Acute extracranial occlusion of the internal carotid artery: emergent surgery remains a viable option

Abstract

Acute symptomatic occlusion of extracranial internal carotid artery (eICA) can lead to a critical and potentially devastating stroke associated with high morbidity and mortality. Optimal treatment remains unclear. We analyzed our institutional experience with emergent surgical recanalization of acutely occluded eICA. Retrospective analysis of hospital records, surgical reports, imaging studies and outpatient records. Final outcome was assessed according to modified Rankin Scale (mRS). Between January 2010 and September 2013, 22 patients underwent emergent surgical recanalization. There were 17 men and five women, mean age 65.4years (range 37-85). Mean admission National Institute of Health Stroke Scale (NIHSS) was 12 (range 6-21). All patients had evidence of salvageable penumbra on perfusion computed tomography. Tandem intracranial lesion was present in nine patients. Surgical recanalization was successful in 16 patients (72.7%). Twenty-four hours after surgery, 17 patients (77.2%) improved by a minimum of 1 point on NIHSS, 14 patients (63.6%) improved by three and more points; two patients deteriorated by two and five points, the latter treated initially with systemic thrombolysis due to intracranial hemorrhage. No other intracranial hematoma was observed. During 30days following surgery, two patients died (9% mortality rate) due to severity of initial stroke. On discharge, four patients were classified as mRS 0, five patients as mRS 1, five patients as mRS 2 and six patients as mRS 4. Favorable recovery (mRS 0-2) was achieved in 14 patients (63.6%). No change in mRS was observed at threemonths. Our results suggest that emergent surgical desobliteration of occluded eICA can lead to favorable recovery in a majority of patients. Patient selection based on penumbra imaging is crucial. Given the popularity and simplicity of carotid endarterectomy, the procedure should by no means be abandoned in the treatment of acute eICA occlusion.