Aetiologies of internal carotid artery pseudo-occlusions in acute stroke patients: what neurointerventionalists can expect

Akpınar, Süha; Gelener, Pınar; Yılmaz, Güliz

doi:10.1259/bjr.20160352

Cited by 11 publications

(10 citation statements)

References 10 publications

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“…Thus, we ultimately included 71 patients with a mean age 70 ± 14 years; 41 (57.7%) were male. The median NIHSS score on admission was 19 (interquartile range [16][17][18][19][20][21]. Of all patients, 56.3% (n = 40) exhibited cICA-POs combined with distal ICA occlusions.…”

Section: Resultsmentioning

confidence: 99%

“…Patients with cICA-POs often have thrombi extending below the level of the posterior communicating artery, thus occluding that artery. Such patients tend to have larger clots (filling the terminal ICA segment) than those without cICA-POs (who usually exhibit contrast-filling of the posterior communicating artery, triggering adequate, antegrade, Willisian circle collateral flow) 7,8,12,17,18 . In other words, circle collateral flow affects cICA-PO status as determined via CTA.…”

Section: Discussionmentioning

confidence: 99%

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Pseudo-Occlusion of the Internal Carotid Artery in Acute Ischemic Stroke: Clinical Outcome after Mechanical Thrombectomy

Jung

Lee

Solander

et al. 2020

Sci Rep

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pseudo-occlusion (po) of the cervical internal carotid artery (cicA) can be caused by distal icA occlusion.We explored the clinical impact of po after mechanical thrombectomy (Mt). patients who underwent MT to treat distal ICA occlusions between July 2012 and March 2018 were reviewed. A cICA-PO was defined as when single phase computed tomography angiography (CTA) revealed a gradual decline in contrast above the level of the carotid bulb. We investigated the relationship between a cicA-po and outcome; we also explored the association between successful recanalization and outcome. Among 71 patients, 40 (56.3%) exhibited cICA-PO and more likely to experience poor outcomes (80.0% vs. 25.8%, P < 0.001), hemorrhagic transformation (32.5% vs. 9.6%, P = 0.01), and a lower rate of successful recanalization (65.0% vs. 90.3%, P = 0.014) than the non-PO group. In binary logistic regression, a cICA-PO was independently associated with a poor outcome (odds ratio, 4.278; 95% CI, 1.080-33.006; P = 0.045). In the cICA-PO group, all patients who failed recanalization (n = 15) experienced poor outcomes, as did 69.2% of patients in whom recanalization was successful (P = 0.018). cICA-POs are common and have worse outcomes than non-po patients. patients with cicA-pos are more likely to exhibit poor outcomes after Mt, particularly when recanalization fails.Recent randomized controlled trials have shown that intra-arterial mechanical thrombectomy (MT) effectively and safely reduces morbidity and mortality in patients who present with acute ischemic strokes caused by large-vessel occlusions 1-5 . In the cited studies, computed tomography angiography (CTA) was most commonly used to detect and localize large artery occlusions.A pseudo-occlusion (PO) of the cervical internal carotid artery (cICA) mimics a true occlusion in CTA but the artery is patent when digital subtraction angiography (DSA) is performed during endovascular treatment 6 . The underlying cause of a cICA-PO is sluggish or absent contrast flow caused by distal occlusion of the intracranial vasculature 7 . Several previous studies have reported that cICA-POs develop in 6-15% of patients with anterior circulation strokes and in almost 50% of those with distal ICA occlusions 7-9 . Recently, several studies have used various CTA protocols featuring delayed-phase imaging, or four-dimensional CTA after CT perfusion, to enhance diagnostic accuracy 6,8,[10][11][12][13] . Here, we explored the relationships between cICA-POs in patients with acute distal ICA occlusions and the clinical outcomes after MT. MethodsStudy population and clinical assessment. We retrospectively reviewed consecutive patients with acute ischemic strokes who underwent reperfusion therapy between July 2012 and March 2018. Our data collection protocol was approved by the Institutional Review Board of Ajou University hospital (approval no. AJIRB-MED-MDB-18-301) and implemented in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. The need for written informed conse...

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Pseudo-Occlusion of the Internal Carotid Artery in Acute Ischemic Stroke: Clinical Outcome after Mechanical Thrombectomy

Jung

Lee

Solander

et al. 2020

Sci Rep

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“…Pseudoocclusion of ICA on single-phase CTA has been studied before, and the authors concluded that single-phase CTA is not reliable to distinguish true occlusions from pseudoocclusions and that there are up to 15% -32.4% cases with pseudo-occlusion. The differentiation between true occlusion and pseudo-occlusion is crucial, because the planning of the endovascular intervention and treatment for acute strokes might change (17,18). We think a multiphase CTA with extended scan range on the A2 and A3 phases might be a potential solution to rule out pseudo-occlusion based on CTA findings, but further well-designed studies for this issue are required.…”

Section: Discussionmentioning

confidence: 99%

Imaging Findings of Multiphase CT Angiography of Acute Internal Carotid Artery Occlusion Within 6-Hour Time-Window After Thrombectomy and Its Clinical Implication

et al. 2020

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Background: Intra-arterial thrombectomy (IAT) is one of the mainstream treatments for acute ischemic stroke. As relatively little evidence on extracranial internal carotid artery (ICA) occlusions exists in the literature, we share our experiences after using IAT for intracranial and extracranial ICA occlusions. We further clarify the imaging characteristics of multiphase computed tomography angiography (CTA) and share the experience of balloon angioplasty in acute ICA occlusion. Objectives: To investigate the imaging findings of multiphase CTA and the clinical conditions and outcomes of acute ICA occlusions at different segments after IAT. Patients and Methods: All participants receiving IAT for acute stroke with isolated ICA occlusions were included, obtained from three hospitals between June 2016 and November 2018. An imaging review for non-enhanced computed tomography (CT), multiphase CTA, and angiography was conducted. Epidemiological and clinical data were reviewed. Further comparisons were evaluated between the occlusion side from the C6 to C7 segments and C1 to C5 segments of the ICA. Results: The average age of the patients was 73.0 years, and the initial National Institutes of Health Stroke scale (NIHSS) score was 18.6. Nineteen percent of cases had good outcomes. Good reperfusion results were achieved in 50% of cases. Compared to the group with occlusion from C6-C7, the group with occlusion from C1-C5 had a relatively good Alberta Stroke Program Early CT score (ASPECTS) in the A1 phase of the multiphase CTA, and more patients had a good collateral. Three cases received a balloon angioplasty for a concurrent proximal cervical ICA tight stenosis, and all cases had good reperfusion results. Conclusion: Distal occlusion of the ICA demonstrates lower ASPECTS and a worse collateral on multiphase CTA. A multiphase CTA with an extended scan range in the A2 and A3 phases is able to exclude pseudo-occlusion of the ICA. Balloon angioplasty is helpful for concurrent proximal cervical ICA tight stenosis.

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“…Carotid artery pseudo-occlusion is defined as segmental occlusion at the origin of the ICA with very thin distal flow. 8 It may be falsely diagnosed as total ICA occlusion by means of DUS, CTA or MRA. 8 Therefore, cases of segmental ICA occlusion may be misdiagnosed as CSS.…”

Section: Discussionmentioning

confidence: 99%

“… 8 It may be falsely diagnosed as total ICA occlusion by means of DUS, CTA or MRA. 8 Therefore, cases of segmental ICA occlusion may be misdiagnosed as CSS. 9 The neurological symptoms in these patients may originate from an atherosclerotic lesion or acute partial thrombosis with a tail that continues to embolise.…”

Section: Discussionmentioning

confidence: 99%

Outcome following open and endovascular intervention for carotid stump syndrome

Dulai

Elsherif

Tawfick

et al. 2018

SAGE Open Medical Case Reports

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Carotid stump syndrome is defined as the persistence of retinal or cerebral ischaemic events with complete occlusion of the ipsilateral internal carotid artery. The aim of this retrospective cases series was to assess the outcomes for patients with carotid stump syndrome managed with surgical intervention. A series of 11 cases of carotid stump syndrome in nine patients presented to our tertiary vascular centre from October 2004 to February 2016. Indications for intervention were amaurosis fugax, transient ischaemic attacks and stroke. In total, 11 procedures were performed on nine patients including carotid angioplasty and stenting or carotid endarterectomy with patching. The mean follow-up period was 56.6 months. One patient suffered a myocardial infarction 30 days, post-operatively, and one patient was lost to follow-up. In the remaining seven patients, there was a complete resolution of symptoms. There were no incidents of death, stroke, cranial nerve injury, wound haematoma or procedural bleeding. Surgical exclusion of carotid stumps combined with dual antiplatelet agents was found to be a safe and effective treatment method for carotid stump syndrome.

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Aetiologies of internal carotid artery pseudo-occlusions in acute stroke patients: what neurointerventionalists can expect

Cited by 11 publications

References 10 publications

Pseudo-Occlusion of the Internal Carotid Artery in Acute Ischemic Stroke: Clinical Outcome after Mechanical Thrombectomy

Pseudo-Occlusion of the Internal Carotid Artery in Acute Ischemic Stroke: Clinical Outcome after Mechanical Thrombectomy

Imaging Findings of Multiphase CT Angiography of Acute Internal Carotid Artery Occlusion Within 6-Hour Time-Window After Thrombectomy and Its Clinical Implication

Outcome following open and endovascular intervention for carotid stump syndrome

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