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01-01-2021 | Stroke | Original Communication

Symptomatic isolated internal carotid artery occlusion with initial medical management: a monocentric cohort

Authors: Adrien Ter Schiphorst, Nicolas Gaillard, Cyril Dargazanli, Isabelle Mourand, Lucas Corti, Mahmoud Charif, Xavier Ayrignac, Anaïs Lippi, Stéphane Bouly, Lalu Thibault, Denis Sablot, Genevieve Blanchet-Fourcade, Nicolas Landragin, Vincent Costalat, Claire Duflos, Caroline Arquizan

Published in: Journal of Neurology | Issue 1/2021

Abstract

Background

Symptomatic isolated carotid artery occlusions (ICAO) can lead to disability, recurrent stroke, and mortality, but natural history and best therapeutic management remain poorly known. The objective of this study was to describe our cohort of ICAO patients with an initial medical management.

Methods

We conducted a retrospective study including consecutive patients admitted to our Comprehensive Stroke Center for ICAO within 24 h after stroke onset between January 2016 and September 2018. Patients with immediate endovascular therapy (EVT) were excluded. Medical treatment was based on anticoagulation (delayed by 24 h if intravenous thrombolysis was performed). ‘Rescue’ EVT was considered if first-week neurological deterioration (FWND) occurred.

Results

Fifty-six patients were included, with a median National Institutes of Health Stroke Scale (NIHSS) of 3. Eleven patients (20%) had FWND during the first week, four benefited from rescue EVT. A mismatch volume > 40 cc on initial perfusion imaging and FLAIR vascular hyperintensities were associated with FWND (p = 0.007 and p = 0.009, respectively). Thirty-eight patients (69%) had a good outcome (modified Rankin Scale mRS 0–2) at 3 months, 36 (69%) had an excellent outcome (mRS 0–1). Seventeen patients (38%) had carotid patency on 3-month control imaging. Recurrences occurred in six (13%) of the survivors (mean follow-up: 13.6 months).

Conclusion

Our results suggest that the prognosis of patients with acute ICAO was favorable with a medical strategy, albeit a substantial rate of FWND and recurrence. FWND was well predicted by a core-perfusion mismatch volume > 40 cc. Randomized controlled trials are necessary to assess the benefit of EVT in ICAO.

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Powers WJ (2003) Atherosclerotic carotid artery occlusion. Curr Treat Options Cardiovasc Med 5:501–509. https://doi.org/10.1007/s11936-003-0039-3CrossRefPubMed

Flaherty ML, Flemming KD, McClelland R et al (2004) Population-based study of symptomatic internal carotid artery occlusion: incidence and long-term follow-up. Stroke 35:e349–e352. https://doi.org/10.1161/01.STR.0000135024.54608.3fCrossRefPubMed

Paciaroni M, Caso V, Venti M et al (2005) Outcome in patients with stroke associated with internal carotid artery occlusion. Cerebrovasc Dis 20:108–113. https://doi.org/10.1159/000086800CrossRefPubMed

Paciaroni M, Agnelli G, Caso V et al (2012) Intravenous thrombolysis for acute ischemic stroke associated to extracranial internal carotid artery occlusion: the ICARO-2 study. Cerebrovasc Dis 34:430–435. https://doi.org/10.1159/000345081CrossRefPubMed

Hankey GJ, Warlow CP (1991) Prognosis of symptomatic carotid artery occlusion. Cerebrovasc Dis 1:245–256. https://doi.org/10.1159/000108851CrossRef

Klijn CJ, Kappelle LJ, Tulleken CA, van Gijn J (1997) Symptomatic carotid artery occlusion. A reappraisal of hemodynamic factors. Stroke 28:2084–2093. https://doi.org/10.1161/01.str.28.10.2084CrossRefPubMed

Klijn CJM, van Buren PA, Kappelle LJ et al (2000) Outcome in patients with symptomatic occlusion of the internal carotid artery. Eur J Vasc Endovasc Surg 19:579–586. https://doi.org/10.1053/ejvs.2000.1129CrossRefPubMed

Grubb RL, Derdeyn CP, Fritsch SM et al (1998) Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 280:6. https://doi.org/10.1001/jama.280.12.1055CrossRef

Lanari A, Silvestrelli G (2012) Acute and chronic carotid occlusion syndromes. In: Paciaroni M, Agnelli G, Caso V, Bogousslavsky J (eds) Frontiers of neurology and neuroscience. Karger, Basel, pp 185–190

10.

Bhatia R, Hill MD, Shobha N et al (2010) Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 41:2254–2258. https://doi.org/10.1161/STROKEAHA.110.592535CrossRefPubMed

11.

Paciaroni M, Balucani C, Agnelli G et al (2012) Systemic thrombolysis in patients with acute ischemic stroke and internal carotid artery occlusion: the ICARO study. Stroke 43:125–130. https://doi.org/10.1161/STROKEAHA.111.630624CrossRefPubMed

12.

Yeo LLL, Kong WY, Paliwal P et al (2016) Intravenous thrombolysis for acute ischemic stroke due to cervical internal carotid artery occlusion. J Stroke Cerebrovasc Dis 25:2423–2429. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.06.014CrossRefPubMed

13.

Goyal M, Menon BK, van Zwam WH et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet Lond Engl 387:1723–1731. https://doi.org/10.1016/S0140-6736(16)00163-XCrossRef

14.

Mokin M, Kass-Hout T, Kass-Hout O et al (2012) Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes. Stroke 43:2362–2368. https://doi.org/10.1161/STROKEAHA.112.655621CrossRefPubMed

15.

Paciaroni M, Inzitari D, Agnelli G et al (2015) Intravenous thrombolysis or endovascular therapy for acute ischemic stroke associated with cervical internal carotid artery occlusion: the ICARO-3 study. J Neurol 262:459–468. https://doi.org/10.1007/s00415-014-7550-1CrossRefPubMed

16.

Jadhav A, Panczykowski D, Jumaa M et al (2018) Angioplasty and stenting for symptomatic extracranial non-tandem internal carotid artery occlusion. J NeuroInterv Surg 10:1155–1160. https://doi.org/10.1136/neurintsurg-2018-013810CrossRefPubMed

17.

Adams HP, Bendixen BH, Leira E et al (1999) Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 53:122–125. https://doi.org/10.1212/wnl.53.1.122CrossRefPubMed

18.

Damania D, Kung NT-M, Jain M et al (2016) Factors associated with recurrent stroke and recanalization in patients presenting with isolated symptomatic carotid occlusion. Eur J Neurol 23:127–132. https://doi.org/10.1111/ene.12819CrossRefPubMed

19.

EC/IC Bypass Study Group (1985) Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. N Engl J Med 313:1191–1200. https://doi.org/10.1056/NEJM198511073131904CrossRef

20.

Powers WJ, Clarke WR, Grubb RL et al (2011) Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the carotid occlusion surgery study randomized trial. JAMA 306:1983–1992. https://doi.org/10.1001/jama.2011.1610CrossRefPubMedPubMedCentral

21.

Seners P, Turc G, Tisserand M et al (2014) Unexplained early neurological deterioration after intravenous thrombolysis: incidence, predictors, and associated factors. Stroke 45:2004–2009. https://doi.org/10.1161/STROKEAHA.114.005426CrossRefPubMed

22.

Kernan WN, Ovbiagele B, Black HR et al (2014) Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 45:2160–2236. https://doi.org/10.1161/STR.0000000000000024CrossRefPubMed

23.

Rebello LC, Bouslama M, Haussen DC et al (2017) Endovascular treatment for patients with acute stroke who have a large ischemic core and large mismatch imaging profile. JAMA Neurol 74:34. https://doi.org/10.1001/jamaneurol.2016.3954CrossRefPubMed

24.

Hacke W (1995) Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA J Am Med Assoc 274:1017–1025. https://doi.org/10.1001/jama.274.13.1017CrossRef

25.

Adams HP, Bendixen BH, Kappelle LJ et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41. https://doi.org/10.1161/01.STR.24.1.35CrossRefPubMed

26.

Hause S, Oldag A, Breja A et al (2019) Acute symptomatic extracranial internal carotid occlusion—natural course and clinical impact. Vasa. https://doi.org/10.1024/0301-1526/a000826CrossRefPubMed

27.

Albers GW, Marks MP, Kemp S et al (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378:708–718. https://doi.org/10.1056/NEJMoa1713973CrossRefPubMedPubMedCentral

28.

Mazya MV, Cooray C, Lees KR et al (2018) Minor stroke due to large artery occlusion. When is intravenous thrombolysis not enough? Results from the SITS International Stroke Thrombolysis Register. Eur Stroke J 3:29–38. https://doi.org/10.1177/2396987317746003CrossRefPubMed

29.

Xu B, Li C, Guo Y et al (2017) Current understanding of chronic total occlusion of the internal carotid artery (review). Biomed Rep. https://doi.org/10.3892/br.2017.1033CrossRefPubMedPubMedCentral

30.

Legrand L, Tisserand M, Turc G et al (2015) Do FLAIR vascular hyperintensities beyond the DWI lesion represent the ischemic penumbra? Am J Neuroradiol 36:269–274. https://doi.org/10.3174/ajnr.A4088CrossRefPubMedPubMedCentral

31.

Saver JL, Goyal M, Bonafe A et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–2295. https://doi.org/10.1056/NEJMoa1415061CrossRefPubMed

32.

Campbell BCV, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018. https://doi.org/10.1056/NEJMoa1414792CrossRefPubMed

33.

Dargazanli C, Arquizan C, Gory B et al (2017) Mechanical thrombectomy for minor and mild stroke patients harboring large vessel occlusion in the anterior circulation: a multicenter cohort study. Stroke 48:3274–3281. https://doi.org/10.1161/STROKEAHA.117.018113CrossRefPubMed

34.

Cagnazzo F, Dargazanli C, Lefevre P-H et al (2019) Chronic occlusion of the internal carotid artery: endovascular revascularization technique of long occlusive lesions. J Neuroradiol. https://doi.org/10.1016/j.neurad.2019.05.005CrossRefPubMed

Title: Symptomatic isolated internal carotid artery occlusion with initial medical management: a monocentric cohort
Authors: Adrien Ter Schiphorst
Nicolas Gaillard
Cyril Dargazanli
Isabelle Mourand
Lucas Corti
Mahmoud Charif
Xavier Ayrignac
Anaïs Lippi
Stéphane Bouly
Lalu Thibault
Denis Sablot
Genevieve Blanchet-Fourcade
Nicolas Landragin
Vincent Costalat
Claire Duflos
Caroline Arquizan
Publication date: 01-01-2021
Publisher: Springer Berlin Heidelberg
Keywords: Stroke
Anticoagulant
Thrombectomy
Published in: Journal of Neurology / Issue 1/2021
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-020-10118-9

At a glance: The STEP trials

Springer Medicine

Symptomatic isolated internal carotid artery occlusion with initial medical management: a monocentric cohort

Abstract

Background

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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