Combined interventional and surgical treatment of tandem middle cerebral artery embolus and internal carotid artery occlusion: case report

Abstract

Tandem internal carotid artery (ICA) origin occlusion and middle cerebral artery (MCA) thromboembolism is a life-threatening condition with poor neurological outcome. The authors report on a patient presenting with acute ischemic stroke from a tandem ICA and MCA occlusion with penumbra. Emergency MCA mechanical thrombectomy was performed through percutaneous cervical ICA access due to the inability to cross the cervical carotid occlusion. Emergency carotid endarterectomy to reperfuse the poorly collateralized hemisphere and repair the ICA access site was performed 2 hours after completion of tissue plasminogen activator (tPA) infusion. This case illustrates the shortest reported interval between tPA infusion and open surgical intervention for carotid revascularization, as well as the role of direct carotid artery access for mechanical thrombectomy. The authors also describe the use of a temporizing femoral artery-to-ICA shunt to maintain cerebral perfusion in the setting of ICA occlusion.

Current understanding of chronic total occlusion of the internal carotid artery (Review)

“…The longer the duration of a CTO of the ICA, the lower the predicted technical success of recanalization ( 111 ). A microwire must pass thorough the occluded arteries during recanalization, and this process is difficult due to the variable course of the vessel, which frequently results in false lumen creation ( 112 ). In 2016, Chen et al ( 38 ) categorized occlusion length using a cut-off of 5 cm, and identified that the technical success rates for occlusions shorter than 5 cm and longer than 5 cm were 73.7 and 59.7%, respectively, suggesting a higher success rate of recanalization for occlusions shorter than 5 cm.…”

Mechanical thrombectomy via direct carotid artery approach for the treatment of acute anterior circulation large vessel occlusion

“…In order to improve the safety of percutaneous carotid artery puncture, we chose to perform carotid artery puncture under fluoroscopic monitoring. Carotid artery incision and CEA are also commonly used surgical methods for thrombectomy [ 24 , 25 , 26 ]. Acute ICA occlusion is the underlying reason in 4–15% patients with ischemic stroke [ 27 ].…”

“…Carotid artery incision and CEA is one of the surgical methods to achieve recanalization of the ICA occlusion. Recanalization of the occluded ICA within the time window may achieve favorable outcomes [ 25 ]. Emergency carotid artery incision would increase the risk of bleeding in patients treated with intravenous rtPA for thrombolysis.…”

“…Emergency carotid artery incision would increase the risk of bleeding in patients treated with intravenous rtPA for thrombolysis. However, Frenkel et al [ 25 ] believe that surgery after rtPA injection is still a viable option because rtPA has a short half-life (<5 min) and does not increase the chance of intracerebral hemorrhage and subcutaneous hematoma. Therefore, carotid artery incision and thrombectomy can be chosen for patients with ICA occlusion when an effective access approach cannot be established through the femoral artery approach.…”

Acute Stroke Treatment by Surgical Recanalization of Extracranial Internal Carotid Artery Occlusion: A Single Center Experience

“…Also a combined surgical and endovascular treatment can be considered. 41 However, this decision should always be made in an interdisciplinary discussion between neurologists, neuroradiologists, and vascular surgeons.…”