The outcome and efficacy of recanalization in patients with acute internal carotid artery occlusion

Abstract

Background and purpose: Acute occlusion of the ICA is often associated with poor outcomes and severe neurologic deficits. This study was conducted to evaluate outcome of the occluded ICA and efficacy of recanalization under protective flow arrest.

Materials and methods: Fifty consecutive patients who underwent endovascular treatment for acute ICA occlusion were identified from the prospectively collected data base. We assessed NIHSSo, occlusion type (cardioembolism vs atherosclerosis), occlusion level (supraclinoid-terminal, petrocavernous, or bulb-cervical), recanalization degree (TICI), and efficacy of recanalization (protective flow arrest vs nonprotection) leading to better outcome.

Results: Successful recanalization (TICI ≥ 2) was obtained in 90% of patients and good recovery (mRS ≤ 2) in 60% of patients. Good outcome was related to National Institutes of Health Stroke Scale score on admission (P < .001), TICI (P < .007), occlusion type (P = .022), and occlusion level (P = .038). Poor initial patient status, less recanalization, cardioembolism, and supraclinoid-terminal occlusion were associated with poor prognosis. Application of protective flow arrest led to better outcome in the distal ICA segment than in the bulb-cervical segment.

Conclusions: In addition to the initial patient status and successful recanalization, the occlusion level or type of the occluded ICA could affect clinical outcome. In this study, treatment benefits of protective flow arrest were accentuated in patients with ICA occlusion above the bulb-cervical segment.

Fig 1.

A, Division of the ICA segments into 3 parts based on embryologic classification (1 = caroticotympanic artery, 2 = mandibular artery, 3 = meningohypophyseal trunk, 4 = inferolateral trunk, 5 = ophthalmic artery, 6 = posterior communicating artery). When there is occlusion in the ICA (B), each branch between the segments may develop as a collateral, leading to thromboembolism by reopening the occluded vessel (C). Arrows in B and C are the direction of the flow. The inferolateral trunk plays a role in reopening the occluded the ICA segment and generating distal emboli.

Fig 2.

Schematic diagrams showing the protective flow arrest methods in each occluded level. A, A distal balloon was deployed beyond the bulb-cervical occlusion through a 4F catheter. Proximal balloons may be used together. Proximal flow arrest may be achieved by a proximal balloon catheter for petrocavernous (B) and supraclinoid-terminal (C) occlusions. Arrows in B and C are the flow direction when a negative pressure is applied by aspiration. There are 2 sources (the A1 and the posterior communicating artery) of the expected collateral channel in the supraclinoid-terminal segment. A fragmented or additional clot in the intracranial artery is subsequently retrieved by a stent retriever under proximal balloon protection (D).

Fig 3.

Different proportions of initial patient status according to the occlusion level based on the occlusion type (large-artery disease vs cardioembolism). There was a reversed trend of patient number for each occlusion type according to the lesion level. The initial status of patients with cardioembolism in the supraclinoid-terminal segment of the ICA was proportionally poorer than that of patients with large-artery disease.