Analysis of reserve capacity and subsequent stenting in a case of subacute occlusion of the internal carotid artery

Abstract

Introduction: While acute internal carotid artery (ICA) occlusions are increasingly being treated with carotid angioplasty and stenting (CAS), the utility of CAS in subacute stages is unclear.

Case Report: A 65-year-old patient with an acute left ICA occlusion and pre-existing occlusion on the right side presented with dysarthria and central right-sided facial palsy. Carbon dioxide (CO₂) reactivity within the left hemisphere was markedly reduced. Due to acute deterioration despite maximal conservative therapy CAS was performed 8 days after the initial event with an excellent result and symptoms subsided.

Conclusion: CAS in subacute ICA occlusion is possible. Patients should be selected carefully. Assessment of cerebrovascular CO₂ reactivity might provide valuable information.

Fig. 1

Catheter angiography (DSA) demonstrates complete occlusion of the left internal carotid artery

Fig. 2

Representative supratentorial slices prior to (left) and after (right) carotid artery stenting show a significant difference in hypercapnia-induced BOLD signal intensity changes between the hemispheres: an initial restriction (left) and the subsequent improvement (right) of cerebrovascular reactivity can be clearly seen in the left MCA territory

Fig. 3

Catheter angiography images showing successful left internal carotid artery (LCI) revascularisation with anterograde filling of MCA branches after stenting and stent position (un-subtracted image)

Fig. 4

The post-interventional DSA image in frontal view shows the filling of the ipsilateral MCA (image quality is considerably diminished as the patient was only minimally sedated for the procedure and became progressively agitated)