Endovascular treatment in proximal and intracranial carotid occlusion 9 hours after symptom onset
- 135 Downloads
A debate is emerging over whether the treatment time window in acute stroke can be extended beyond 6 h if penumbral tissue can be identified. Treatment decisions are very difficult in cases of tandem proximal carotid occlusion with arterioarterial intracranial embolism. We enter this debate with the present report on a case of atherosclerotic proximal carotid occlusion and resulting periocclusional carotid T embolism that was successfully treated 9 h after symptom onset.
The case of a 68-year-old man with fluctuating symptoms of right-hemispheric stroke is presented (NIHSS score 12–20 on admission). CT angiography demonstrated proximal carotid occlusion and periocclusional embolism of the entire internal carotid artery (ICA) including the carotid T segment. Penumbral tissue was diagnosed by nonenhanced and perfusion CT imaging 7.5 h after symptom onset. Treatment was initiated 9 h after symptom onset by passing the proximal occlusion with a microcatheter and local administration of recombinant tissue plasminogen activator (rt-PA) into the carotid T segment at the level of posterior communicating artery (PCoA) origin.
Recanalization of the ICA and middle cerebral artery was accomplished within 1 h by flow establishment via the PCoA. The atherosclerotic proximal ICA occlusion was not stented due to the risk of embolism from remnant thrombi in the petrous and cavernous ICA segments. Follow-up MRI showed only mild haemorrhagic infarct transformation of the initial infarct core. The patient was discharged from hospital 18 days after treatment with NIHSS score 5.
If penumbral tissue can be conclusively identified, endovascular treatment in proximal and intracranial tandem occlusion can be successful, even in treatments initiated 6–9 h after stroke onset. If the intracranial flow after recanalization can be established via the circle of Willis, the underlying proximal ICA occlusion may not require treatment.
KeywordsAcute stroke Thrombolysis Endovascular Intraarterial Carotid artery
We thank Dr. Jarold Knispel, Hamburg, for his language advice
Conflict of interest statement
We declare that we have no conflict of interest.
- 2.Rother J, Schellinger PD, Gass A, Siebler M, Villringer A, Fiebach JB, Fiehler J, Jansen O, Kucinski T, Schoder V, Szabo K, Junge-Hulsing GJ, Hennerici M, Zeumer H, Sartor K, Weiller C, Hacke W; Kompetenznetzwerk Schlaganfall Study Group (2002) Effect of intravenous thrombolysis on MRI parameters and functional outcome in acute stroke <6 hours. Stroke 33:2438–2445PubMedCrossRefGoogle Scholar
- 3.Wintermark M, Flanders AE, Velthuis B, Meuli R, van Leeuwen M, Goldsher D, Pineda C, Serena J, van der Schaaf I, Waaijer A, Anderson J, Nesbit G, Gabriely I, Medina V, Quiles A, Pohlman S, Quist M, Schnyder P, Bogousslavsky J, Dillon WP, Pedraza S (2006) Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke 37:979–985PubMedCrossRefGoogle Scholar
- 4.Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F (1999) Intra-arterial prourokinase for acute ischemic stroke: PROACT II study – a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA 282:2003–2011PubMedCrossRefGoogle Scholar
- 6.von Kummer R, Bourquain H, Bastianello S, Bozzao L, Manelfe C, Meier D, Hacke W (2001) Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology 219:95–100Google Scholar
- 9.Hacke W, Furlan A; for the DIAS-2 Investigators (2007) Results from the Phase III study of Desmoteplase In Acute Ischemic Stroke Trial 2 (DIAS 2). Oral presentation. XVI European Stroke Conference, Glasgow, UK. Available at: http://www.esc-archive.eu/glasgow07. Accessed 4 Dec 2007
- 11.Zaidat OO, Suarez JI, Santillan C, Sunshine JL, Tarr RW, Paras VH, Selman WR, Landis DM (2002) Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion. Stroke 33:1821–1826. Comment in: Stroke. 2002;33:1827PubMedCrossRefGoogle Scholar