Management of Patients With Atherosclerotic Carotid Occlusion

Cerebrovascular Disorders (Harold P. Adams Jr., Section Editor)

Opinion statement

• Patients with acute ischemic stroke due to atherosclerotic carotid artery occlusion (ACAO) should receive intravenous tissue plasminogen activator (alteplase) if they meet eligibility criteria of the National Institute of Neurological Disorders and Stroke (NINDS) or the European Cooperative Acute Stroke Study III (ECASS III). • Patients with acute stroke due to ACAO who are not eligible for intravenous tissue plasminogen activator should receive aspirin. Heparin or heparin-like drugs do not improve outcome and should not be used. • Therapy for prevention of recurrent stroke in patients with ACAO should consist of lifestyle modifications, risk factor intervention, and antiplatelet drugs. Warfarin is not indicated. • Extracranial-intracranial bypass surgery provides no benefit over medical therapy in preventing recurrent stroke in a general population of patients with ACAO or in any subgroups selected by clinical, arteriographic, or hemodynamic criteria. • Other surgical or endovascular procedures have no proven value in treating or preventing stroke due to ACAO. • Asymptomatic carotid occlusion has a benign prognosis and requires no specific treatment other than lifestyle modification and risk factor intervention.

References and Recommended Reading

  1. 1.
    Pessin MS, Duncan GW, Mohr JP, Poskaner DC. Clinical and angiographic features of carotid transient ischemic attacks. N Engl J Med. 1977;296:358–62.PubMedCrossRefGoogle Scholar
  2. 2.
    Mead GE, Murray H, Farrell A, O’Neill PA, McCollum CN. Pilot study of carotid surgery for acute stroke. Br J Surg. 1997;84:990–2.PubMedCrossRefGoogle Scholar
  3. 3.
    Marquardt L, Fairhead JF, Rothwell PM. Lower rates of intervention for symptomatic carotid stenosis in women than in men reflect differences in disease incidence. A population-based study. Stroke. 2010;41:16–20.PubMedCrossRefGoogle Scholar
  4. 4.
    Paciaroni M, Caso V, Venti M, et al. Outcome in patients with stroke associated with internal carotid artery occlusion. Cerebrovasc Dis. 2005;20:108–13.PubMedCrossRefGoogle Scholar
  5. 5.
    Rothwell PM, Eliasziw M, Gutnikov SA, et al. Carotid Endarterectomy Trialists’ Collaboration. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361:107–16.PubMedCrossRefGoogle Scholar
  6. 6.
    Thanvi B, Robinson T. Complete occlusion of extracranial carotid artery: clinical features, pathophysiology, diagnosis and management. Postgrad Med J. 2007;83:95–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Hankey GJ, Warlow CP. Prognosis of symptomatic carotid occlusion-an overview. Cerebrovasc Dis. 1991;1:245–56.CrossRefGoogle Scholar
  8. 8.
    Klijn CJM, Kappelle LJ, Tulleken CAF, van Gijn J. Symptomatic carotid artery occlusion: a reappraisal of hemodynamic factors. Stroke. 1997;28:2084–93.PubMedCrossRefGoogle Scholar
  9. 9.
    Grubb Jr RL, Derdeyn CP, Fritsch SM, et al. Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. JAMA. 1998;280:1055–60.PubMedCrossRefGoogle Scholar
  10. 10.
    Klijn CJ, van Buren PA, Kappelle LJ, et al. Outcome in patients with symptomatic occlusion of the internal carotid artery. Eur J Vasc Endovasc Surg. 2000;19:579–86.PubMedCrossRefGoogle Scholar
  11. 11.
    Flaherty ML, Flemming KD, McClelland R, Jorgensen NW, Brown Jr RD. Population-based study of symptomatic internal carotid artery occlusion. Incidence and long-term follow-up. Stroke. 2004;35:e349–52.PubMedCrossRefGoogle Scholar
  12. 12.
    Derdeyn CP, Grubb Jr RL, Powers WJ. Cerebral hemodynamic impairment: methods of measurement and association with stroke risk. Neurology. 1999;53:251–9.PubMedGoogle Scholar
  13. 13.
    Ogasawara K, Ogawa A, Terasaki K, et al. Use of cerebrovascular reactivity in patients with symptomatic major cerebral artery occlusion to predict 5-year outcome: comparison of xenon-133 and iodine-123-IMP single-photon emission computed tomography. J Cereb Blood Flow Metab. 2002;22:1142–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Yamauchi H, Fukuyama H, Nagahama Y, et al. Significance of increased oxygen extraction fraction in five-year prognosis of major cerebral arterial occlusive diseases. J Nucl Med. 1999;40:1992–8.PubMedGoogle Scholar
  15. 15.
    Ogasawara K, Ogawa A, Yoshimoto T. Cerebrovascular reactivity to acetazolamide and outcome in patients with symptomatic internal carotid or middle cerebral artery occlusion: a xenon-133 single-photon emission computed tomography study. Stroke. 2002;33:1857–62.PubMedCrossRefGoogle Scholar
  16. 16.
    Powers WJ, Clarke WR, Grubb RL Jr, et al. Results of the Carotid Occlusion Surgery Study [Presentation LB2]. Presented at the American Heart Association 2011 International Stroke Conference, Los Angeles, CA; February 2, 2011. Accessed April 30, 2011 at
  17. 17.
    Powers WJ, Derdeyn CP, Fritsch SM, et al. Benign prognosis of never-symptomatic carotid occlusion. Neurology. 2000;54:878–82.PubMedGoogle Scholar
  18. 18.
    Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38:1655–711.PubMedCrossRefGoogle Scholar
  19. 19.
    Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:227–76.PubMedCrossRefGoogle Scholar
  20. 20.
    The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–7.CrossRefGoogle Scholar
  21. 21.
    Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–29.PubMedCrossRefGoogle Scholar
  22. 22.
    Kimura K, Iguchi Y, Shibazaki K, Aoki J, Uemura J. Early recanalization rate of major occluded brain arteries after intravenous tissue plasminogen activator therapy using serial magnetic resonance angiography studies. Eur Neurol. 2009;62:287–92.PubMedCrossRefGoogle Scholar
  23. 23.
    Rudolf J, Neveling M, Grond M, et al. Stroke following internal carotid artery occlusion—a contra-indication for intravenous thrombolysis? Eur J Neurol. 1999;6:51–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Christou I, Felberg RA, Demchuk AM, et al. Intravenous tissue plasminogen activator and flow improvement in acute ischemic stroke patients with internal carotid artery occlusion. J Neuroimaging. 2002;12:119–23.PubMedCrossRefGoogle Scholar
  25. 25.
    Johnston SC. The economic case for new stroke thrombolytics. Stroke. 2010;41:S59–62.PubMedCrossRefGoogle Scholar
  26. 26.
    Chen ZM, Sandercock P, Pan HC, et al. Indications for early aspirin use in acute ischemic stroke: a combined analysis of 40 000 randomized patients from the Chinese Acute Stroke Trial and the International Stroke Trial. Stroke. 2000;31:1240–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Adams Jr HP, Bendixen BH, Leira E, et al. 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. 1999;53:122–5.PubMedGoogle Scholar
  28. 28.
    Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999;282:2003–11.PubMedCrossRefGoogle Scholar
  29. 29.
    Ogawa A, Mori E, Minematsu K, et al. MELT Japan Study Group: randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke: The Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial (MELT) Japan. Stroke. 2007;38:2633–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005;36:1432–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Penumbra Pivotal Stroke Trial Investigators. The Penumbra Pivotal Stroke Trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke. 2009;40:2761–8.CrossRefGoogle Scholar
  32. 32.
    PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033–41.CrossRefGoogle Scholar
  33. 33.
    PATS Collaborating Group. Post-stroke antihypertensive treatment study. Chin Med J (Engl). 1995;108:710–7.Google Scholar
  34. 34.
    Rothwell PM, Howard SC, Spence JD. Carotid Endarterectomy Trialists’ Collaboration: relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke. 2003;34:2583–90.PubMedCrossRefGoogle Scholar
  35. 35.
    Yokota C, Hasegawa Y, Minematsu K, Yamaguchi T. Effect of acetazolamide reactivity on [corrected] long-term outcome in patients with major cerebral artery occlusive diseases. Stroke. 1998;29:640–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Amarenco P, Bogousslavsky J, Callahan 3rd A, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355:549–59.PubMedCrossRefGoogle Scholar
  37. 37.
    Powers WJ, Clarke WR, Grubb RL Jr, et al. Improved prognosis of medically treated hemodynamic cerebral ischemia is associated with more lipid-lowering therapy. [abstract S12.001] Presented at the 2011 Meeting of the American Academy of Neurology, Honolulu, HI. April 12, 2011. Accessed April 30, 2011, at
  38. 38.
    Mohr JP, Thompson JL, Lazar RM, et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med. 2001;345:1444–51.PubMedCrossRefGoogle Scholar
  39. 39.
    EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. N Engl J Med. 1985;313:1191–200.CrossRefGoogle Scholar
  40. 40.
    Ogasawara K, Ogawa A. JET study (Japanese EC-IC Bypass Trial). Nippon Rinsho. 2006;64 Suppl 7:524–7.PubMedGoogle Scholar
  41. 41.
    Baracchini C, Meneghetti G, Manara R, Ermani M, Ballotta E. Cerebral hemodynamics after contralateral carotid endarterectomy in patients with symptomatic carotid occlusion: a 10-year follow-up. J Cereb Blood Flow Metab. 2006;26:899–905.PubMedCrossRefGoogle Scholar
  42. 42.
    Terada T, Okada H, Nanto M, et al. Endovascular recanalization of the completely occluded internal carotid artery using a flow reversal system at the subacute to chronic stage. J Neurosurg. 2010;112:563–71.PubMedCrossRefGoogle Scholar
  43. 43.
    Lin MS, Lin LC, Li HY, et al. Procedural safety and potential vascular complication of endovascular recanalization for chronic cervical internal carotid artery occlusion. Circ Cardiovasc Interv. 2008;1:119–25.PubMedCrossRefGoogle Scholar
  44. 44.
    Shojima M, Nemoto S, Morita A, et al. Protected endovascular revascularization of subacute and chronic total occlusion of the internal carotid artery. AJNR Am J Neuroradiol. 2010;31:481–6.PubMedCrossRefGoogle Scholar
  45. 45.
    Yue X, Xu G, Liu W, et al. Angioplasty and stenting for the occluded internal carotid artery. J Thromb Thrombolysis. 2010 Apr 14 (Epub ahead of print).Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of North Carolina at Chapel HillChapel HillUSA

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