Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture

Abstract

A brupt intracranial large-vessel occlusion is associated with poor functional outcomes and a high mortality rate. The only possible solution is restoration of flow as soon as possible within a limited therapeutic time window. 1,13,18 Among these large vessel occlusions, the internal carotid artery (ICA) terminus occlusion is extremely difficult to manage.Acute ICA terminus occlusion responds poorly to intravenous administration of tissue plasminogen activator (tPA) due to its high clot burden; the recanalization rate is 4.4% in response to intravenous tPA alone and is 43.5% in response to intravenous tPA followed by additional endovascular treatment.1 Although new endovascular devices have accomplished better outcomes, the recanalization aBBReViatioNS ACoA = anterior communicating artery; CEA = carotid endarterectomy; DWI = diffusion-weighted imaging; ICA = internal carotid artery; MCA = middle cerebral artery; MRA = magnetic resonance angiography; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; PCoA = posterior communicating artery; TIMI = Thrombolysis In Myocardial Infarction; tPA = tissue plasminogen activator. SuBmitted December 25, 2013. accepted November 13, 2014. iNclude wheN citiNg Published online January 9, 2015; DOI: 10.3171/2014.11.JNS132855. diScloSuRe The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture hirotaka hasegawa, md, tomohiro inoue, md, akira tamura, md, phd, and isamu Saito, md, phd Department of Neurosurgery, Fuji Brain Institute and Hospital, Shizuoka, Japan Acute internal carotid artery (ICA) terminus occlusion is associated with extremely poor functional outcomes or mortality, especially when it is caused by plaque rupture of the cervical ICA with engrafted thrombus that elongates and extends into the ICA terminus. The goal of this study was to evaluate the efficacy and safety of surgical embolectomy in conjunction with carotid endarterectomy (CEA) for acute ICA terminus occlusion associated with cervical plaque rupture resulting in tandem occlusion. A retrospective review of medical records was performed. Clinical and radiographic characteristics were evaluated, including details of surgical technique, recanalization grade, recanalization time, complications, modified Rankin Scale (mRS) score at 3 months, and National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month. Three patients (mean age 77.3 years; median presenting NIHSS Score 22, range 19-26) presented with abrupt tandem occlusion of the cervical ICA and ICA terminus and were selected for surgery after confirmation of embolic high-density signal at the ICA terminus on CT and diffusion-weighted imaging (DWI)/magnetic resonance angiography (MRA) mismatch. All patients under...

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

“…Our experience corroborates this finding. For CTO of the ICA, the thrombosis at the distal end of the ICA may occasionally be directly pulled out following CEA, and the vessels may be recanalized ( 108 ). Under the restored blood flow and blood pressure, the atrophied and collapsed vessels distal to the thrombus are restored to normal diameter and morphology during follow-up ( 109 ).…”

Microsurgical thrombectomy: where the ancient art meets the new era

“…Few authors have reported their experience in the surgical treatment of acute LVO through single center case series or case reports [7-11, 14, 15]. The reported advantages of surgical thrombectomy include a high rate of recanalization[8, 10] rare occurrence of distal migration or segmentation of the thrombus[8, 16], the capacity to perform a simultaneous cervical carotid thrombectomy or CEA [15], and its role as rescue treatment for either failed endovascular mechanical thrombectomy or its contraindications (e.g. severe contrast allergy) [10,17].…”

“…Similarly, Hasegawa et.al. described their experience and surgical technique for the treatment of tandem lesions starting from the cranial site followed by the neck [15]. We described our simultaneous approach to a tandem lesion representative of our series (video) with a skin to nal recanalization of 34 minutes (cranial = 26min; cervical = 34min).…”

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

“…One group reported thrombolytic therapy and intracranial thrombectomy followed by delayed CEA for a partially occlusive eICA thrombus, 13 and another group reported on 3 patients who underwent emergency surgical embolectomy of ICA terminus emboli followed by CEA with significant postoperative improvements in their NIHSS scores (median 17 points). 12 Historically, CEA for ICA occlusion in acute stroke was associated with an increased risk of intracranial hemorrhage and poor clinical outcome, 6 and these concerns are amplified in patients who receive thrombolytics. However, in the modern era of endovascular therapy and penumbra imaging, this may be a reasonable option in selected patients.…”