Cognitive and cerebral hemodynamic effects of endovascular recanalization of chronically occluded cervical internal carotid artery: single-center study and review of the literature

Abstract

OBJECTIVERevascularization of a symptomatic, medically refractory, cervical chronically occluded internal carotid artery (COICA) using endovascular techniques (ETs) has surfaced as a viable alternative to extracranial-intracranial bypass. The authors aimed to assess the safety, success, and neurocognitive outcomes of recanalization of COICA using ETs or hybrid treatment (ET plus carotid endarterectomy) and to identify candidate radiological markers that could predict success.METHODSThe authors performed a retrospective analysis of their prospectively collected institutional database and used their previously published COICA classification to assess the potential benefits of ETs or hybrid surgery to revascularize symptomatic patients with COICA. Subjects who had undergone CT perfusion (CTP) imaging and Montreal Cognitive Assessment (MoCA) testing, both pre- and postprocedure, were included. The authors then performed a review of the literature on patients with COICA to further evaluate the success and safety of these treatment alternatives.RESULTSThe single-center study revealed 28 subjects who had undergone revascularization of symptomatic COICA. Five subjects had CTP imaging and MoCA testing pre- and postrevascularization and thus were included in the study. All 5 patients had very large penumbra involving the entire hemisphere supplied by the ipsilateral COICA, which resolved postoperatively. Significant improvement in neurocognitive outcome was demonstrated by MoCA testing after treatment (preprocedure: 19.8 ± 2.4, postprocedure: 27 ± 1.6; p = 0.0038). Moreover, successful revascularization of COICA led to full restoration of cerebral hemodynamics in all cases. Review of the literature identified a total of 333 patients with COICA. Of these, 232 (70%) showed successful recanalization after ETs or hybrid surgery, with low major and minor complication rates (3.9% and 2.7%, respectively).CONCLUSIONSETs and hybrid surgery are safe and effective alternatives to revascularize patients with symptomatic COICA. CTP imaging could be used as a radiological marker to assess cerebral hemodynamics and predict the success of revascularization. Improvement in CTP parameters is associated with significant improvement in neurocognitive functions.

Endovascular recanalization of chronically occluded internal carotid artery

“…Eleven studies were retrospective series,6 7 9–17 one study had a prospective design,18 and one was done from a prospective registry 4. Overall, 10 articles4 7 9 10 12–16 18 were rated as high-quality studies based on the Newcastle-Ottawa quality assessment criteria (online supplementary table 3). Seven studies (54%) clearly stated that their series represented consecutive cases of endovascularly treated COICA, including failed attempts.…”

“…In a retrospective series, improvement of hypoperfusion after endovascular treatment of COICA is reported to be between 70% and 100% 4 18 19…”

“…Our meta-analysis, although derived from a retrospective series, showed that ischemic complications and mortality decreased by about 80% (OR=0.2, 95% CI 0.8 to 0.6, p=0.01) and 50% (OR=0.5, 95% CI 0.1 to 0.9, p=0.04) among symptomatic patients having endovascular treatment with successful recanalization, compared with medical management. It is likely that revascularization via an endovascular approach leads to improvement of the cerebral hypoperfusion due to the full anatomical restoration of blood flow to all ICA branches 4. Accordingly, recent series have also shown improvement of cognitive function after stenting COICA as measured with different neurocognitive scales 4 .…”

“…COICA was defined as a 100% cross-sectional stenosis of the vessel lumen as documented on CT angiography, MR angiography, and confirmed by DSA. Chronicity was defined as ≥1 month of known occlusion of the cervical internal carotid artery (ICA) documented on imaging studies 4. The inclusion criteria were the following: (1) studies reporting series of patients with COICA who underwent endovascular carotid recanalization; and (2) studies comparing the outcome between endovascular treatment versus medical treatment.…”

“…Treatment of these lesions is difficult, as both carotid endarterectomy and extracranial/intracranial bypass have been shown to have a limited benefit in symptomatic patients 3. Recently, endovascular recanalization of a COICA has been proposed and has been associated with heterogeneous rates of technical success and neurological improvement 4. However, whether endovascular treatment should be evaluated for selected symptomatic patients with a COICA is undetermined, because the related success rate and complications have not been well investigated.…”