Emergent carotid artery stenting in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion: Comparison of tandem intracranial occlusion and isolated cervical internal carotid artery occlusion

Abstract

Purpose: Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion.

Materials and methods: We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome.

Results: Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups (p = 0.454).

Conclusions: Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.

Keywords: Carotid artery; arterial occlusive diseases; endovascular procedures; stents; stroke.

Figure 1.

Flow diagram showing screening and selection of patients. pts: patients; hrs: hours; ICA: internal carotid artery; pICA: proximal internal carotid artery.

Figure 2.

Case example of 72-year-old man with acute onset of left hemispheric syndrome (NIHSS score 19). (a) Pre-procedural extracranial lateral projection angiography. Note the severe stenosis of the right cervical ICA (arrow). (b) Pre-procedural intracranial anterior to posterior projection of right internal carotid angiography. Note the tandem occlusion of the proximal portion on the right MCA M1 segment (arrow). (c) Subtracted image acquired immediately after stent deployment shows recanalization of right cervical ICA. (d) After intracranial thrombectomy, the vessel is fully recanalized to a TICI 2b state. NIHSS: National Institutes of Health Stroke Scale; ICA: internal carotid artery; MCA: middle cerebral artery; TICI: thrombolysis in cerebral infarction.

Figure 3.

Case example of 69-year-old man with tandem occlusion (NIHSS score 19). (a and b): Initial MR images demonstrate wide spread mismatch between extent of lesion of diffusion-weighted image and perfusion-weighted image with mean transit time in the left MCA territory. (c) Diagnostic angiography shows total occlusion of left cervical ICA (arrow). (d) After passing the cervical ICA occlusion using a 0.014-inch microwire, anterior to posterior projection of left internal carotid angiography shows tandem occlusion of the left MCA M1 segment (arrow). (e) After stent placement and balloon angioplasty, anterior to posterior projection angiography shows complete restoration of left cervical ICA. (f) Post-procedural intracranial anterior to posterior projection angiography. The spontaneous recanalization of the left MCA is observed (arrow). NIHSS: National Institutes of Health Stroke Scale; MCA: middle cerebral artery; ICA: internal carotid artery.