal and mural changes determined by 3D SPACE high-resolution MRI could also predict successful endovascular recanalization. Endovascular recanalization for non-acute internal carotid artery occlusion is feasible, but prudent case selection is mandatory considering the high periprocedural complication rate.

The conundrum of asymptomatic carotid stenosis-determinants of decision and evidence

Management of asymptomatic carotid disease continues to challenge medical practice and present evidence is often conflicting. Stroke is a significant burden in Public Health and 11% to 15% appear as first neurologic event associated with asymptomatic carotid stenosis. Randomized trials provided support for Guidelines and Recommendations to intervene on asymptomatic stenosis, but at a known cost of a high number of unnecessary operations. Conflicting evidence from natural history studies and the widespread use of proper medical management including risk factors control, lowering-lipid drugs and strict control of arterial hypertension have reduced the incidence of strokes associated to asymptomatic carotid disease challenging established practice. Need to identify vulnerable lesions prone to develop thromboembolic brain events and also vulnerable patients at a higher risk of stroke is necessary and essential to further improve effectiveness of our interventions. After review of published literature on natural history of asymptomatic carotid stenosis, diagnostic methods to identify plaque vulnerability and present-day results of both endarterectomy and stenting, a strategy for management of asymptomatic carotid stenosis is suggested aiming to reduce unnecessary interventions and effectively contribute to stroke prevention.

Surgery of acute occlusion of the extracranial internal carotid artery - a meta-analysis

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.

Characterization and Natural History of Patients with Internal Carotid Occlusion: A Comparative Study

BACKGROUND

To characterize patients with internal carotid occlusion (ICO) with respect to demographic data, associated diseases, medical management, and risk factors and to compare these patients with those with nonsignificant stenosis (NSS; less than 50% stenosis). Secondary end points were new neurologic events, progression of contralateral degree of stenosis, cardiovascular symptoms, and death during follow-up.

METHODS

Retrospective analysis was performed using data collected from clinical records and added to a prospective database. Missing data were obtained during phone interviews or requested medical appointments.

RESULTS

From 2005 to 2013, 213 patients with ICO and 172 with NSS were studied (medium follow-up 37.81 months). Among the patients with ICO, a greater proportion were men, had a history of smoking, and presented with peripheral arterial disease and a lower creatinine clearance compared with those with NSS (P < 0.05). At the time of diagnosis, 76.1% of the patients with ICO were symptomatic compared with 35.5% of those with NSS (P = 0.000001). The patients in the ICO group exhibited significant progression of contralateral stenosis compared with those in the control group with progression on any side (15.0% vs. 2.3%, P = 0.00011). In addition, 18 patients in the ICO group (8.5%) exhibited new neurological symptoms compared with 13 (7.6%) in the NSS group (P = 0.41). When the ICO and NSS groups were combined, 10.8% of the initially symptomatic patients presented with new symptoms compared with 4.3% of those who were initially asymptomatic (P = 0.0218). The number of deaths was significantly higher among the patients in the ICO group (14.1% vs. 6.4%, P = 0.0150).

CONCLUSIONS

Patients presenting with ICO have more risk factors and higher mortality by any cause. Initially, symptomatic patients will likely present with more neurological symptoms during follow-up, independent of carotid morphology, ICO, or NSS. Efforts must be made to identify those at risk before occlusion and to prevent secondary events and death.