Symptomatic Internal Carotid Artery Occlusion Research Articles

Significance of atherosclerotic plaque location in recanalizing non-acute long-segment occlusion of the internal carotid artery

To investigate the significance of atherosclerotic plaque location in hybrid surgery comprising both endovascular recanalization approaches and carotid endarterectomy for symptomatic atherosclerotic non-acute long-segment occlusion of the internal carotid artery (ICA), 162 patients were enrolled, including 120 (74.1%) patients in the proximal plaque group and 42 (25.9%) in the distal plaque group. Surgical recanalization was performed in all patients, with successful recanalization in 119 (99.2%) patients in the proximal and 39 (92.9%) in the distal plaque group. The total successful recanalization rate was 97.5% (158/162) with a failure rate of 2.5% (4/162). Periprocedural complications occurred in 5 (4.2% or 5/120) patients in the proximal plaque group, including neck infection in two (1.7%), recurrent nerve injury in 1 (0.8%), and laryngeal edema in 2 (1.7%), and 2 (4.8%) in the distal plaque group, including femoral puncture infection in 2 (4.8%). No severe complications occurred in either group. Univariate analysis showed plaque location was a significant (P = 0.018) risk factor for successful recanalization, and multivariate analysis indicated that the plaque location remained a significant independent risk factor for recanalization success (P = 0.017). In follow-up 6–48 months after the recanalization surgery, reocclusion occurred in two (2.8%) patients in the proximal plaque group and 4 (13.3%) in the distal plaque group. In conclusion, although hybrid surgery achieves similar outcomes in patients with ICA occlusion caused by either proximal or distal atherosclerotic plaques, plaque location may be a significant risk factor for successful recanalization of symptomatic non-acute long-segment ICA occlusion.

Long-term outcomes after formation of a low-flow STA-MCA bypass for treatment of symptomatic occlusion of the internal carotid artery

Aim. To evaluate short‑ and long‑term effectiveness of low‑flow bypass between superficial temporal artery and M4 segment of middle cerebral artery (low‑flow STA‑MCA bypass) in patients with symptomatic occlusion of the internal carotid artery (ICA).Materials and methods. Between 2016 and 2019 at the Department of Neurosurgery of the N. V. Sklifosovsky Research Institute of Emergency Medicine, 54 patients who underwent low‑flow STA‑MCA bypass formation at the side of symptomatic ICA occlusion between 2013 and 2015 were examined. Symptomatic ICA occlusion was more common in men than in women (7:1 ratio). Patient age varied between 48 and 73 years (mean age was 62 years).During low‑flow STA‑MCA bypass formation surgery for symptomatic ICA occlusion, intraoperative flowmetry was used in 52 (96 %) patients, in 2 (4 %) patients this diagnostic method was impossible to perform due to technical difficulties. The main examination methods in the long term after cerebral revascularization were evaluation of neurological status dynamics per the National Institute of Health Stroke Scale (NIHSS); modified Rankin scale; Rivermead mobility index; computed tomography angiography of the extra‑intracranial arteries; ultrasound (US) examination of the STA‑MCA bypass for eval uation of linear and volumetric blood flow velocities; single‑photon emission computed tomography. The type and size of trephination were evaluated, and operative time was taken into account.The patients were divided into 3 groups: group 1 included patients with follow‑up period of 1–2 years after cerebral revascularization, group 2 – 3–4 years, group 3 – 5–6 years. All results were compared to preoperative, early, and longterm measurements.Results. In the long‑term postoperative period between 1 and 6 years after cerebral revascularization, 54 patients were examined. Computed tomography angiography and US showed functioning STA‑MCA bypass in 53 (98 %) patients. According to single‑photon emission computed tomography of the brain, regional cerebral blood flow in the longterm postoperative period varied between 28 and 40 mL / 100 g / min, median regional cerebral blood flow in the long‑term postoperative period was 38 mL / 100 g / min. Intraoperative flowmetry was performed in 52 (96 %) patients, median was 15.5 mL / min. US showed that linear blood flow velocity in the STA‑MCA bypass varied between 20 and 95 cm / s, median was 49 cm / s. Volumetric blood flow varied between 30 and 85 mL / min with median of 75 mL / min.Resection trephination was performed in 36 (67 %) patients, mean size of trephination hole was 3 cm3. In the study, operative time was measured: mean value was 212 min; no significant correlation between operative time and trephination size was observed.Improved neurological status was observed in all study groups. Per the NIHSS, in group 1 (1–2 years) improvement was observed in 59 % of patients, in group 2 (3–4 years) in 48 %, in group 3 (5–6 years) in 47 %. Per the modified Rankin scale, in group 1 improvement was observed in 36.4 % of patients, in group 2 – in 48 %, in group 3 – in 42.9 %. Per the Rivermead mobility index, in group 1 improvement was observed in 63.3 % patients, in group 2 – in 56 %; in group 3 – in 57.1 %. The best outcomes were observed in group 1 (63.3 %).Conclusion. Instrumental diagnostic methods and evaluation of neurological status showed positive dynamics both in the postoperative period and in long‑term period between 1 and 6 years after low‑flow STA‑MCA bypass formation. In the long term, repeat abnormalities of cerebral blood flow of ischemic type and repeat transient ischemic attacks were not observed. Correct selection of patients in the preoperative period and comprehensive treatment including drug therapy in the postoperative and long‑term periods allow to prevent repeat ischemic cerebrovascular disease and therefore improve patients’ quality of life.

Perfusion Profiles May Differ Between Asymptomatic Versus Symptomatic Internal Carotid Artery Occlusion.

Perfusion Profiles May Differ Between Asymptomatic Versus Symptomatic Internal Carotid Artery Occlusion.

Hybrid surgery can improve neurocognitive function in patients with internal carotid artery occlusion

Internal carotid artery occlusion (ICAO) is a relatively uncommon but important cause of transient ischaemic attack and cerebral infarction. Hybrid surgery (HS) improves cerebral perfusion, but its impact on neurocognitive function has been controversial. Patients with symptomatic chronic ICAO treated by hybrid surgery or medical treatment from 2016 to 2019 were included. We recorded and analysed the clinical characteristics, angiographic data, outcomes and cognitive status. Functional assessments, including the National Institutes of Health Stroke Scale (NIHSS), the Barthel Index, and a battery of neuropsychological tests, including the Mini-Mental State Examination (MMSE), Alzheimer Disease Assessment Scale–Cognitive Subtest (ADAS-cog), verbal fluency, and Colour Trail test Parts 1 and 2, were administered. Significant improvements in the ADAS (before, 7.5 ± 6.2 versus after, 5.2 ± 5.7; P = 0.022), MMSE (before, 25.5 ± 2.8 versus after, 28.1 ± 2.3; P = 0.013), and Colour Trail test Part 1 (before, 118.3 ± 26.5 versus after, 96.2 ± 23.1; P = 0.016) were observed six months after HS. Moreover, the abovementioned postprocedure scales were ameliorated in the HS group. This study found that in patients with multiple symptomatic ICAO and objective ipsilateral ischaemia, successful HS leads to improvement in the scores of three cognitive tests.

Endovascular Recanalization for Nonacute Carotid Artery Occlusion: A Nationwide Registry‐Based Cohort Study

Background The management of nonacute symptomatic internal carotid artery occlusion remains unsatisfactory. Endovascular recanalization has been reported to be feasible but associated with a noteworthy risk of postprocedural complications in patients with symptomatic internal carotid artery occlusion. The present study aimed to investigate whether successful recanalization exerts clinical benefits over procedural risks. Methods We analyzed consecutive patients who underwent endovascular treatment of nonacute symptomatic internal carotid artery occlusion in a nationwide prospective registry. The primary outcome was the ipsilateral ischemic stroke recurrence. Other outcomes of interest included all strokes and death during follow‐up, and 30‐day symptomatic intracranial hemorrhage, and all strokes after intervention. Results The final analysis included 511 patients. Endovascular revascularization was successful in 300 patients (58.7%) but failed in 211 patients (41.3%). Patients with successful recanalization had less time from the last ischemic event to the endovascular treatment as compared with patients with failed recanalization (median [interquartile range] days, 18 [12–33] versus 22 [14–50]; P =0.003). Successful recanalization was associated with a higher rate of symptomatic intracranial hemorrhage within 30 days after intervention (odds ratio [OR], 7.99 [95% CI, 1.02–62.39]; P =0.047). Thirty‐day all strokes (OR, 1.91 [95% CI, 0.83–4.40]; P =0.128) and ischemic stroke (OR, 0.90 [95% CI, 0.33–2.46]; P =0.839) did not differ significantly. During a median follow‐up of 37 months, patients with successful recanalization demonstrated a reduced risk of ipsilateral ischemic stroke (adjusted hazard ratio, 0.28 [95% CI, 0.13–0.59]; P <0.001). The 5‐year risk of all strokes and death was likewise lower in patients with successful recanalization (restricted mean survival time difference, 3.77 months [95% CI, 0.16–7.38]; P =0.041). Conclusion Despite an increase in the 30‐day symptomatic intracranial hemorrhage, successful recanalization was associated with reduced long‐term risk of ipsilateral ischemic stroke in patients with symptomatic internal carotid artery occlusion.

Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion

Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. ClinicalTrials.gov Identifier: NCT01758614.

Endovascular recanalization for symptomatic chronic internal carotid artery occlusion: proposal of a modified angiographic classification and clinical outcomes

PurposeTo stratify angiographic images of chronic internal carotid artery occlusion (CICAO) into a newly modified angiographic classification, and identify suitable candidates for endovascular recanalization. MethodsThis study included 51 consecutive patients with symptomatic CICAO who underwent endovascular recanalization at our institution. Patients’ clinical information, angiographic findings, procedural results, and outcomes were recorded. We attempted to stratify all angiographic images into categories based on morphological occlusive patterns and distal internal carotid artery (ICA) lumen reconstitution on digital subtraction angiography (DSA). ResultsFour types (I–IV) of CICAO were identified based on angiographic characteristics. We defined type I as having a tapered (IA) or blunt stump (IB) and distal ICA lumen reconstitution with collateral filling; type II as having no stump but with distal ICA lumen reconstitution; type III as having a tapered (IIIA) or blunt stump (IIIB) but no distal ICA lumen reconstitution; type IV as having no stump and no distal ICA lumen reconstitution. The rate of successful recanalization was 90.3 % for type I, 60.0 % for type II, 50.0 % for type III, 0 % for type IV, respectively (P = 0.002). The overall intraoperative complication rate was 11.8 %, and none of them led to severe neurological damage or death. The follow-up modified Rankin Scale (mRS) scores were significantly decreased in successfully revascularized patients, whilst there were no significant changes in the other failed patients. ConclusionFor symptomatic CICAO, our newly modified angiographic classification may be comprehensive and useful in selecting suitable patients for recanalization and grading the difficulty of the procedures.

Endovascular Surgery Revascularization of Chronic Cervical Carotid Occlusions: Systematic Review and Meta‐Analysis

Background Chronic symptomatic internal carotid artery occlusion is an important cause of ischemic strokes. Medical management alone remains suboptimal for secondary prevention, and randomized controlled trials failed to demonstrate the efficacy and safety of extracranial‐intracranial vascular bypass. Carotid occlusion endovascular surgery (COES) is a promising technique, yet its efficacy and safety remain unclear. Methods This systematic review and meta‐analysis included studies in which patients with chronic symptomatic internal carotid artery occlusion underwent treatment with COES and medical management. Primary outcomes included successful reperfusion rates and periprocedural ischemic and hemorrhagic events rates. Secondary outcomes included rates of ischemic events recurrence, other periprocedural events, and mortality. Studies contained at least one of the treatment groups and outcomes of interest. Results Twenty‐two studies were selected for systematic review, with 18 of them for meta‐analysis. From 14 studies (N=561) the rate of successful recanalization was achieved in 74% of all patients undergoing COES. Thirteen studies (N=534) showed that the rate of COES was 2% both for periprocedural ischemic and hemorrhagic events. At long‐term follow‐up, the COES cohort included a total of 10 studies (N=311) and had a 12% rate of ischemic events, while the medical management group, which included 5 studies (N=313), showed a rate of 19%, with nonsignificant subgroup differences ( P =0.09, I 2 , 12%). Rates of other periprocedural mortality were 4% and 1%, respectively. Conclusion This meta‐analysis supports the use of COES as a promising and innovative technique for the secondary prevention of symptomatic internal carotid artery occlusion. Our findings suggest that COES may be superior to medical management alone, although further research is needed to fully evaluate its efficacy and safety.

Abstract Number ‐ 66: Symptomatic Chronic Internal Carotid Artery Occlusion Managed With Bilateral Common Carotid Angioplasty: A Case Report

Introduction Several guidelines have addressed symptomatic or asymptomatic carotid artery stenosis treatment with intensive medical management and surgical management based on the severity of stenosis [1]. In acute occlusions, endovascular treatment (EVT) and carotid endarterectomy (CEA) with or without prior thrombolytics provide the best recanalization and functional outcomes when compared to intravenous or intra‐arterial thrombolysis alone. There is, however, less robust evidence on management of symptomatic chronic internal carotid artery (ICA) occlusion occurring in tandem with significant contralateral ICA stenosis [2]. In chronic ICA occlusion (ICAO), EVT and carotid endarterectomy (CEA) are technically unfeasible, but indirect procedures have been arising as safe and effective alternatives, notably CEA or stenting of contralateral stenotic ICA [3] and CEA or stenting of ipsilateral external carotid artery (ECA) [4]. We hereby report a case of symptomatic chronic ICAO that was managed with staggered angioplasty and stenting of bilateral common carotid artery (CCA) bifurcations. Methods We hereby present a case report. Results A 62‐year‐old male with atrial fibrillation and hypertension woke up with sudden dysarthria and right upper extremity and facial weakness. NIHSS at presentation was 4. Last seen normal 9 hours prior. Non‐contrast head computerized tomography (CT) did not show acute intracranial abnormality, CT angiogram of head and neck showed severe right ICA stenosis and complete occlusion of the left ICA at cervical, petrous and cavernous segments, with distal reconstitution at the supraclinoid segment with left proximal middle cerebral artery (MCA) thrombus. CT perfusion showed a core infarct volume of 8cc in left MCA territory, mismatch volume of 78cc and ratio of 10.8. Risks of acute neuro‐intervention were deemed to outweigh benefits. Given favorable perfusion imaging, and in concordance with the EXTEND trial [5], tPA was administered. The patient remained stable without hemorrhagic complications with residual deficits of mild right upper extremity weakness and mild expressive aphasia. MRI confirmed left ICA territory ischemic infarcts. Patient underwent stenting of the asymptomatic right ICA at the CCA bifurcation first, followed by left CCA stent after one month with impressive improvement in subsequent perfusion imaging. Conclusions Our case encourages consideration of well‐timed angioplasty and stenting in cases of chronic bilateral carotid artery disease especially when the asymptomatic side is also significantly stenotic

Abstract WP134: Long-Term Spontaneous Recanalization Rates Of Symptomatic Cervical Carotid Artery Occlusions

Background: Long-term rates of spontaneous recanalization of a previously acutely symptomatic cervical internal carotid artery occlusion (ICAO) have not been well characterized. The purpose of this study was to determine the rate of ICAO recanalization after index transient ischemic attack (TIA)/stroke in patients with serial vessel imaging, and the clinical factors associated with recanalization. Methods: This was a single-center, retrospective analysis from 2012-2020 of patients presenting with TIA/stroke due to an acute cervical ICAO. Patients were included if follow-up neck vessel imaging (CTA, MRA or ultrasound) was performed after index TIA/stroke. Recanalization was classified as the presence of continuous flow within the cervical carotid artery on repeat imaging. Patients were excluded if they received catheterization of the occluded artery during index admission or if the occlusion was previously documented (i.e., chronic). Results: Fifty-five patients were included in this study (mean age 61 ± 12 years, 27% female). The most common etiology for cervical ICAO was atherosclerosis (71%), followed by dissection (22%). Twelve patients (22%) demonstrated recanalization on follow-up imaging at a median of 125 days from index TIA/stroke (range 2-1072 days). Three patients with recanalization underwent carotid revascularization with endarterectomy or stenting. The administration of intravenous alteplase during index stroke admission was associated with recanalization (p=0.008). However, discharge antithrombotic regimen (antiplatelet or anticoagulation) or the etiology of the occlusion were not associated with recanalization (p=0.48 and p=0.73, respectively). There was no difference in 6-month recurrent TIA/stroke rates between those with recanalization (1 patient, 8.3%) and those without recanalization (4 patients, 9.3%), p=1.0. Conclusion: Cervical ICAO recanalization occurred in 12 (22%) patients in our cohort at follow-up and allowed for carotid revascularization procedures in 3 (25%) of these patients. Outpatient follow-up cervical vessel imaging should be considered after symptomatic cervical ICAO, as identifying spontaneous recanalization can alter management.

High posterior cerebral artery flow predicts ischemia recurrence in patients with internal carotid artery occlusion.

Recurrent stroke is a dreaded complication of symptomatic internal carotid artery occlusion (ICAO). Transcranial Duplex (TCD)-derived increased flow velocity in the ipsilateral posterior cerebral artery (PCA)-P2 segment indicates activated leptomeningeal collateral recruitment and hemodynamic impairment. Leptomeningeal collaterals are pial vascular connections between the anterior and posterior vascular territories. These secondary collateral routes are activated when primary collaterals via the Circle of Willis are insufficient. Our goal was to test the TCD parameter PCA-P2 flow for prediction of ipsilateral ischemia recurrence. We retrospectively analyzed clinical and ultrasound parameters in patients with ICAO. Together with clinical variables, we tested systolic PCA-P2 flow velocity as predictor of a recurrent ischemic event using logistic regression models. Of 111 patients, 13 showed a recurrent ischemic event within the same vascular territory. Increased flow in the ipsilateral PCA-P2 on transcranial ultrasound (median and interquartile range [IQR]: 60 cm/s [IQR 26] vs. 86 cm/s [IQR 41], p = <0.001), as well as previous transient ischemic attack (TIA) and low NIHSS were associated with ischemia recurrence. Combined into one model, accuracy of these parameters to predict recurrent ischemia was 89.2%. Our data suggest that in patients with symptomatic ICAO, flow increases in the ipsilateral PCA-P2 suggest intensified compensatory efforts when other collaterals are insufficient. Together with the clinical variables, this non-invasive and easily assessable duplex parameter detects ICAO patients at particular risk of recurrent ischemia.

Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions

ObjectivesParadoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. Materials and methodsWe prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. Results36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). ConclusionsIHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.

Successful throb endarterectomy in a patient with occlusion of the internal carotid artery

Strokes account for 15–25 % of confirmed cases internal carotid artery (ICA) occlusion. The frequency of ICA occlusion in asymptomatic patients is unknown. The strategy of treatment patients with symptomatic ICA occlusion has not been determined. A clinical observation is presented with the stage of surgical treatment of a 67‑year-old patient with a developed stroke in the basin of the left middle cerebral artery. The examination according to MSCT angiography revealed occlusion of the left ICA. To assess the brain perfusion, a single-photon emission computed tomography (SPECT) with 99mTc was performed. Throb endarterectomy of the left internal carotid artery was performed, with a control ultrasound examination on the 6th day after the operation and after 6 months the blood flow through the internal carotid artery was preserved. Control SPECT with 99mTc was performed, in comparison with the previous study, a significant improvement perfusion on both hemispheres is determined. Improvements in the neurological status were noted in the form of a complete regression of neurological symptoms. On the sixth day after surgical treatment, the patient was discharged in a satisfactory condition. During the hospital stay, the patient was “examined” using a questionnaire for assessing the quality of life – The Short Form‑36 (SF‑36) and MoCA (Montreal Cognitive Impairment Assessment Scale). The survey was conducted on the 15th day of inpatient treatment, before surgery, and on the 6th day after surgery. After 6 months, the patient was re-interviewed. The results obtained indicate a correlation between the improvement of brain perfusion and cognitive impairment, as well as a positive effect of revascularization of the internal carotid artery on the patient’s quality of life. The presented results indicate not only the possibility, but also the high efficiency of surgical treatment of occlusive lesions of the internal carotid artery. Surgical treatment in the early stages after occlusion against the background of the collapse of atherosclerotic plaque and thrombosis of the lumen is a determining factor in the successful restoration of blood flow, improvement of brain perfusion.

[Related factors of internal border-zone infarcts in patients with symptomatic chronic internal carotid artery occlusion].

Objective: To explore the related factors of internal border-zone (IBZ) infarcts in patients with symptomatic chronic internal carotid artery occlusion (CICAO). Methods: From January 2011 to May 2019, the symptomatic CICAO patients in the Second Affiliated Hospital of Soochow University and the Ninth People's Hospital of Suzhou were retrospectively analyzed. The patients were divided into IBZ group and non-IBZ group. The demographic data, laboratory examination and imaging data of the two groups were collected. Binary logistic regression analysis was used to identify the related factors of IBZ infarcts in patients with symptomatic CICAO. Results: A total of 185 patients (147 males and 38 females) were finally enrolled, with a mean age of (65±11) years old. There were 64 and 121 cases in IBZ group and non-IBZ group, respectively. The ratio of patients with ophthalmic artery (OA) reflux in IBZ group was 64.1% (41/64), which was significantly higher than that in non IBZ group [47.8% (55/121), P=0.037], while the ratio of patients with collateral compensation (ASTIN/SIR 3-4) in non-IBZ group was 66.1% (80/121), which was significantly higher than that in IBZ group [29.7% (19/64), P<0.001]. Multivariate logistic regression analysis showed that history of cerebral infarction (OR=2.233, 95%CI: 1.023-4.874), low density lipoprotein (LDL) (OR=1.516, 95%CI: 1.006-2.285) and OA reflux (OR=5.060, 95%CI: 1.160-22.081) were independent risk factors for IBZ infarcts in patients with symptomatic CICAO (all P<0.05); while prothrombin international normalized ratio (INR) (OR=0.010, 95%CI: 0.000-0.970) and collateral compensation (ASTIN/SIR 3-4) (OR=0.172, 95%CI: 0.079-0.373) were protective factors (all P<0.05). Conclusion: OA reflux, LDL, and history of cerebral infarction are independent risk factors for IBZ infarcts in patients with symptomatic CICAO, while INR and collateral compensation scores (ASTIN/SIR 3-4) are the protective factors.

Safety and Efficacy of Carotid Artery Stenting with the CGuard Double-layer Stent in Acute Ischemic Stroke

BackgroundDouble-layer stents show promising results in preventing periinterventional and postinterventional embolic events in elective settings of carotid artery stenting (CAS). We report a single-center experience with the CGuard stent in the treatment of acute ischemic stroke (AIS) due to symptomatic internal carotid artery (ICA) stenosis or occlusion with or without intracranial occlusion.MethodsWe retrospectively analyzed all patients who received a CGuard stent in the setting of AIS at our institution. Neuroimaging and clinical data were analyzed with the following primary endpoints: technical feasibility, acute and delayed stent occlusion or thrombosis, distal embolism, symptomatic intracranial hemorrhage (sICH) and functional outcome at 3 months.ResultsIn 33 patients, stenting with the CGuard was performed. Stent deployment was successful in all patients (28 with tandem occlusions, 5 with isolated ICA occlusion). Transient acute in-stent thrombus formation occurred in three patients (9%) without early stent occlusion. Delayed, asymptomatic stent occlusion was seen in 1 patient (3%) after 49 days. Asymptomatic periinterventional distal emboli occurred in 2 patients (6%), 1 patient experienced a transient ischemic attack 79 days after the procedure and 1 patient (3%) developed sICH. Favorable clinical outcome (mRS 0–2) at 3 months was achieved in 12 patients (36%) and the mortality rate was 24%.ConclusionThe CGuard use in emergencies was technically feasible, the safety has to be confirmed by further multicentric studies.

Chronic remote ischemic conditioning for symptomatic internal carotid or middle cerebral artery occlusion: A prospective cohort study.

AimsRemote ischemic conditioning (RIC) has been demonstrated to reduce recurrent stroke in patients with intracranial artery stenosis. This study aimed to evaluate the effects of RIC in patients with the symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion.MethodsThis study is based on a high‐volume single‐center prospective cohort study in China, which included patients with symptomatic ICA or MCA occlusion with impaired hemodynamics and receiving chronic RIC. Clinical follow‐up visits were performed regularly, and cardio‐cerebrovascular events were assessed.ResultsIn total, 131 patients (68 with ICA occlusion and 63 with MCA occlusion; mean age, 52.6 ± 13.7 years; stroke, 73.5%; transient ischemic attack TIA, 26.5%) qualified for the analysis; the mean follow‐up period was 8.8 years (range, 3–14 years). The compliance of RIC was 95.6 ± 3.7%, and no associated severe adverse events happened. The annual risk of ischemic stroke and ischemic cerebrovascular events was 2.4% and 3.3%, respectively. The cumulative probabilities of ischemic cerebrovascular events and major adverse cardiovascular and cerebrovascular events were 32.8% and 44.8% at 14 years, respectively.ConclusionIn patients with symptomatic ICA or MCA occlusion with impaired hemodynamics, chronic RIC is well‐tolerated, and it appears to be associated with a low annual risk of ischemic stroke and cardio‐cerebrovascular events.

Multimodal Recanalization for Subacute Symptomatic Internal Carotid Artery Occlusion Due to Atherosclerosis: Outcomes and Notes on Hybrid Techniques

Subacute internal carotid artery occlusion (ICAO) is associated with ipsilateral recurrent stroke, and successful recanalization of ICAO can improve cerebral blood perfusion (CBP) and prevent stroke. However, the optimal treatment remains controversial. We conducted a retrospective analysis of patients with subacute symptomatic ICAO due to atherosclerosis treated at our center. The hybrid surgical procedures included carotid endarterectomy, Fogarty balloon catheter embolectomy, aspiration thrombectomy, and percutaneous transluminal angioplasty/stenting. Recanalization rates, CBP improvement, stroke recurrence, and restenosis/reocclusion were investigated. Fourteen symptomatic atherosclerotic ICAO patients (type A, 4; type C, 10; men, 11; women, 3; average age, 68.1±7.9years) in the subacute phase were treated with a multimodal recanalization technique. Symptoms included mild cerebral infarction, transient ischemic attack (TIA), and amaurosis fugax. The average onset-to-treatment time was 18.1±4.8days. The successful recanalization (thrombolysis in cerebral ischemia grade 2 or 3) rate was 100%. The ipsilateral-to-contralateral mean transit time ratio was significantly lower at the 1-year follow-up than preoperatively (1.01±0.05 vs. 1.26±0.09, P<0.0001). There was one case of restenosis detected 1year after surgery and no cases of reocclusion. During the 28.3±10.0months of follow-up, only two cases of TIA occurred. The average modified Rankin Scale score and National Institute of Health Stroke Scale score were significantly lower at the most recent follow-up than before recanalization (1.21±0.89 vs. 1.86±0.66, P=0.0003; 1.36±1.55 vs. 2.00±1.88, P=0.0066). Multimodal recanalization techniques performed in a hybrid operation theater can safely achieve high recanalization rates in atherosclerotic ICAO patients in the subacute phase, which can be beneficial for recovering CBP and preventing stroke.

Leptomeningeal collateral activation indicates severely impaired cerebrovascular reserve capacity in patients with symptomatic unilateral carotid artery occlusion

For patients with symptomatic unilateral internal carotid artery (ICA) occlusion, impaired cerebrovascular reactivity (CVR) indicates increased stroke risk. Here, the role of collateral activation remains a matter of debate, whereas angio-anatomical collateral abundancy does not necessarily imply sufficient compensatory flow provided. We aimed to further elucidate the role of collateral activation in the presence of impaired CVR. From a prospective database, 62 patients with symptomatic unilateral ICA occlusion underwent blood oxygenation-level dependent (BOLD) fMRI CVR imaging and a transcranial Doppler (TCD) investigation for primary and secondary collateral activation. Descriptive statistic and multivariate analysis were used to evaluate the relationship between BOLD-CVR values and collateral activation. Patients with activated secondary collaterals exhibited more impaired BOLD-CVR values of the ipsilateral hemisphere (p = 0.02). Specifically, activation of leptomeningeal collaterals showed severely impaired ipsilateral hemisphere BOLD-CVR values when compared to activation of ophthalmic collaterals (0.05 ± 0.09 vs. 0.12 ± 0.04, p = 0.005). Moreover, the prediction analysis showed leptomeningeal collateral activation as a strong independent predictor for ipsilateral hemispheric BOLD-CVR. In our study, ipsilateral leptomeningeal collateral activation is the sole collateral pathway associated with severely impaired BOLD-CVR in patients with symptomatic unilateral ICA occlusion.

Mapping Cerebrovascular Reactivity Impairment in Patients With Symptomatic Unilateral Carotid Artery Disease.

BackgroundComprehensive hemodynamic impairment mapping using blood oxygenation‐level dependent (BOLD) cerebrovascular reactivity (CVR) can be used to identify hemodynamically relevant symptomatic unilateral carotid artery disease.Methods and ResultsThis prospective cohort study was conducted between February 2015 and July 2020 at the Clinical Neuroscience Center of the University Hospital Zurich, Zurich, Switzerland. One hundred two patients with newly diagnosed symptomatic unilateral internal carotid artery (ICA) occlusion or with 70% to 99% ICA stenosis were included. An age‐matched healthy cohort of 12 subjects underwent an identical BOLD functional magnetic resonance imaging examination. Using BOLD functional magnetic resonance imaging with a standardized CO2 stimulus, CVR impairment was evaluated. Moreover, embolic versus hemodynamic ischemic patterns were evaluated on diffusion‐weighted imaging. Sixty‐seven patients had unilateral ICA occlusion and 35 patients unilateral 70% to 99% ICA stenosis. Patients with ICA occlusion exhibited lower whole‐brain and ipsilateral hemisphere mean BOLD‐CVR values as compared with healthy subjects (0.12±0.08 versus 0.19±0.04, P=0.004 and 0.09±0.09 versus 0.18±0.04, P<0.001) and ICA stenosis cohort (0.12±0.08 versus 0.16±0.05, P=0.01 and 0.09±0.09 versus 0.15±0.05, P=0.01); however, only 40 (58%) patients of the cohort showed significant BOLD‐CVR impairment. Conversely, there was no difference in mean BOLD‐CVR values between healthy patients and patients with ICA stenosis, although 5 (14%) patients with ICA stenosis showed a significant BOLD‐CVR impairment. No significant BOLD‐CVR difference was discernible between patients with hemodynamic ischemic infarcts versus those with embolic infarct distribution (0.11±0.08 versus 0.13±0.06, P=0.12).ConclusionsComprehensive BOLD‐CVR mapping allows for identification of hemodynamically relevant symptomatic unilateral carotid artery stenosis or occlusion.

Recanalization of symptomatic chronic internal carotid artery occlusions by hybrid treatment

ObjectiveTo evaluate the efficacy and safety of hybrid revascularization by carotid endarterectomy and endovascular intervention in the treatment of chronic internal carotid artery occlusion (ICAO). MethodsWe performed a retrospective analysis of patients who received hybrid treatment for symptomatic chronic ICAO between December 2016 and December 2018. Fifty-six patients with long-segment ICAO were enrolled and divided into the short duration (1–3 months) and long ICAO duration (>3 months) groups, and their clinical and angiographic data were analyzed. ResultsThe mean duration was 106.8 ± 36.1 days from the date of ICAO diagnosis to revascularization. Totally, 10 patients (17.8%, n = 56) in the short duration group while no patients in the long duration group failed recanalization (n = 7). Perioperative complications included intraoperative thromboembolism in 1 (1.8%) patient and subarachnoid hemorrhage in 2 (3.6%) patients. Early phase postoperative hypertension was noted in 11 (19.6%) patients and cervical hemorrhage in 1 (1.8%) patient. No severe neurological deficits occurred. Overall, the 6-month modified Rankin score, Mini-mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in patients with successful recanalization significantly improved versus the baseline (P < 0.05). After successful recanalization, the long duration group demonstrated more stents for revascularization compared with the short duration group (P < 0.05). Five (10.8%) patients had recurrent transient ischemic attack, and 1 (2.2%) patient developed stroke in the successful revascularization group during 6 months of follow-up. ICA restenosis occurred in 5 (8.9%) patients and re-occlusion was noted in 1 (1.8%) patient. ConclusionsHybrid operation may be feasible and effective for patients with symptomatic chronic complete ICAO according to our limited data. The original occlusion site from the carotid bifurcation and the duration of ICAO should be considered as independent indicators for successful recanalization as well as perioperative outcomes.