Introduction: Carotid occlusion in the setting of stage II hemodynamic failure is associated with high rates of cerebral ischemia. Carotid Thromboendarterectomy (CTEA) is thought to be an effective intervention in a select group of patients with carotid occlusion. To date, the association of degree of Internal Carotid Artery (ICA) reflux on Digital Subtraction Angiography (DSA) with operative and functional outcome has yet to be fully elucidated.

Methods: Presented, is a single center, retrospective review of patients who underwent CTEA after presenting with symptomatic acute ICA and stage II hemodynamic failure. Based on previously reported data, we selected patients with at least petrocavernous reflux on CCA injection for potential revascularization. All subjects underwent postoperative CTP to assess hemodynamic status and were followed for the development of stroke or any cause mortality.

Results: Ten patients met 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. CTEA was successful in all patients, as confirmed by intraoperative restoration of flow. On follow up, nine (90%) patients had postoperative angiographic imaging available for review. Of those, all patients showed persistent patency of the artery. 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: Degree of ICA reflux on DSA is an adequate predictor of successful revascularization with CTEA in the setting of acute carotid occlusion. CTEA for acute carotid occlusion can be performed safely and provides restoration of normal cerebral hemodynamics in patients presenting with documented stage II hemodynamic failure. Consideration should be given to routine angiographic assessment of patients presenting with symptomatic ICA occlusion with subsequent CTEA for select patients with adequate reflux.

Patient Care: This review represents a potential new treatment paradigm with regards to acute ICA occlusion. Previously though of as "do not touch" lesions, acute ICA occlusion can now be treated successfully in carefully selected patients.

Learning Objectives: 1.Review selection criteria for patient's who would benefit from Carotid Thromboendarterectomy 2.Review the association of ICA reflux on DSA with improved intraooperative revascularization. 3.Review the utility of evaluation of hemodynamic state with Perfusion imaging.

References: 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