Acute Simultaneous Occlusion of the Distal Common Carotid Artery and Middle Cerebral Artery

Abstract

Occlusion of the proximal segment of the internal carotid artery (ICA) or distal part of the common carotid artery (CCA) together with a thromboembolic occlusion of the middle cerebral artery (MCA) is one of the most critical conditions for acute ischemia. The low rate of recanalization and the high mortality rate for this clinical category of patients with major stroke are discouraging. The author reports on his experience in the management of one single patient, discussing different strategies of treatment with a review of the literature. A 70-year-old patient presented with acute major stroke indicating left hemisphere at risk (NIHSS-Score [National Institute of Health Stroke Scale] 20). Magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) and perfusion imaging (PI) revealed an extended DWI/PI mismatch. Magnetic resonance angiography (MRA) showed occlusion of the ICA, collateral flow was poor. The patient underwent intraarterial diagnostic three-vessel angiography. The thrombotic occlusion of the left distal CCA was revascularized by urgent stenting using an oversized carotid stent followed by a gentle balloon expansion with an undersized balloon. Additionally, local intraarterial fibrinolysis (LIF) of the MCA occlusion was performed. The endovascular procedure was uneventful and led to a marked improvement in perfusion of the hemisphere with regression of the neurologic deficit (NIHSS score 4). In acute major stroke patients with an entire hemisphere at risk, urgent stenting of the occluded cervical CCA may improve the outcome.