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  • Carotid Occlusion Revisited: Using Imaging Modalities to Predict Patients Who Would Benefit from Carotid Thromboendarterectomy

    Final Number:

    Kendrick Johnson; Klopfenstein Jeffrey

    Study Design:

    Subject Category:
    Ischemic Stroke

    Meeting: AANS/CNS Cerebrovascular Section 2017 Annual Meeting

    Introduction: Carotid occlusion in the setting of Stage II hemodynamic failure is associated with high rates of subsequent cerebral ischemia. Carotid Thromboendarterectomy (CTEA) is thought to be an effective intervention in a select group of patients with carotid occlusion. To date, the effect of CTEA on cerebral hemodynamics of the affected hemisphere has not been assessed.

    Methods: Presented, is a single center, retrospective review of patients who underwent CTEA after presenting with symptomatic acute internal carotid occlusion and stage II hemodynamic failure. Patient inclusion criteria were carotid occlusion confirmed by angiography with siphon reflux and computed tomography perfusion (CTP) studies demonstrating steal phenomenon, consistent with stage II hemodynamic failure. All subjects underwent postoperative CTP to assess hemodynamic status and were followed for the development of stroke or any cause mortality.

    Results: Ten patients conformed to all inclusion criteria. Mean time to intervention was 49 hours (range 2-240 hours). Seven (70%) patients returned to stage 0 cerebral hemodynamic state. The remaining 3 (30%) patients improved to stage I cerebral hemodynamic state. CTEA was successful in all patients, as confirmed by intraoperative restoration of flow. On follow up, nine patients had postoperative angiographic imaging available for review. Of those available for review, all patients showed persistent patency of the carotid artery with restored antegrade flow. Upon discharge, mean NIHSS was 4.1, compared to mean preoperative NIHSS of 6.6. No strokes or any cause mortality were noted within the first 30 postoperative days.

    Conclusions: CTEA for acute carotid occlusion can be performed safely and appears to provide partial or complete restoration of normal cerebral hemodynamics in patients presenting with documented stage II hemodynamic failure. Consideration should be given to routine hemodynamic assessment of patients presenting with symptomatic carotid occlusion with subsequent CTEA for select patients with stage II hemodynamic failure.

    Patient Care: CTEA safely results in cerebrovascular flow restoration in the vast majority of symptomatic, acute carotid occlusion patients presenting with evidence of ICA petrocavernous reflux and “misery perfusion”. It is in this subset of patients who would otherwise likely progress to potentially devastating cerebral ischemia and thus, consideration should be given to CTEA whenever feasible.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe current imaging modalities effective in the evaluation of acute Carotid Occlusion 2) Describe indications for Carotid Thromboendarectectomy using the proposed treatment algorithm. 3) Predict patients who would benefit from surgical intervention for the acutely occluded carotid artery.

    References: McCormick PW, Spetzler RF, Bailes JE, Zambranski JM, Frey JL: Thromboendarterectomy of the symptomatic occluded internal carotid artery. J Neurosurg 76:752–758, 1992 Derdeyn CP, Videen TO, Yundt KD, Fritsch SM, Carpenter DA, Grubb RL, Powers WJ: Variability of cerebral blood volume and oxygen extraction: stages of cerebral hemodynamic impairment revisited. Brain 125:595–607, 2002 EC/IC Bypass Study Group: Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke-results of an international randomized trial. NEJM 313(19):1191-1200, 1985 Grubb RL Jr, Derdeyn CP, Fritsch SM, Carpenter DA, Yundt KD, Videen TO, Spitznagel EL, Powers WJ: Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA 280(12):1055-60, 1998 Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP, Derdeyn CP: Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: The Carotid Occlusion Surgery Study randomized trial. JAMA 306(18):1983-1992, 2011 Przybylski GJ, Yonas H, Smith HA: Reduced stroke risk in patients with compromised cerebral blood flow reactivity treated with superficial temporal artery to distal middle cerebral artery bypass surgery. J Stroke Cerebrovasc Dis 7(5):302-9, 1998

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