Abstract
PurposeAcute stroke patients presenting with a distal internal carotid artery occlusion and patent carotid terminus, allowing for collateral flow via the circle of Willis, may have a more favorable natural history. Therefore, benefit of endovascular treatment (EVT) is less evident. We performed an exploratory analysis of EVT results compared to conservative treatment in patients with ‘carotid-I’ occlusions.MethodsWe report on EVT-treated and non-EVT-treated patients with carotid-I occlusions from the MR CLEAN Registry, MR CLEAN trial, and our comprehensive stroke center. CT-angiography was reviewed on primary collateral patency and choroid plexus enhancement. Perfusion deficits were assessed on CT-perfusion (CTP). Clot migration was assessed by comparing clot location on baseline CTA to its location on periprocedural digital subtraction angiography. Outcomes included 90-day functional independence (mRS 0–2), successful reperfusion and mortality.ResultsWe included 51 patients. Forty-one patients received EVT, ten patients did not. Intravenous thrombolysis was administered in 32 (78%) EVT-treated patients and 6 (60%) non-EVT-treated patients. CTP, available for 17 patients, showed hypoperfusion on cerebral blood flow maps in 13 (76%) patients. Successful reperfusion after EVT occurred in 23 (56%), and clot migration in 8 patients (20%). Functional independence was achieved in 54% (21/39) of EVT-treated and in 10% (1/10) of non-EVT-treated patients. Mortality was 26% (10/39) and 30% (3/10), respectively. Anterior choroidal artery patency and choroid plexus enhancement were positively associated with functional independence.ConclusionIn our population, data suggest improved outcomes after EVT in carotid-I occlusion patients and provide no arguments to withhold EVT in these patients.
Highlights
Multiple clinical trials have proven the benefit of endovascular treatment (EVT) in patients with acute ischemic stroke caused by proximal occlusions of the anterior circulation, up to as much as 24 h after stroke onset [1,2,3,4]
Acute occlusion of the distal intracranial internal carotid artery (ICA) with an open ICA-terminus allows for substantial collateral flow to the middle cerebral artery (MCA) via the circle of Willis, mostly through the anterior communicating artery (ACOM)
*Hypodensity on non-contrast CT (NCCT) is defined as ASPECTS ≤ 9. This explorative study examining the results of EVT in patients with ischemic stroke due to isolated distal internal carotid artery occlusion (“carotid-I occlusion”) suggests increased rates of functional independence and decreased mortality rates after EVT compared with conservative treatment, including intravenous thrombolysis (IVT) if patients are eligible
Summary
Multiple clinical trials have proven the benefit of endovascular treatment (EVT) in patients with acute ischemic stroke caused by proximal occlusions of the anterior circulation, up to as much as 24 h after stroke onset [1,2,3,4]. Acute occlusion of the distal intracranial internal carotid artery (ICA) with an open ICA-terminus allows for substantial collateral flow to the middle cerebral artery (MCA) via the circle of Willis, mostly through the anterior communicating artery (ACOM). This occlusion pattern was previously described as “carotid-I occlusion” [5]. Due to the primary collateral flow, the natural history of these occlusions might be more favorable and the benefits of EVT may be limited.
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