Chronic Internal Carotid Artery Occlusion Research Articles

Carotid endarterectomy alone or combined with fogarty catheter embolectomy for chronic symptomatic occlusion of the internal carotid artery

Objective To investigate the therapeutic effect of carotidendarterectomy(CEA) alone or combined with Fogarty catheter embolectomy in the treatment of chronic symptomatic internal carotid artery occlusion. Methods From April 2008 to December 2013, 12 patients with transient ischemic attack (TIA) or minor stroke underwent digital subtraction angiograph to confirmation t of ICA occlusion. All patients underwent operative exploration with CEA or CEA plus Fogarty thrombectomy. Patients who failed revascularization underwent external CEA and ICA ligation. All clinical and radiological data were retrospectively reviewed. Results CEA in 7 patients and CEA plus Fogarty thrombectomy in 3 patients were performed successfully to restore blood flow of internal carotid artery. External CEA and internal carotid artery ligation were performed in 2 patients. Postoperative CT angiography or DSA imaging demonstrated patency of the internal carotid artery in 10 patients. The ischemic symptoms were relieved in most of the patients. Postoperatively, 3 patients suffered from hyperperfusion syndrome, but there were no perioperative stroke or death.The duration of follow-up was 15-66 months. No patient developed a new stroke. No re-occlusion but one mild re-stenosis(40%) was detected. 2 patients suffered from TIA occasionally.One of the two patients failed in recanalization relieved from the symptom, the another still suffered from TIA. Conclusions Carotid endarterectomy alone or combined with Fogarty catheter embolectomy to treat chronic symptomatic internal carotid artery occlusion is feasible and safe, but preoperative evaluation and selection of patient should be carefully. Key words: Carotid artery, internal; Arterial occlusive diseases; Endarterectomy, carotid; Embolectomy; Fogarty catheter

Late spontaneous recanalization of symptomatic atheromatous internal carotid artery occlusion.

Definitive treatment of symptomatic atheromatous internal carotid artery occlusion remains controversial, as far as in rare cases, late spontaneous recanalization has been seen. We consecutively studied 182 patients (January 2003 to August 2012) with an ischemic stroke in the internal carotid artery territory and diagnosis of atheromatous internal carotid artery occlusion during hospitalization. Seven patients presented a late spontaneous recanalization (>3 months) of the internal carotid artery. We described therapeutic attitude according to usual care in these patients. The authors attempt to highlight the unusual condition of recanalization after a symptomatic atheromatous chronic internal carotid artery occlusion. If these patients can be treated similar to patients with asymptomatic carotid pathology, then this needs to be clarified. However, due to the risk of ipsi- and contralateral ischemic strokes, revascularization techniques should be considered in certain cases. More studies are needed to establish the most appropriate therapeutical approach in order to avoid arbitrary treatment of these patients.

Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion

Symptomatic internal carotid artery (ICA) occlusion with hemodynamic impairment remains a dismal disease when untreated. In this prospective, single-center, controlled study, we investigated the feasibility, safety, and long-term outcome of stenting by endovascular recanalization for patients with chronic ICA occlusion. Forty patients with symptomatic chronically occluded ICA were assigned to receive endovascular recanalization (group A, n = 18) or conservative management (group B, n = 22). The primary end point was 100% complete recanalization of the primary occlusion at 60 minutes, and secondary end points were improvement in neurologic function and cognitive function. Patients in the 2 groups were comparable in demographic and baseline characteristics. Successful recanalization was achieved in 88.9% (16 of 18) of patients with the restoration of Thrombolysis in Myocardial Ischemia/Thrombolysis in Cerebral Ischemia 2 or 3 flow. There was no procedural or new cerebral ischemic event. Improvement in brain perfusion was observed in 12 (12 of 18, 75%) patients on single-photon emission computed tomography. Improvement in neurologic function defined as a reduction of ≥4 points on the National Institutes of Health Stroke Scale (NIHSS) at 6 months was observed in group A (baseline, 6.83 ± 3.01 vs 6 months, 2.61 ± 1.20; P < .01) and group B (baseline, 6.05 ± 2.75 vs 6 months, 4.77 ± 1.69; P < .05). A significant difference in NIHSS scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Improvement in cognitive function defined as an increase of ≥8 on the Montreal Cognitive Assessment (MoCA) was observed in group A at 3 and 6 months (baseline, 14.67 ± 3.56 vs 3 months, 24.17 ± 3.55 and 6 months, 24.72 ± 2.85; P < .01). Significant improvement in MoCA was also observed in group B (P < .01). Furthermore, a significant difference in MoCA scores was noted between group A and B at 1, 3, and 6 months (P < .05 or .001). Endovascular recanalization is feasible and safe for patients with symptomatic chronic carotid artery occlusion. Successful carotid artery stenting can improve neurological function and global cognitive function than nonrevascularization.

Urgent Extracranial-Intracranial Bypass in the Treatment of Acute Hemodynamic Ischemic Stroke: Case Report

Extracranial-intracranial (EC-IC) bypass surgery is performed to allow flow augmentation in selected cases of occlusive cerebrovascular disease. The majority of EC-IC bypasses are described as an elective procedure in the prevention of hemodynamic ischemic stroke. There is only limited and controversial experience of superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis performed under urgent circumstances as a treatment of acute cerebral ischemia. We describe a unique case of a 75-year-old patient presenting with acute progressive hemodynamic ischemia after carotid endarterectomy (CEA), which developed contralaterally to the performed CEA in the region of chronic internal carotid artery (ICA) occlusion. Urgent performance of a standard STA-MCA bypass rapidly improved the cerebral hemodynamic and had an excellent therapeutic effect. The patient had recovered completely within 4 weeks of surgery. The role of urgent EC-IC bypass for stroke treatment is discussed.

網膜虚血により視力の急性増悪を呈した内頚動脈慢性閉塞症に対して血行再建術を施行した1例

網膜虚血により視力の急性増悪を呈した内頚動脈慢性閉塞症に対して血行再建術を施行した1例

Safety and Efficacy of Surgical Treatment of Carotid Stump Syndrome: Pilot Study

Surgical exclusion of the internal carotid artery (ICA) stump combined with endarterectomy of the external carotid artery is an established treatment approach. The aim of this pilot study was to compare the risk of cerebrovascular events between surgical treatment and best medical treatment in patients with ICA occlusion and carotid stump syndrome. Forty patients (23 males; age: 43-80 years; mean age: 61.1 ± 9.0 years) with carotid occlusion and carotid stump syndrome were enrolled. Ten patients with asymptomatic ICA occlusion and 10 patients with symptomatic ICA occlusion and carotid stump syndrome were enrolled to the best medical therapy group. Patients with chronic ICA occlusion, carotid stump syndrome, and one (15 patients) or recurrent (three patients) episodes of ipsilateral stroke or transient ischemic attack were enrolled to the surgical group. Neurological examination was undertaken on the day of randomization and then every 6 months in all patients for 4 years. All vascular events and death were recorded. Only one vascular event occurred in patients with symptomatic ICA occlusion without recurrent stroke or transient ischemic attack who were treated medically. No other vascular event was noted in the other subgroups. One patient with symptomatic carotid occlusion without recurrent stroke died due to myocardial infarction 6 months after surgery. Surgical treatment of carotid stump syndrome seems to be a safe procedure. Nevertheless, the benefit of a surgical approach in comparison with the best medical treatment is not clear.

Letter by Sposato et al Regarding Article, “Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion and Cerebral Ischemia”

To the Editor: We read with interest the article “Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion and Cerebral Ischemia” by Lin et al.1 The authors state that they found an improvement of global cognitive function, attention, and psychomotor processing speed in patients with chronic internal carotid artery occlusion undergoing carotid artery stenting. Similarly, in a recent prospective study, we found an improvement of executive functioning after carotid artery stenting among patients with internal carotid artery stenosis.2 Despite the innovative aspect of Lin et al's study (eg, comprising patients with internal carotid artery occlusion, unlike previous studies including participants with unilateral internal carotid artery stenosis), we would like to point out some concerns regarding methodological aspects that could affect the validity of its results. The authors found an improvement of mean values on the Alzheimer Disease Assessment Scale, …

Response to Letter Regarding Article “Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion and Cerebral Ischemia”

Response: We appreciate the interest of Dr Sposato and his colleagues1 in our recent publication regarding neurocognitive function improvement after endovascular recanalization in patients with chronic carotid artery occlusion and ipsilateral hemisphere ischemia.2 The authors call attention to some methodological points in our study and are concerned about the interpretation of the result. First of all, they considered that group analysis may not reflect actual changes of individual patients. We therefore did event rate analysis according to their suggestion and still found a trend of a higher proportion of improvement in the successful group on 3 cognitive tests (Alzheimer Disease Assessment Scale–Cognitive Subtest: 8 of 12 [66.7%] versus …

Neurocognitive Improvement After Carotid Artery Stenting in Patients With Chronic Internal Carotid Artery Occlusion and Cerebral Ischemia

Chronic cerebral hypoperfusion may lead to impairment in neurocognitive performance in patients with chronic internal carotid artery occlusion, and the effects of carotid artery stenting on neurocognitive function have been unclear. We prospectively enrolled 20 chronic internal carotid artery occlusion patients with objective ipsilateral hemisphere ischemia, in whom carotid artery stenting was attempted. Functional assessments, including the National Institutes of Health Stroke Scale, Barthel Index, and a battery of neuropsychological tests, including the Mini-Mental State Examination, Alzheimer Disease Assessment Scale-Cognitive Subtest, verbal fluency, and Color Trail Making A and B, were administered before and 3 months after intervention. Successful recanalization was achieved in 12 of 20 patients (60%). There was no procedural or new cerebral ischemic event, except for 1 intracranial hemorrhage, which occurred during the procedure and had neurologic sequelae; this case was excluded from analysis. The demographics and baseline cognitive performance were similar between the group with a successful outcome (group 1, n=12) and patients who did not (group 2, n=7). Ten of 12 patients in group 1 had improvement in ipsilateral brain perfusion after the procedure, but none in group 2 had improvement. Significant improvement in the scores on the Alzheimer Disease Assessment Scale-Cognitive Subtest (before, 7.7±8.9 versus after, 5.7±7.1; P=0.024), Mini-Mental State Examination (before, 25.8±3.8 versus after, 27.7±2.7; P=0.015), and Color Trail Making A (before, 123.2±68.6 versus after, 99.3±51.5; P=0.017) were found in group 1 but not in group 2. Successful carotid artery stenting improves global cognitive function as well as attention and psychomotor processing speed in patients with chronic internal carotid artery occlusion.

Ultrasonographic and Perioperative Macroscopic Findings in Acute Carotid Artery Occlusion

acute ischemic stroke (AIS) may occur both in the acute and chronic internal carotid artery occlusion (ICAo). Thus, it is important to assess the ICAo character when considering the recanalization method. The aim was to assess the agreement between the ultrasonographic (US) and perioperative macroscopic (PM) finding in AIS patients with acute ICAo, undergoing an emergent carotid endarterectomy. in a retrospective, hospital-based study, the set consisted of 47 patients (36 males; age 49-79, mean 63.7 ± 8.5 years). ICAo character was classified as an acute thromboembolus either isolated or in combination with atherosclerotic plaque using the US (B-mode) and the PM evaluation. Cohen's Kappa and AC(1) coefficient were applied to assess the methods agreement. an acute ICAo character diagnosed by US was confirmed by the PM evaluation in all cases. US and PM findings were consistent in 41 cases. The agreement between both methods in the classification of acute ICAo was 87.2% [95% confidence interval (CI): 77.7-96.8%], κ= .589 (95% CI: .293-.885) (P < .0001), AC(1) = .815. US is a reliable method in the diagnostics of the acute character of ICAo and it has a good agreement with PM finding regarding a differentiation of atherosclerotic plaque and fresh thromboembolus.

Procedural Safety and Potential Vascular Complication of Endovascular Recanalization for Chronic Cervical Internal Carotid Artery Occlusion

Patients with chronic cervical internal carotid artery occlusion (ICAO) and cerebral ischemia may benefit from revascularization. The feasibility of endovascular recanalization for chronic ICAO has been reported recently, but its safety is still unproven. We report the follow-up results of 54 chronic ICAO patients who underwent endovascular recanalization, focusing on potential vascular complications and corresponding management. Endovascular recanalization for chronic ICAO was attempted in 54 consecutive patients (48 men; 69.2 + or - 9.8 years old) with either recurrent neurological deficit or objective ipsilateral hemisphere ischemia. Mean duration from occlusion documentation to the procedure was 237 + or - 327 days (range, 56 to 1424 days). Adverse events while in the hospital and during the 3-month follow-up were recorded. Successful recanalization was achieved in 35 of 54 patients (65%). Three-month cumulative stroke and death rate was 4% (2 of 54), including 1 in-hospital fatal nonipsilateral stroke and 1 in-hospital minor ipsilateral stroke secondary to systemic hypotension. Vascular complications developed in 3 of 54 patients (6%), including 1 late pseudoaneurysm formation 3 months after recanalization, 1 immediate carotid-cavernous fistula after recanalization, and 1 minor extravasation at carotid bifurcation after failed recanalization. However, no clinical sequela was noted with close follow-up and adequate management. Certain immediate or delayed vascular complications may develop during or after the endovascular recanalization for chronic ICAO. Although periprocedural death and stroke rate is limited in our study, further study combining neuroimaging tools and cognitive function evaluation is mandatory to assess its utility and appropriateness in patients with chronic ICAO.

Cortical excitability and ischemia in patients with chronic unilateral internal carotid artery occlusion

Abstract Relationships between cortical excitability and regional cerebral blood flow (rCBF) were investigated in eight patients with chronic internal carotid artery occlusion using somatosensory evoked field recovery function (SEF-R). At interstimulus intervals (ISIs) of 120 and 160 ms, the SEF-R curve of the affected hemisphere demonstrated a significant overshoot above that of the non-affected hemisphere, suggesting cortical hyperexcitability. Furthermore, the rCBF at the hand area of the primary sensory area and the SEF-R at the ISI of 160 ms were inversely correlated. These results suggest that cortical hyperexcitability occurs at the primary sensory area in association with the severity of ischemia in the patients with chronic ICA occlusion.

Carotid angioplasty with stenting for chronic internal carotid artery occlusion: technical note

Carotid angioplasty with stenting (CAS) is becoming accepted as an effective and reliable treatment option for severe carotid artery stenosis. However, it is rarely applied for carotid occlusion, especially in its chronic stage. We report our experience of CAS for chronic internal carotid artery occlusion representing compromised cerebral blood flow using various protection methods. A 77-year-old woman, who was already diagnosed with severe left internal carotid artery stenosis, suddenly had right hemiparesis and aphasia. At that time, she was treated conservatively because her neurological status was quite good, in spite of left carotid artery occlusion. Her symptoms improved in the short term, except slight aphasia, but deteriorated again 18 days from the onset, and magnetic resonance imaging (MRI) showed new ischemic lesions. CAS was then performed for the occluded carotid artery on the 23rd day from the first onset. Using the proximal protection technique, the occluded lesion was crossed carefully with a microguidewire. Stents were also placed successfully with the distal protection technique. The occluded carotid artery was completely recanalized without any unfavorable events or neurological deterioration. In this patient, CAS was successfully to treat chronic carotid artery occlusion. These procedures and techniques are reviewed and discussed.

Unusual Case of 2 Renal Cell Carcinoma Metastases Ipsilateral to an Occluded Internal Carotid Artery

Hemodynamic factors may play a role in the seeding and subsequent growth of cerebral metastasis. The authors present a case with 2 foci of cerebral metastasis in the same vascular territory ipsilateral to an occluded internal carotid artery. A 65-year-old man with chronic left frontal lobe infarct and left internal carotid artery occlusion was diagnosed with 2 large hemorrhagic metastases in the left middle cerebral artery territory. Diminished flow signals were seen in the trunk and branches of the left middle cerebral artery on magnetic resonance angiography. This case illustrates preferential seeding and growth of cerebral metastases in a region of the brain with diminished blood flow.

Perfusion CT investigation of chronic internal carotid artery occlusion: comparison with SPECT

This study investigated the usefulness of perfusion computed tomography (CT) for the evaluation of patients with chronic internal carotid artery (ICA) occlusion by comparing the findings with those of iodine-123 iodoamphetamine ([ 123I]IMP) single photon emission computed tomography (SPECT). Twenty five patients with chronic ICA occlusion were investigated on the same day by perfusion CT to measure the cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transient time (MTT), and [ 123I]IMP SPECT to measure the regional CBF, significant correlations were observed between regional CBF measured by SPECT and CBF measured by perfusion CT ( r = 0.659, R 2 = 0.434, p < 0.001), regional CBF and CBV ( r = −0.406, R 2 = 0.165, p < 0.001) and regional CBF and MTT ( r = −0.592, R 2 = 0.350, p < 0.001). Significant correlations were also observed between CBF and CBV ( r = −0.153, R 2 = 0.023, p < 0.001), CBF and MTT ( r = −0.580, R 2 = 0.337, p < 0.001) and MTT and CBV ( r = 0.763, R 2 = 0.582, p < 0.001). Perfusion CT is useful to evaluate the hemodynamic state of patients with chronic major cerebral artery occlusive disorders.

Unstable cerebral hemodynamics in carotid artery occlusion and large hemispheric stroke: a cerebral blood flow volume study.

In chronic internal carotid artery (ICA) occlusion, cerebral hemodynamics are likely to be stable due to collateral flow. The authors evaluated cerebral hemodynamics in ICA occlusion using the sonographic method of cerebral blood flow volume (CBVF) measurement to find differences that might identify patients with large hemispheric stroke in ICA occlusion. The ultrasound method of CBVF measurement was used, which represents the sum of flow volumes of both internal carotid and both vertebal arteries. CBVF was measured in 29 patients with ICA occlusion including patients with (1) chronic ICA occlusion without acute minor stroke, (2) chronic ICA occlusion with acute minor stroke, (3) acute minor stroke due to acute ICA occlusion, and (4) ICA occlusion and large hemispheric stroke. In ICA occlusion, overall CBVF is lower compared to healthy volunteers, due to a significant reduction of CBVF in groups 3 and 4. Comparing groups, there were no differences in CBVF between groups 1, 2, and 3. CBVF in group 4 is reduced compared to all other groups. By receiver-operating characteristic analysis, a CBVF cutoff value for large hemispheric stroke was computed with a sensitivity of 100% and a specificity of 95.8%. Stroke due to acute ICA occlusion is associated with decreased CBVF compared to chronic ICA occlusion. Moreover, ICA occlusion and large hemispheric stroke are associated with decreased CBVF compared to all other groups, indicating instability of cerebral hemodynamics. CBVF measurement thus may be a useful tool in predicting large middle cerebral artery stroke early in ICA occlusion.

Unstable Cerebral Hemodynamics in Carotid Artery Occlusion and Large Hemispheric Stroke: A Cerebral Blood Flow Volume Study

ABSTRACT Purpose. In chronic internal carotid artery (ICA) occlusion, cere bral hemodynamics are likely to be stable due to collateral flow. The authors evaluated cerebral hemodynamics in ICA occlusion using the sonographic method of cerebral blood flow volume (CBVF) measurement to find differences that might identify patients with large hemispheric stroke in ICA occlusion.Methodand Results. The ultrasound method of CBVF measurement was used, which represents the sum of flow volumes of both internal carotid and both vertebal arteries. CBVF was measured in 29 patients with ICA occlusion including patients with (1) chronic ICA occlusion without acute minor stroke, (2) chronic ICA occlusion with acute minor stroke, (3) acute minor stroke due to acute ICA occlusion, and (4) ICA occlusion and large hemispheric stroke. In ICA occlusion, overall CBVF is lower compared to healthy volunteers, due to a significant reduction of CBVF in groups 3 and 4. Comparing groups, there were no differences in CBVF between groups 1, 2, and 3. CBVF in group 4 is reduced compared to all other groups. By receiver‐operating characteristic analysis, a CBVF cutoff value for large hemi spheric stroke was computed with a sensitivity of 100% and a specificity of 95.8%.Conclusion. Stroke due to acute ICA occlusion is associated with decreased CBVF compared to chronic ICA occlusion. Moreover, ICA occlusion and large hemispheric stroke are associated with decreased CBVF compared to all other groups, indicating instability of cerebral hemodynamics. CBVF measurement thus may be a useful tool in predicting large middle cerebral artery stroke early in ICA occlusion.

EVALUATION OF ABNORMAL HEMODYNAMICS IN INTRACRANIAL ARTERY OCCLUSION USING DYNAMIC SPECT

P55 We evaluated the hemodynamics under ischemic state to examine cerebral blood flow tracer processing toward equilibrium using Tc-99m ethyl cysteinate dimer (Tc-99m ECD) dynamic SPECT. Dynamic SPECT studies were performed in 32 patients with unilateral chronic internal carotid artery or middle cerebral artery occlusion and 16 controls in the absence of arterial stenosis on MR angiography. Dynamic SPECT data (30sec′24frames) were acquired immediately after the administration of Tc-99m ECD. Although the radioactivity of both cerebral hemispheres reached plateau phase within 180sec after the injection based on time-activity curve, the radioactivity of affected cerebral hemisphere showed slower build-up than that of contralateral unaffected hemisphere. The build-up (0–180sec) and plateau phase (540–720sec) images were analyzed statistically. Twenty of 32 patients demonstrated reduced accumulation of the affected hemisphere on the build-up phase images, although all patients showed normal accumulation on plateau phase images. In 17 of 32 patients, the discrepancy of the accumulation on the affected hemisphere between the build-up and plateau phase images was corresponded to that with reduced reactivity to acetazolamide, reflecting the impairment of vasucular reseve in brain tissue. We speculate that the reduced accumulation of the affected hemisphere in the build-up phase image was derived from flow delay due to arterial occlusion and the collateral flow. Our finding suggests that dynamic SPECT allow detecting the compensatory vasodilatation by means of the evaluation of tracer s equilibrium process in brain tissue where ischemic change such as misery perfusion is present. In conclusion, not only tracer extraction (plateau phase) image but also intra-vascular tracer delivery (build-up phase) image would provide important information of abnormal hemodynamics.

Stroke following internal carotid artery occlusion - a contra-indication for intravenous thrombolysis?

Between March 1996 and December 1997, 15 consecutive patients with carotid artery occlusion diagnosed with duplex sonography were treated with intravenous recombinant tissue plasminogen activator (rt-PA), following a protocol similar to that of the National Institute of Neurological Disorders and Stroke (NINDS) study. On the basis of ultrasound findings, six of the 15 patients had internal carotid artery dissection (ICD), and the remaining nine had atherothrombotic internal carotid artery (ICA) occlusion. No relevant haemorrhagic complications were observed after rt-PA treatment of ICA occlusion. Excellent late functional outcome was observed in three of the 15 patients with ICA occlusion, moderate and poor outcome in four patients. Four patients died, and mortality was related to stroke severity upon admission. A good outcome seemed to be more likely in the small group of patients with ICD, than in the patients suffering atherothrombotic ICA occlusion. As the results of rt-PA treatment in this case series are by no means devastating, our data do not corroborate the hypothesis that patients with acute ischemic stroke following ICA occlusion should a priori be excluded from intravenous thrombolysis. The possible benefit of rt-PA treatment in stroke following acute or chronic ICA occlusion should be assessed in a larger prospective trial, for which this case series might serve as a pilot study.

Surgical treatment of chronic internal carotid artery occlusion by saline endarterectomy.

Surgical treatment of chronic internal carotid artery occlusion by saline endarterectomy.