Stroke in patients with occlusion of the internal carotid artery: options for treatment

Abstract

Ischemic stroke may occur in patients in whom vascular imaging shows the ipsilateral internal carotid artery (ICA) to be occluded. In younger patients this is often due to carotid artery dissection, while in older people this most likely results from cardiac embolism or thrombosis secondary to high-grade stenosis at the carotid bifurcation. Interventional techniques aim at recanalization of the carotid artery for early restoration of cerebral blood flow and secondary prevention of future strokes. In chronic ICA occlusion the ischemic infarct may be related to hemodynamic compromise. In this situation, extracranial-intracranial bypass surgery was introduced, but its role remains still unclear. Ischemic stroke may also occur in patients with a chronic occlusion of the contralateral ICA. This situation demands the usual stroke treatment, but surgical and neuroradiological interventions face a higher risk than unilateral vascular pathology. Medical treatment supports stroke prevention in carotid artery occlusion.

Keywords::

• carotid artery occlusion
• carotid surgery
• interventional recanalization
• ischemic stroke
• stroke prevention
• vascular imaging

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Rapid multimodal imaging of the cerebral arteries, of the cerebral hemodynamics and of brain water diffusion is required for assessing the potential risk of an internal carotid artery (ICA) occlusion for subsequent manifestation of an ischemic stroke.

• The pathogenesis underlying an ICA occlusion in a given patient is an important prognostic factor for patient outcome.

• ICA dissection is a severe disorder, particularly when associated with large embolic territorial brain infarction.

• Systemic thrombolysis often fails to induce rapid recanalization in acute ICA additional occlusion, which typically goes along with an occlusion of an intracranial carotid T occlusion.

• Surgical and especially interventional therapeutic approaches have been shown to be suited for rapid ICA recanalization within 48 h after symptom onset. They need to be compared regarding recanalization rate, long-term efficacy and safety.

• Medical treatment typically relies on platelet aggregation inhibitors in chronic ICA occlusions.

• A chronic ICA occlusion enhances the risk of interventions on a symptomatic process of the contralateral ICA.

• Extracranial-intracranial bypass surgery appears attractive, but has not been proven to be beneficial in chronic ICA occlusion even in highly selected patients who were subjected to modern multimodal imaging.

Notes