No evidence that severity of stroke in internal carotid occlusion is related to collateral arteries

Comparison of the treatment strategies for symptomatic chronic internal carotid artery occlusion

OBJECTIVE

The best management of symptomatic chronic internal carotid artery occlusion (CICAO) has been controversial. This systematic review and meta-analysis were to compare the outcomes of different treatment strategies for symptomatic CICAO.

METHODS

Two independent researchers conducted a search of articles on the treatment of CICAO published between January 2000 and October 2023 in PubMed, Web of Science, Embase, and The Cochrane Library. Twenty-two articles were eligible for meta-analysis using a random effects model to combine and analyze the data for the pooled rates of stroke and death, and the rates of procedural success and significant restenosis/occlusion.

RESULTS

A total of 1193 patients from 22 publications were included in this study. Six of them had bilateral internal carotid artery occlusion. The 30-day stroke and death rates were 1.1% (95% confidence interval [CI], 0%-4.4%) in the best medical treatment (BMT) group, 4.1% (95% CI, 0.7%-9.3%; I2 = 71.4%) in the extracranial-intracranial (EC-IC) bypass group, 4.4% (95% CI, 2.4%-6.8%; I2 = 0%) in the carotid artery stenting (CAS) group, and 1.2% (95% CI, 0%-3.4%; I2 = 0%) in the combined carotid endarterectomy (CEA) and stenting (CEA + CAS) group. During follow-up of 16.5 (±16.3) months, the stroke and death rates were 19.5%, 1.2%, 6.6%, and 2.4% in the BMT, EC-IC, CAS, and CEA + CAS groups respectively. The surgical success rate was 99.7% (95% CI, 98.5%-100%; I2 = 0%) in the EC-IC group, 70.1% (95% CI, 62.3%-77.5%; I2 = 64%) in the CAS group, and 86.4% (95% CI, 78.8%-92.7%; I2 = 60%) in the CEA + CAS group. The rate of post-procedural significant restenosis or occlusion was 3.6% in the EC-IC group, 18.7% in the CAS group, and 5.7% in the CEA + CSA group. The surgical success rate was negatively associated by the length of internal carotid artery (ICA) occlusion. Surgical success rate was significantly higher in the patients with occlusive lesion within C1 to C4 segments, compared with those with occlusion distal to C4 segment (odds ratio, 11.3; 95% CI, 5.0-25.53; P < .001). A proximal stump of ICA is a favorable sign for CAS. The success rate of CAS was significantly higher in the patients with an ICA stump than that in the patients without (odds ratio, 11.36; 95% CI, 4.84-26.64; P < .01). However, the success rate of CEA + CAS was not affected by the proximal ICA stump.

CONCLUSIONS

For the management of symptomatic CICAO, BMT alone is associated with the highest risk of mid- and long-term stroke and death. EC-IC bypass surgery and CEA + CAS should be considered as the choice of treatment based on operator's expertise and patient's anatomy. CAS may be employed as an alternative option in high surgical risk patients, especially when proximal ICA stump exists.

Life-threatening bilateral internal carotid artery and unilateral vertebral artery total occlusion presenting with dizziness: a case report

Introduction

It is well known that whereas bilateral occlusion is less common, unilateral internal carotid artery blockage happens regularly. Asymptomatic to fatal ischemic stroke can be the clinical presentation, depending on whether there is adequate collateral blood flow. Internal carotid artery occlusion is often associated with significant neurologic events, both at the time of initial occlusion and during follow-up.

Case presentation

The authors describe a patient's experience of dizziness followed by a fall. The hyperdense position of the basilar artery near its bifurcation was identified following a computed tomography (CT) scan. Furthermore, the pons, midbrain, and medial parts of the right temporal lobe showed numerous small hypodensities suggestive of an ischemic injury. The patient had medical treatment without surgery after it was determined that they had bilateral internal carotid arteries and a blocked right vertebral artery. After taking dual anti-platelet therapy for 5 days, the patient recovered without incident and was discharged from the hospital.

Discussion

In a young patient with bilateral internal carotid arteries occlusion (BICAO), the authors highlighted the significance of prompt diagnosis of stroke-like symptoms, diagnostic possibilities, and treatment options. Options for diagnosis include brain MRI and CT head to check for ischemia and CT angiography (CTA) head and neck to assess for artery obstruction. Options for treatment include severe medical and surgical treatments, such as carotid endarterectomy, stent implantation, or balloon angioplasty, or medical management alone, such as dual anti-platelet medication and thrombolysis.

Conclusion

BICAO is associated with a grave prognosis and significant cerebrovascular complications. High-quality studies are needed to establish the best treatment strategy, considering the complex and individualized nature of the condition.

Impact of implementing good care and management practice guidelines in carotid revascularization procedures

BACKGROUND

Studies assessing the effect of implementing good practice management guidelines (GPMG) in carotid revascularization within the same hospital are scarce. Thus, we aimed to evaluate the impact of GPMG implementation on the clinical outcomes of carotid revascularization procedures within a quaternary hospital.

METHOD

We retrospectively studied 177 patients with atherosclerotic carotid disease who underwent revascularization (carotid endarterectomy and carotid artery stenting) at a quaternary hospital between January 2012 and December 2019. The patients were divided into two groups: the pre-guideline group with 73 patients and the post-guideline group with 104 patients who underwent the procedures before and after the implementation of GPMG, respectively.

RESULTS

Twelve (16.4%) and 3 (2.9%) patients had neurological complications in the pre- and post-guideline groups, respectively (p = 0.001); most complications were cases of ischemic stroke. There were fewer complications in men than in women (OR = 0.22; 95% CI 0.06-0.77). A significant decrease in neurological complications was observed in the carotid artery stenting group (pre-guideline 25.7% vs post-guideline 13.2%; p = 0.004). Logistic regression analysis of the predisposing factors for neurological complications in carotid endarterectomy and carotid artery stenting demonstrated that the implementation of GPMG was a determining factor for the improved results (odds ratio = 0.11, 95% CI 0.02-0.59).

CONCLUSIONS

Implementing GPMG for carotid revascularization resulted in better clinical results, with decreased neurological complications in patients that underwent angioplasty and endarterectomy.

Bilateral cerebral infarction in diabetic ketoacidosis and bilateral internal carotid artery occlusion: A case report and review of literature

BACKGROUND

Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus (T1DM). Very rarely does DKA lead to cerebral edema, and it is even rarer for it to result in cerebral infarction. Bilateral internal carotid artery occlusion (BICAO) is also rare and can cause fatal stroke. Moreover, case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce. In this study, we present a patient with BICAO, T1DM, hypertension, and hyperlipidemia, who had a catastrophic bilateral cerebral infarction after a DKA episode. We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction.

CASE SUMMARY

A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata, bilateral frontal lobe, and parietal lobe with right hemiplegia and Broca's aphasia. She had a history of hypertension for 5 years, hyperlipidemia for 4 years, hyperthyroidism for 3 years, and T1DM for 31 years. The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion. She was admitted to our ward for rehabilitation due to prior stroke sequalae. DKA took place on hospital day 2. On hospital day 6, she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory. After weeks of aggressive treatment, she remained in a coma and on mechanical ventilation due to respiratory failure. After discussion with her family, compassionate extubation was performed on hospital day 29 and she died.

CONCLUSION

DKA can lead to cerebral infarction due to several mechanisms. In people with existing BICAO and several stroke risk factors such as hypertension, T1DM, hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.

Facing the crossroads: acute stroke with bilateral carotid occlusion

We present a previously unreported case of endovascular therapy in the acute setting of ischaemic stroke in a patient with bilateral carotid occlusion (BCO). A 54-year-old man presents with sudden onset of right-sided weakness, difficulty speaking and left-sided gaze, with National Institute of Health Stroke Scale of 22 and no abnormalities on plain CT head. CT angiography showed BCO and CT perfusion demonstrated extensive area of penumbra in both hemispheres. The patient was sent for cerebral angiography that confirmed BCO. Since symptomatology was a left middle cerebral arteries syndrome, decision was made to angioplasty and stent the left internal carotid artery emergently, which was performed successfully and the patient had complete resolution of symptoms. Acute stroke with BCO represents a challenge in decision making regarding acute management and individual assessment must be made.

Symptomatic Bilateral Carotid Artery Occlusion: An Uncommon Pattern of Carotid Pathology

We report an unusual case of an 83-year-old man who was admitted with dizziness and repeated drop attacks. He was diagnosed with bilateral carotid artery occlusion and he underwent a left subclavian to left carotid bypass with ringed polytetrafluoroethylene graft. The patient’s postoperative course was uneventful and no symptoms presented during a 6-month follow-up. Finally, we discuss on proper management of such patients.

4D Flow MR Imaging of Ophthalmic Artery Flow in Patients with Internal Carotid Artery Stenosis

Background and Purpose:

To assess the clinical feasibility of time-resolved 3D phase contrast (4D Flow) MRI assessment of the ophthalmic artery (OphA) flow in patients with internal carotid artery stenosis (ICS).

Materials and Methods:

Twenty-one consecutive patients with unilateral ICS were recruited. 4D Flow MRI and acetazolamide-stress brain perfusion single photon emission computed tomography (SPECT) were performed. The flow direction on the affected-side OphA was categorized into native flow (anterograde or unclear) and non-native flow (retrograde flow) based on 4D Flow MRI. In the affected-side middle cerebral artery (MCA) territory, the ratio of rest cerebral blood flow to normal control (RCBF_MCA) and cerebral vascular reserve (CVR_MCA) were calculated from SPECT dataset. High-risk patients were defined based on the previous large cohort study (RCBF_MCA < 80% and CVR_MCA < 10%).

Results:

Eleven patients had native OphA flow (4 anterograde, 7 unclear) and the remaining 10 had non-native OphA flow. RCBF_MCA and CVR_MCA each were significantly lower in non-native flow group (84.9 ± 18.9% vs. 69.8 ± 7.3%, P < 0.05; 36.4 ± 20.6% vs. 17.0 ± 15.0%, P < 0.05). Four patients in the non-native flow group and none in the native flow group were confirmed as high-risk (Sensitivity/Specificity, 1.00/0.65).

Conclusion:

The 6 min standard 4D Flow MRI assessment of OphA in patients with ICS can predict intracranial hemodynamic impairment.

Bilateral atherosclerotic internal carotid artery occlusion and recurrent ischaemic stroke

Bilateral internal carotid artery occlusion (BICAO) is a rare disease that carries a gloomy prognosis. We report a case of a 52-year-old man who developed ischaemic infarction at the region of the right middle cerebral artery; he was found to have atherosclerotic occlusion of both internal carotid arteries on Doppler-duplex examination. He received medical treatment only. After 1 year, he developed a new infarction at the region of the left middle cerebral artery. Conventional angiography revealed bilateral occlusion of internal carotid arteries at their origin, approximately 50% stenosis of the common carotid bulbs and mild stenosis of the origin of external carotid arteries. The patient did not undergo any form of surgical revascularisation procedures and died of severe aspiration pneumonia approximately 2 months after the second stroke. BICAO portends a poor outcome and carries a risk of recurrent ischaemic events. The best management strategy for this vascular occlusion remains unclear.

Perioperative results eversion carotid endarterectomy in bilateral symptomatic stenosis

Introduction:

Carotid endarterectomy (CEA) is a standard treatment for the prevention of stroke and death in patients with significant stenosis of the internal carotid artery. Eversion endarterectomy is warranted in patients with symptoms of cerebral ischemia and the degree of stenosis of 70-99%. The same is suitable for treating a symptomatic carotid artery stenosis with contralateral stenosis (50-70%).

Purpose:

The aim of this study was to evaluate perioperative complications (ICV, TIA, MI, mortality) in patients treated with carotid eversion endarterectomy with unilateral and bilateral symptomatic stenosis (with bilateral stenosis treated with ACI stenosis ≥70%).

Patients and Methods:

The study included 139 patients with symptomatic carotid artery stenosis at the Department of Vascular Surgery of the University Clinical Center of Sarajevo in the period from January 2012 to December 2014 year. Given the involvement of ACI stenosis patients were divided into two groups. Group A consisted of 74 patients with bilateral stenosis (surgically treated with ACI stenosis ≥70%, while the degree of stenosis opposite ACI was from 50-70%), and group B of 65 patients with unilateral stenosis ≥70%.

Results:

Of the 139 patients included in the study, in the group A was 74, of which 46 male (62.2%) and 28 female (37.8%), while in group B were 42 male (64.6%) and 23 female (35.4%) (p = 0.90). The subjects in group A were slightly older 65.9 (± 7.8) compared to group B 64.2 (± 7.7) (p = 0.17). Analysis of risk factors indicating a higher number in Group A compared to group B, but the difference was not statistically significant: 34 smokers (45.9%) versus 36 (55.4%); p = 0:34), patients with hypertension (63 (85.1%) against the 52 (80.0%); p = 0.56), with statin therapy (62 (83.8%) versus 52 (80.0%); p = 0.72), diabetes (18 (24.3%) versus 18 (27.7%); p = 0.79) and with a heart disease (18 (24.3%) versus 7 (10.8%); p = 0.06). Analysis of the frequency of perioperative complications between the groups was not statistically significant: ICV (2/74 versus 3/65; p = 1.00), TIA (2/74 versus 3/65; p = 0.88), one death was recorded in group A, while myocardial infarction (MI) we had in either group.

Conclusion:

In this study, no statistically about significant differences in the number of perioperative complications (from 0 to 30 days) between the two groups. With this risk is acceptable to perform carotid endarterectomy in a patient in the opposite ACI stenosis of 50-70%.

Link between cerebral blood flow and autonomic function in survivors of internal carotid artery occlusion

PURPOSE

Symptomatic internal carotid artery occlusion (ICAO) is an important cause of cerebral ischemia with poor long-term outcome. Reductions in baroreflex function is reported in carotid atherosclerosis and implicated in increased risk of recurrent cardiovascular events. A distributed network of forebrain regions can exert modulatory influences over the cardio-vagal and baroreflex functions. The successful clinical translation of these approaches offers insights into underlying modulatory mechanisms and to possible therapeutic strategy.

METHODS

This study enrolled 20 symptomatic ICAO survivors, 20 patients with small vessel disease (SVD) as risk control, and 20 healthy controls. All underwent a standardized evaluation of cardiovascular autonomic function testing that included baroreflex sensitivity (BRS), Valsalva ratio (VR), and heart rate response to deep breathing (HR_DB). The regional cerebral blood flow (rCBF) of the central autonomic network (CAN) was obtained from arterial spin-labeling magnetic resonance imaging. Parameters of autonomic function between symptomatic ICAO survivors with and those without recurrent cardiovascular events were compared.

RESULTS

Valsalva ratio and HR_DB levels were significantly higher in the control group, followed by the SVD and ICAO groups (p=0.009 and p=0.007, respectively). Spontaneous BRS and BRS during the early phase II of Valsalva maneuver levels were both significantly higher in the control group, followed by the SVD and ICAO groups (p<0.001 and p=0.042, respectively). The rCBF of CAN inversely correlated with spontaneous BRS.

CONCLUSION

Autonomic dysregulation, including reduced BRS and impaired cardio-vagal function in the convalescent stage ICAO, can persist for a long time. Reduced BRS is inversely correlated with CAN activity.

Reversal of ophthalmic artery flow as a predictor of intracranial hemodynamic compromise: implication for prognosis of severe carotid stenosis

BACKGROUND AND PURPOSE

High-grade cervical carotid stenosis (70-99%) or occlusion often accompanies reversed ophthalmic artery flow (ROAF), but its potential clinical significances remain poor understood. This study assessed ROAF and the related variables caused by carotid hemodynamic compromise in patients with unilateral severe cervical carotid stenosis.

METHODS

The study consisted of 200 patients diagnosed as unilateral high-grade cervical carotid stenosis/occlusion using ultrasonography. The hemodynamic parameters of 152 patients, excluding 48 with cervical carotid occlusion, were compared based on the presence of ROAF. Out of 200 patients, 159 underwent brain magnetic resonance imaging and were analysed for risk factors impacting functional outcomes including ROAF.

RESULTS

The patients (n = 48) with internal carotid artery occlusion had significantly higher incidence (62.5%) of ROAF compared with that of 25.0% in those patients (n = 152) with unilateral high-grade carotid stenosis (P < 0.001). In ROAF patients (n = 38) with the unilateral high-grade stenosis, a significant retrobulbar arteries hemodynamic difference was observed between the stenotic and non-stenotic vessels. The patients (n = 159) with history of stroke (P = 0.035), ROAF (P = 0.023) and intracranial stenosis (P < 0.001) exhibited significantly higher incidence of poor functional outcome compared with the corresponding control groups. In the same patients (n = 159), those with both cervical and intracranial stenosis showed sevenfold higher risk (OR, 7.60; 95% CI, 3.44-16.81) for ROAF than those with only cervical stenosis.

CONCLUSIONS

ROAF may result from intracranial hemodynamic compromise. Patients with unilateral high-grade cervical carotid stenosis/occlusion in combination with intracranial stenosis appear to be a significant risk factor for poor functional outcome and increased incidence of ROAF.

Bilateral intracavernous carotid artery occlusion caused by invasive lymphocytic hypophysitis

Lymphocytic hypophysitis is a rarely recognized disease that is characterized by inflammatory infiltration and destruction of the pituitary gland. The etiology of lymphocytic hypophysitis is still unclear, but an autoimmune pathogenesis has been advocated. In fact, histopathologic specimens reveal a diffuse infiltration of the hypophysis by CD3(+)CD4(+) T cells and CD20(+) plasma cells, and antipituitary antibodies are usually found in sera of affected patients. Although previous cases were found to be correlated only to pregnancy and the postpartum period, recent reports in men and women (without association with pregnancy) suggest a possibly higher prevalence of disease. We present the case of a 55-year-old woman affected by an unusually aggressive form of lymphocytic hypophysitis that infiltrated both cavernous sinuses causing bilateral internal carotid artery occlusion and acute ischemic stroke. Diagnosis was achieved with both a biopsy specimen of the pituitary gland and the detection of antipituitary antibodies. The prompt administration of steroid therapy was effective to obtain regression and stabilization of the disease, but both carotid arteries remained permanently occluded. The natural history of lymphocytic hypophysitis is unpredictable. It usually has a benign evolution, but in exceptional cases the inflammatory process may extend beyond the pituitary gland and infiltrate the surrounding structures. These extremely serious consequences highlight the importance of early diagnosis and treatment of this otherwise curable disease.

Anterior choroidal artery ischaemic patterns predict outcome of carotid occlusion

OBJECTIVE

To investigate whether anterior choroidal artery (AChA) territory sparing or AChA infarction restricted to the medial temporal lobe (MT), implying good collateral status, predicts good outcome, defined as modified Rankin Scale 0-2, at discharge in acute internal carotid artery (ICA) occlusion.

METHODS

The authors studied consecutive patients with acute ICA occlusion admitted to an academic medical centre between January 2002 and August 2010, who underwent MRI followed by conventional angiography. The pattern of AChA involvement on initial diffusion-weighted imaging was dichotomised as spared or MT only versus other partial or full. The association of AChA infarct patterns and good outcome at discharge was calculated by multivariate logistic regression with adjustment.

RESULTS

For the 60 patients meeting entry criteria, mean age was 68.3 years and median admission NIH Stroke Scale score was 19. AChA territory was spared or restricted to the MT in 27 patients and other partially involved or fully involved in 33 patients. AChA territory spared or ischaemia restricted to MT only, compared with other partial infarct patterns or full infarct, was independently associated with good discharge outcome (44.4% vs 12.1%, OR 7.24, 95% CI 1.32 to 39.89, p=0.023).

CONCLUSION

In acute ICA occlusion, the absence of AChA infarction or restriction to the MT is an independent predictor of good discharge outcome. Analysis of AChA infarct patterns may improve early prognostication and decision-making.

Haemodynamic stroke: clinical features, prognosis, and management

Haemodynamic stroke is a type of ischaemic stroke that is caused by hypoperfusion rather than by embolism or local vasculopathy. It can be caused by systemic diseases such as heart failure or hypotension, but also by severe obstruction of the carotid or vertebral arteries. Patients with haemodynamic stroke or transient ischaemic attack might show specific clinical features that distinguish them from patients with embolism or local small-vessel disease. Ancillary investigations of cerebral perfusion can show whether blood flow to the brain is compromised and provide important prognostic information. Management of patients who have hypoperfusion as the major cause of ischaemic stroke or as a contributing factor is hampered by the lack of clinical trials. Treatment aimed at increasing cerebral blood flow might be considered in selected patients on the basis of information from case series. Further research is needed to define criteria for the diagnosis of haemodynamic stroke and to investigate treatment options in controlled studies.

Bilateral carotid artery occlusion with transient or moderately disabling ischaemic stroke: clinical features and long-term outcome

Information on the prognosis of patients with transient ischaemic attack or moderately disabling ischaemic stroke associated with bilateral internal carotid artery (ICA) occlusion is scarce. We prospectively studied 57 consecutive patients (46 men; mean age 60 +/- 9 years) with bilateral ICA occlusion who had presented with unilateral transient or moderately disabling cerebral or retinal ischaemic symptoms. We determined the long-term risk of recurrent ischaemic stroke and the composite outcome of stroke, myocardial infarction or vascular death. Four patients had a recurrent ischaemic stroke during a mean follow-up of 5.9 years, resulting in an annual stroke rate of 1.2% (95% confidence interval (CI) 0.3-3.1). Risk factors for recurrent ischaemic stroke could not be identified. Eighteen patients suffered a stroke, myocardial infarction or vascular death, resulting in an annual rate for major vascular events of 5.3% (95% CI 3.1-8.3). Age and a history of ischaemic heart disease were significant risk factors for future vascular events. Patients with transient or moderately disabling symptoms of cerebral or retinal ischaemia associated with bilateral ICA occlusion have a relatively low risk of recurrent ischaemic stroke. Although this study was not designed to compare conservative treatment with surgical intervention, the favourable outcome suggests that a policy of medical therapy and control of risk factors may be justified in these patients.

Assessment of the Contribution of the External Carotid Artery to Brain Perfusion in Patients With Internal Carotid Artery Occlusion

Background and Purpose— The purpose of this study was to prospectively investigate the contribution of the ipsilateral external carotid artery (ECA) to cerebral perfusion in patients with internal carotid artery occlusion.

Methods— Institutional Review Board approval and informed consent were obtained. Thirty functionally independent patients (24 men, 6 women; mean age, 63 years) with an angiographically proven unilateral internal carotid artery occlusion and transient or minor disabling ischemic attacks ipsilateral to the side of the internal carotid artery occlusion were included. Grading of ECA collateral flow was performed with intraarterial digital subtraction angiography. The contribution of the ECA to regional cerebral blood flow was assessed with selective arterial spin labeling MRI. Differences in regional cerebral blood flow were analyzed with Student t test.

Results— Twenty percent of the patients had ECA Grade 0 collateral flow (no filling of ophthalmic artery), 20% Grade 1 (filling of carotid siphon), and 60% Grade 2 (filling of anterior and/or middle cerebral artery) as demonstrated on digital subtraction angiography. Although in the Grade 1 group, the ECA supplied a smaller region of the brain compared with the Grade 2 group, the mean regional cerebral blood flow of the perfusion territory supplied by the ECA is similar ( P =0.70) in the Grade 1 group (mean±SD 57±16 mL/min/100 g) and the Grade 2 group (60±12 mL/min/100g).

Conclusion— In patients with symptomatic internal carotid artery occlusion, focal brain regions may strongly depend on the contribution to cerebral perfusion of the ECA ipsilateral to the side of the internal carotid artery occlusion, even in patients with limited ECA collateral supply as demonstrated on digital subtraction angiography.