Early Carotid Artery Stenting and Angioplasty in Patients with Acute Ischemic Stroke

A Survived Case of Acute Bilateral Internal Carotid Artery Occlusion Treated by Mechanical Thrombectomy

OBJECTIVE

We report a survived case of acute bilateral internal carotid artery occlusion successfully treated by mechanical thrombectomy.

CASE PRESENTATION

The patient was an 82-year-old right-handed man. Sudden consciousness disturbance and aphasia appeared, and cranial magnetic resonance angiography (MRA) revealed bilateral internal carotid artery occlusion. Cerebral angiography demonstrated occlusion between the cervical and cavernous portions of the bilateral internal carotid artery, and the growth of collateral circulation to the areas where the bilateral internal carotid artery perfused. We performed mechanical thrombectomy first on the left side, which was the main cause of his symptoms and relatively wide ischemic penumbra, and achieved recanalization of the bilateral internal carotid artery and suppressed extensive enlargement of the infarction.

CONCLUSION

Acute bilateral internal carotid artery occlusion requires an optimal treatment strategy based on the clinical symptoms and preoperative imaging.

Treatment Outcome of Carotid Artery Stenting Underwent within 14 Days of Stroke Onset - Consideration of Safety and Efficacy of Urgent Carotid Artery Stenting for Neurologically Progressing Patients

As the safety and effectiveness of urgent carotid artery stenting (CAS) for neurologically progressing patients remain controversial, we retrospectively analyzed the outcome of urgent CAS based on the patients’ pathophysiological condition and neuroimaging findings. We divided 71 patients who underwent CAS within 14 days of stroke onset into two groups. Group 1 (n = 35) was comprised of patients with progressing neurologic signs and a reversible ischemic penumbra on magnetic resonance images (MRI). They were treated by urgent CAS. Group 2 (n = 36) was neurologically stable and underwent prophylactic CAS. In all patients we recorded the National Institutes of Health Stroke Scale (NIHSS) score and the modified Rankin scale (mRS). Urgent CAS resulted in significant improvement in the NIHSS score, when compared before and after CAS in group 1 (5.3 ± 4.3, P < 0.01). The rate of good outcomes (mRS 0–2 at 3 months post-CAS) was 48.6% in group 1, and 75% in group 2. The cumulative incidence of ipsilateral stroke between 31 days and 1 year was 5.9% in group 1, and 0% in group 2. The procedural complication rate was similar in both groups (group 1: 5.7%, n = 2; group 2: 5.6%, n = 2). No patient suffered a symptomatic intracerebral hemorrhage. When the pathophysiological status and neuroimaging findings are used to determine patient eligibility for urgent CAS, this treatment improve neurologic outcome and can be performed as safely as prophylactic CAS in our cohort of patients with acute ischemic stroke.

Usefulness of Early Stenting for Symptomatic Extracranial Carotid Stenosis

BACKGROUND

While carotid angioplasty and stenting (CAS) have become an established procedure, outcomes of early CAS for symptomatic extracranial carotid stenosis (SECS) remain poorly understood. The present study aimed at determining the effectiveness of early CAS in SECS.

METHODS

Herein, 224 SECS patients underwent elective CAS between January 2008 and June 2015. The study population was stratified based on the time from symptom onset to the procedure (early CAS group: within 14 days; delayed CAS group: later than 14 days). Subgroup analysis (chi-square test, Mantel-Haenszel chi-square test, and analysis of covariance) evaluated the demographics, incidence of periprocedural thromboembolic complications, cerebral hyperperfusion syndrome (CHS), intracranial bleeding, and treatment outcomes on the modified Rankin Scale (mRS).

RESULTS

Symptomatic thromboembolic complications and CHS were noted in 2.68% and 0.89% of patients, respectively. The initial National Institutes of Health Stroke Scale (NIHSS) score was significantly higher in patients who underwent early CAS than in those who underwent delayed CAS (2.50 ± 3.97 vs. 0.97 ± 2.08, P = 0.001). After adjusting for age, duration of preprocedural dual antiplatelet therapy, initial NIHSS score, and preprocedural NIHSS score, the groups did not differ significantly regarding the incidence of symptomatic thromboembolic complications (P = 0.195), incidence of CHS (P = 0.950), incidence of intracranial bleeding (P = 0.970), 30-day mRS score (P = 0.124), and mRS score at final follow-up (P = 0.132).

CONCLUSIONS

For SECS patients who cannot undergo early carotid endarterectomy, early CAS is effective and safe if selectively indicated considering disease severity. Early and delayed CAS provide comparable mRS scores, incidence of symptomatic thromboembolic complications, CHS, and intracranial bleeding.

Importance of perioperative management for emergency carotid artery stenting within 24h after intravenous thrombolysis for acute ischemic stroke: Case report

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We report a patient treated successfully via endovascular surgery within 24 h after intravenous thrombolysis using recombinant tissue plasminogen activator for acute cervical internal carotid artery occlusion.

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Emergency carotid artery stenting for the acute internal carotid artery occlusion may be considered a safe procedure in preventing early stroke recurrence in selected patients.

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When trying to perform emergency carotid artery stenting within 24 h after intravenous recombinant tissue plasminogen activator administration, several issues require attention, such as the decisions regarding the type of stent and embolic protection device, the selection of antiplatelet therapy and the methods of preventing hyper perfusion syndrome.

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We administered aspirin and clopidogrel for the prevention of subacute thrombosis, and we used dexmedetomidine for preventing hyperperfusion syndrome, so that we also obtained a good result.

Introduction

We report a patient treated successfully via endovascular surgery within 24 h after intravenous thrombolysis using recombinant tissue plasminogen activator for acute cervical internal carotid artery occlusion.

Presentation of case

A 68-year-old man was admitted to our hospital. Neurological examination revealed severe left-sided motor weakness. Magnetic resonance imaging showed no cerebral infarction, but magnetic resonance angiography revealed complete occlusion of the right internal carotid artery. Systemic intravenous injection of recombinant tissue plasminogen activator was performed within 4 h after the onset. But, magnetic resonance angiography still revealed complete occlusion. Revascularization of the right cervical internal carotid artery was performed via endovascular surgery. The occluded artery was successfully recanalized using the Penumbra System^® and stent placement at the origin of the internal carotid artery. Immediately after surgery, dual antiplatelet therapy (aspirin and clopidogrel) was initiated, and then cilostazol was added on the following day. Carotid ultrasonography and three-dimensional computed tomographic angiography at 14 days revealed no further obstruction to flow.

Discussion

When trying to perform emergency carotid artery stenting within 24 h after intravenous recombinant tissue plasminogen activator administration, several issues require attention, such as the decisions regarding the type of stent and embolic protection device, the selection of antiplatelet therapy and the methods of preventing hyperperfusion syndrome.

Conclusion

Emergency carotid artery stenting for the acute internal carotid artery occlusion may be considered a safe procedure in preventing early stroke recurrence in selected patients.

Debate: Whether carotid endarterectomy is safer than stenting in the hyperacute period after onset of symptoms

The carotid artery has been a regular battleground for debates regarding many issues, including appropriate management of symptomatic and asymptomatic lesions, the conduct, timing, and safety of such interventions, and now, whether endarterectomy or stenting is safer in the hyperacute period. Our discussants agree that, as a prophylactic procedure, a carotid intervention should occur early after index symptoms to prevent as many strokes as possible. However, which intervention is best?

Emergent Recanalization with Stenting for Acute Stroke due to Athero-Thrombotic Occlusion of the Cervical Internal Carotid Artery : A Single Center Experience

Objective

The purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting (CAS) for acute stroke due to athero-thrombotic occlusion of the cervical internal carotid artery (ICA).

Methods

Review of medical records identified 17 patients who underwent emergent CAS for treatment of athero-thrombotic occlusion of the cervical ICA with acute stroke between 2009 and 2013. Eleven patients (64.7%) presented with concomitant intracranial artery occlusion, which was treated primarily by mechanical thrombectomy after CAS.

Results

Successful revascularization of the cervical ICA with emergent CAS was achieved in all patients. After CAS, intracranial recanalization with Thrombolysis in Cerebral Infarction ≥2b flow was achieved in four of the 11 patients (36.4%). The overall recanalization rate (cervical ICA and intracranial artery) was 10 of 17 patients (58.8%). Symptomatic intracranial hemorrhage occurred in two patients (11.8%), resulting in death. Ten patients (58.8%) showed improvement (decrease in NIHSS score of ≥4 points) at seven days after recanalization. Nine patients (52.9%) showed a favorable outcome (mRS ≤2) at the last follow-up. A favorable outcome (mRS ≤2) was obtained in four of the six patients with isolated cervical ICA occlusion (4/6, 66.7%) and five of 11 patients with intracranial tandem occlusion (5/11, 45.5%).

Conclusion

Emergent CAS for acute stroke due to athero-thrombotic occusion of the cervical ICA showed a good technical feasibility and favorable clinical outcome.

Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke

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.

Safety of early carotid artery stenting after systemic thrombolysis: a single center experience

Background. Patients with acute ischemic stroke due to internal carotid artery (ICA) disease are at high risk of early stroke recurrence. A combination of IV thrombolysis and early carotid artery stenting (CAS) may result in more effective secondary stroke prevention. Objective. We tested safety and durability of early CAS following IV thrombolysis in stroke patients with residual stenosis in the symptomatic ICA. Methods. Of consecutive patients treated with IV rtPA, those with residual ICA stenosis ≥70% or <70% with an ulcerated plaque underwent early CAS (>24 hours). The protocol included pre-rtPA MRI and MR angiography, and post-rtPA carotid ultrasound and CT angiography. Stroke severity was assessed by the NIH Stroke Scale (NIHSS). Three- and twelve-month stent patency was assessed by ultrasound. Twelve-month functional outcome was assessed by the modified Rankin Scale (mRS). Results. Of 145 consecutive IV rtPA-treated patients, 6 (4%) underwent early CAS. Median age was 76 (range 67-78) years, median NIHSS at stroke onset was 12 (range 9-16) and 7 (range 7-8) before CAS. Median onset-to-CAS time was 48 (range 30-94) hours. A single self-expandable stent was implanted to cover the entire lesion in all patients. The procedure was uneventful in all patients. After 12 months, all patients had stent patency, and the functional outcome was favourable (mRS ≤ 2) in all but 1 patient experiencing a recurrent stroke for new-onset atrial fibrillation. Conclusion. This small case series of a single centre suggests that early CAS may be considered a safe alternative to CEA after IV rtPA administration in selected patients at high risk of stroke recurrence.

Carotid artery stenting: rationale, technique, and current concepts

Carotid stenosis is a major risk factor for stroke. With the aging of the general population and the availability of non-invasive vascular imaging studies, the diagnosis of a carotid plaque is commonly made in medical practice. Asymptomatic and symptomatic carotid stenoses need to be considered separately because their natural history is different. Two large randomized controlled trials (RCTs) showed the effectiveness of carotid endarterectomy (CEA) in preventing ipsilateral ischemic events in patients with symptomatic severe stenosis. The benefit of surgery is much less for moderate stenosis and harmful in patients with stenosis less than 50%. Surgery has a marginal benefit in patients with asymptomatic stenosis. Improvements in medical treatment must be taken into consideration when interpreting the results of these previous trials which compared surgery against medical treatment available at the time the trials were conducted. Carotid artery stenting (CAS) might avoid the risks associated with surgery, including cranial nerve palsy, myocardial infarction, or pulmonary embolism. Therefore and additionally to well-established indications of CAS, this endovascular approach might be a valid alternative particularly in patients at high surgical risk. However, trials of endovascular treatment of carotid stenosis have failed to provide enough evidence to justify routine CAS as an alternative to CEA in patients suitable for surgery. More data from ongoing randomized trials of CEA versus CAS will be soon available. These results will help determining the role of CAS in the management of patients with carotid artery stenosis.

Cerebral hyperperfusion syndrome post-carotid artery stenting

Cerebral hyperperfusion syndrome is increasingly recognized as a complication in carotid artery stenting for severe internal carotid artery stenosis. This study reviews the cases of hyperperfusion syndrome occurring after this procedure. We reviewed our database of 170 cases of internal carotid artery stenting carried out at our hospital between January 1999 and June 2006. A radiology search was also carried out to identify those who had CT or MRI within 1 month of post-carotid artery stenting. We had four patients who developed cerebral hyperperfusion syndrome. One patient developed cerebral oedema, one patient had petechial intracerebral haemorrhage and two patients had large intracerebral haemorrhages, one of whom died. This gives a risk of 2.3% (95% confidence interval 2.27-2.323). All patients with cerebral haemorrhage presented within 6 h. Both patients with large intracerebral haemorrhage had carotid stenting within 3 weeks after presentation of symptoms and all had critically severe stenosis of 95% or more. In our series, large intracerebral haemorrhage has occurred only in patients who have been treated early. Cerebral hyperperfusion is an uncommon but serious complication post-carotid stenting. Further studies comparing early treatment of endarterectomy and carotid stenting are awaited.

Hyperperfusion syndrome following endovascular cerebral revascularization

Endovascular cerebral revascularization is becoming a frequently used alternative to surgery for the treatment of atherosclerotic disease, especially in the intracranial circulation where options are limited. Recent literature regarding the equivalent efficacy of carotid artery stenting and carotid endarterectomy in certain patient populations, as well as the recognition of the significant risk for recurrent stroke posed by intracranial lesions, will only serve to amplify this trend. Hyperperfusion syndrome has been well documented in the setting of carotid endarterectomy; however, a paucity of literature exists regarding the incidence, pathophysiology, and management as it relates to percutaneous interventions. The purpose of this review is to outline the current state of knowledge, with particular attention to the distinct attributes of endovascular treatment that would be expected to modify the course of hyperperfusion syndrome.

Cervical arterial dissection: current concepts

The increasing use and safety of noninvasive imaging in recent years has revealed the surprising frequency of dissection of the carotid and vertebral arteries (cervical arterial dissection [CAD]) as a cause of ischemic and hemorrhagic stroke. This review is an overview of current concepts and practice of patients with CAD, but our ideas are constantly evolving with new discoveries from neurovascular imaging and medical and surgical management in this area.

Stellenwert der Revaskularisation eines akuten Karotisverschlusses

BACKGROUND AND PURPOSE

We examined indications for emergent revascularisation of acutely occluded internal carotid artery (ICA) using current diagnostic methods.

MATERIAL AND METHODS

From 1997 to 2006 we prospectively followed 34 consecutive patients undergoing emergency revascularisation due to acute extracranial ICA occlusion and acute ischaemic stroke within 72 h after symptom onset (mean 25) and within 36 h after admission (mean 16). Exclusion criteria were occlusion of the intracranial ICA or ipsilateral middle cerebral artery (MCA), ischaemic infarction of more than one third of the MCA perfusion area, or reduced level of consciousness. All patients underwent duplex sonography, cerebral CT, and/or MRI and angiography (MRA and/or DSA). We performed endarterectomy and thrombectomy of the ICA.

RESULTS

Confirmed by postoperative duplex sonography at discharge, ICA revascularisation was successful in 30 (88%) of 34 cases. Postoperative intracranial haemorrhage was detected in two patients (6%) and perioperative reinfarction in one (3%). Compared to the preoperative status, 20 patients (59%) showed signs of clinical improvement by at least one point on the Rankin scale, ten patients (29%) remained stable, and two patients (6%) had deteriorated. The 30-day mortality was 6% (two patients).

CONCLUSION

After careful diagnostic workup, revascularisation of acute extracranial ICA occlusion is feasible with low morbidity and mortality.

Emergent combined intracranial thrombolysis and carotid stenting in the hyperacute management of stroke patients with severe cervical carotid stenosis

BACKGROUND AND PURPOSE

The timely re-establishment of intracranial perfusion, the effective prevention of early recurrent strokes, and the limitation of the incidence of reperfusion injury are the major factors that are key to successful treatment of patients with hyperacute stroke who had severe ipsilateral cervical internal carotid artery (ICA) stenosis. In an effort to reduce both the extent of the ongoing neurologic injury and the risk of early recurrent stroke, we have adopted an aggressive combined endovascular approach of intracranial thrombolysis and cervical carotid stent placement during the hyperacute phase. We report on the results of 5 such consecutive patients who presented to our center from January 2003 through January 2005.

MATERIALS AND METHODS

From January 2003 through January 2005, 5 consecutive patients presented to our center with hyperacute strokes and severe ipsilateral cervical ICA stenosis. All were treated with emergent carotid stent placement and intra-arterial thrombolysis. The medical records were reviewed and summarized.

RESULTS

One patient died. The remaining 4 patients had an average hospital stay of 4 days (range, 3-5 days) and a mean National Institutes of Health Stroke Scale (NIHSS) score of 2 (range, 0-3) at the time of discharge. With a mean clinical follow-up of 11 months (range, 6-24 months), all had excellent functional outcome with a modified Rankin score of 0 or 1.

CONCLUSIONS

Data on emergent carotid stent placement in the hyperacute management of stroke are limited. The summarized experience in these 5 patients demonstrates the feasibility of this aggressive therapeutic strategy that may bring about a good outcome.

Percutaneous Interventions in Patients with Acute Ischemic Stroke Related to Obstructive Atherosclerotic Disease or Dissection of the Extracranial Carotid Artery

PURPOSE

To determine the safety, feasibility, and efficacy of carotid artery stenting (CAS) in patients with acute stroke who underwent angioplasty of the extracranial internal carotid artery (ICA).

METHODS

Patients were eligible for CAS if they presented within 6 hours of symptom onset and had a National Institutes of Health Stroke Scale (NIHSS) score >4. The records of all 18 acute stroke patients (11 men; mean age 68.3+/-14.3 years) who underwent endovascular intervention in the stroke-related extracranial ICA between May 2003 and February 2006 were reviewed. Fourteen (77.8%) had atheromatous obstructions and 4 (22.2%) had dissection of the extracranial ICA. Major adverse cerebral and cardiac events (MACCEs) and neurological status, including NIHSS and the modified Rankin Scale (mRS) scores, were recorded for all patients.

RESULTS

Successful revascularization was achieved in 83.3% (15/18) of the patients. Cerebral protection devices were applied successfully in 13 (72.2%). At discharge, a neurological improvement (NIHSS reduction > or =4) was observed in 77.8% (14/18) of patients. The clinical success rate was 72.2% (13/18). The median NIHSS was 8.5 on admission versus 4.5 at discharge (p<0.01). The 30-day death and stroke rate was 11.1%. During the 14.6+/-9.3-month follow-up, the MACCE and the death/stroke rates were 33.3% and 27.8%, respectively. The median mRS scores at 30 days and at midterm follow-up were 1 and 2.5, respectively (p = NS).

CONCLUSION

Endovascular revascularization of the extracranial ICA in patients with acute ischemic stroke is associated with high procedural success rates and favorable midterm outcome.

Recovery from ischemic stroke: a translational research perspective for neurology

Ischemic stroke is the most frequent neurological disease, characterized by an age-related incidence and chronic disability in the majority of patients. A great challenge in acute stroke is to predict the degree to which a patient will eventually recover. Magnetic resonance imaging has revealed that treatment-induced reperfusion limits the extent of ischemic brain damage, thereby enabling rapid and profound recovery. Nevertheless, patients may retain deficits in motor, sensory or cognitive functions due to the residual lesion. Functional neuroimaging and transcranial magnetic stimulation have shown that recovery is associated with abnormal activation in the perilesional vicinity and in brain areas remote from the lesion. This is likely related to altered functional properties or morphological changes in both cerebral hemispheres. Recent neurorehabilitative strategies, including forced use, mental imagery and peripheral nerve or cortex stimulation, aim at modulating these functional networks. Accordingly, translational research has provided new vistas on the neurobiological mechanisms of recovery and opened future avenues for science-based pharmacological and neurophysiological training strategies in stroke.

Review of developments in anesthesia for carotid endarterectomy

PURPOSE OF REVIEW

Analysis of recent data indicates a clear benefit of carotid endarterectomy for symptomatic patients with high-grade carotid artery stenosis, and a marginal benefit for asymptomatic patients. Despite myriad challenges presented by patients undergoing carotid endarterectomy, excellent outcomes have been achieved and many centers have shown the technique to be safe as an outpatient procedure for specific populations. Greater attention to comorbidities and their management in the perioperative period is increasingly important as older and more complex patients present for invasive treatment of carotid disease. Scientific study aimed at defining which characteristics merit our attention will only lead to improved outcomes and greater understanding of carotid disease, endarterectomy and anesthesia. While controversial, the efficacy, safety, and durability of stenting and angioplasty have improved in recent years. Potential advantages of stenting and angioplasty of the carotid artery include avoiding cranial nerve damage, wound hematoma, and general anesthesia. Staying abreast of the science regarding such endovascular therapies will be increasingly important.

RECENT FINDINGS

The major areas of investigative interest include patient selection, anesthetic technique, and monitoring for carotid endarterectomy, and durability of stenting and angioplasty of the carotid artery.

SUMMARY

Patients with significant comorbidities may be managed safely by a variety of anesthetic techniques. Maintaining hemodynamic stability and monitoring cerebral oxygen delivery remain important goals of perioperative management. Recent data regarding the durability and safety of stenting and angioplasty of the carotid artery suggest that outcomes may approach those of carotid endarterectomy.