Carotid embolectomy and endarterectomy for symptomatic complete occlusion of the carotid artery as a rescue therapy in acute ischemic stroke

Abstract

Emergency endarterectomy of an occluded internal carotid artery (ICA) has not been investigated as an option of rescue therapy for severe acute ischemic stroke in the era of intravenous (IV) thrombolysis treatment neither as a primary treatment nor after failed IV thrombolysis. Data from the pre-IV thrombolysis era are conflicting and therefore emergency endarterectomy has not been recommended. The number of patients reaching the emergency room within the IV thrombolysis time window has vastly grown due to advanced acute stroke treatment protocols. The efficacy of mechanical thrombectomy as a primary or add-on to IV thrombolysis therapy option is being actively investigated. We herein report 2 cases of acute ischemic stroke with computerized tomography (CT) angiography-documented occlusion of an ICA that were treated with emergency carotid endarterectomy and embolectomy to restore cerebral blood flow. Both cases presented with severe stroke symptoms and signs not responding to IV thrombolysis and showed severe CT-perfusion deficits mainly representing ischemic penumbra. Blood flow was surgically restored after 5 h of symptom onset. Both patients achieved a favorable outcome. We conclude that timely surgical approach of acute ICA occlusion after failed thrombolysis as a rescue therapy may be a viable option in well-selected patients.

Keywords: Acute stroke treatment; Carotid endarterectomy; Embolectomy; Internal carotid artery.

Fig. 1

Eighty minutes after onset of right-sided hemiparesis and aphasia (patient 1). CT angiogram shows normal contrast enhancement of the right carotid artery (arrow) but missing enhancement on the left side indicating total occlusion of the left carotid artery (a). Large intracranial vessels show contrast enhancement indicating collateral flow (arrow) in the left MCA (b). TTD (c), CBF (d), and CBV (e) maps show severe perfusion defect of the left hemisphere.

Fig. 2

At day 7 after acute right-sided hemiparesis and aphasia due to occlusion of the left carotid artery and successful surgical restoration of blood flow after 5 h of ischemia, T2-weighted (a), FLAIR (b), and diffusion-weighted (c) MR images of patient 1 show minor infarction changes, whereas MR angiography (d) shows now normal blood flow in the left carotid vessel (arrow).

Fig. 3

Seventy minutes after onset and of left-sided hemiparesis and neglect after 8 h of fluctuating symptoms (patient 2). CT angiogram (a) shows total occlusion of the right ICA (arrow). Large intracranial vessels show contrast enhancement indicating collateral flow (arrow) in the right MCA (b). TTD (c), CBF (d), and CBV (e) maps show severe perfusion defect of the right hemisphere.

Fig. 4

At day 7 after acute left-sided hemiparesis and neglect due to occlusion of the right carotid artery and successful surgical restoration of blood flow after 5 hours of ischemia in patient 2, MR detects minor ischemic lesions on T2 (a), FLAIR (b), and DWI (c). MR angiography (d) shows now normal blood flow in the right carotid vessel (arrow).