Use of Transcranial Doppler (TCD) ultrasound in the Neurocritical Care Unit

Unveiling the potential of ultrasound in brain imaging: Innovations, challenges, and prospects

Within medical imaging, ultrasound serves as a crucial tool, particularly in the realms of brain imaging and disease diagnosis. It offers superior safety, speed, and wider applicability compared to Magnetic Resonance Imaging (MRI) and X-ray Computed Tomography (CT). Nonetheless, conventional transcranial ultrasound applications in adult brain imaging face challenges stemming from the significant acoustic impedance contrast between the skull bone and soft tissues. Recent strides in ultrasound technology encompass a spectrum of advancements spanning tissue structural imaging, blood flow imaging, functional imaging, and image enhancement techniques. Structural imaging methods include traditional transcranial ultrasound techniques and ultrasound elastography. Transcranial ultrasound assesses the structure and function of the skull and brain, while ultrasound elastography evaluates the elasticity of brain tissue. Blood flow imaging includes traditional transcranial Doppler (TCD), ultrafast Doppler (UfD), contrast-enhanced ultrasound (CEUS), and ultrasound localization microscopy (ULM), which can be used to evaluate the velocity, direction, and perfusion of cerebral blood flow. Functional ultrasound imaging (fUS) detects changes in cerebral blood flow to create images of brain activity. Image enhancement techniques include full waveform inversion (FWI) and phase aberration correction techniques, focusing on more accurate localization and analysis of brain structures, achieving more precise and reliable brain imaging results. These methods have been extensively studied in clinical animal models, neonates, and adults, showing significant potential in brain tissue structural imaging, cerebral hemodynamics monitoring, and brain disease diagnosis. They represent current hotspots and focal points of ultrasound medical research. This review provides a comprehensive summary of recent developments in brain imaging technologies and methods, discussing their advantages, limitations, and future trends, offering insights into their prospects.

Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review

Intracranial pressure (ICP) monitoring is necessary for managing patients with traumatic brain injury (TBI). Although gold-standard methods include intraventricular or intraparenchymal transducers, these systems cannot be used in patients with coagulopathies or in those who are at high risk of catheter-related infections, nor can they be used in resource-constrained settings. Therefore, a non-invasive modality that is more widely available, cost effective, and safe would have tremendous impact. Among such non-invasive choices, transcranial Doppler (TCD) provides indirect ICP estimates through waveform analysis of cerebral hemodynamic changes. The objective of this scoping review is to describe the existing evidence for the use of TCD-derived methods in estimating ICP in adult TBI patients as compared with gold-standard invasive methods. This review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, with a main search of PubMed and Embase. The search was limited to studies conducted in adult TBI patients published in any language between 2012 and 2022. Twenty-two studies were included for analysis, with most being prospective studies conducted in high-income countries. TCD-derived non-invasive ICP (nICP) methods are either mathematical or non-mathematical, with the former having slightly better correlation with invasive methods, especially when using time-trending ICP dynamics over one-time estimated values. Nevertheless, mathematical methods are associated with greater cost and complexity in their application. Formula-based methods showed promise in excluding elevated ICP, exhibiting a high negative predictive value. Therefore, TCD-derived methods could be useful in assessing ICP changes instead of absolute ICP values for high-risk patients, especially in low-resource settings.

Intracranial Pressure and Cerebral Hemodynamics in Infants Before and After Glenn Procedure

OBJECTIVES

This prospective cohort study aimed to investigate changes in intracranial pressure (ICP) and cerebral hemodynamics in infants with congenital heart disease undergoing the Glenn procedure, focusing on the relationship between superior vena cava pressure and estimated ICP.

DESIGN

A single-center prospective cohort study.

SETTING

The study was conducted in a cardiac center over 4 years (2019-2022).

PATIENTS

Twenty-seven infants with congenital heart disease scheduled for the Glenn procedure were included in the study, and detailed patient demographics and primary diagnoses were recorded.

INTERVENTIONS

Transcranial Doppler (TCD) ultrasound examinations were performed at three time points: baseline (preoperatively), postoperative while ventilated (within 24-48 hr), and at discharge. TCD parameters, blood pressure, and pulmonary artery pressure were measured.

MEASUREMENTS AND MAIN RESULTS

TCD parameters included systolic flow velocity, diastolic flow velocity (dFV), mean flow velocity (mFV), pulsatility index (PI), and resistance index. Estimated ICP and cerebral perfusion pressure (CPP) were calculated using established formulas. There was a significant postoperative increase in estimated ICP from 11 mm Hg (interquartile range [IQR], 10-16 mm Hg) to 15 mm Hg (IQR, 12-21 mm Hg) postoperatively (p = 0.002) with a trend toward higher CPP from 22 mm Hg (IQR, 14-30 mm Hg) to 28 mm Hg (IQR, 22-38 mm Hg) postoperatively (p = 0.1). TCD indices reflected alterations in cerebral hemodynamics, including decreased dFV and mFV and increased PI. Intracranial hemodynamics while on positive airway pressure and after extubation were similar.

CONCLUSIONS

Glenn procedure substantially increases estimated ICP while showing a trend toward higher CPP. These findings underscore the intricate interaction between venous pressure and cerebral hemodynamics in infants undergoing the Glenn procedure. They also highlight the remarkable complexity of cerebrovascular autoregulation in maintaining stable brain perfusion under these circumstances.

Transcranial Doppler ultrasonography (uses, limitations, and potentials): a review article

Background

The additional information that transcranial Doppler can provide as part of a multimodal imaging protocol in many clinical settings has not been evaluated.

Main body

Transcranial Doppler is a bedside procedure used to assess cerebral blood flow velocity via cerebral circulation and pulsatility index (PI). Many diseases can lead to cerebral vessels vasospasm as in subarachnoid hemorrhage and trauma. Cerebral vessels vasospasm represented by abnormal elevation of cerebral blood flow velocity. Intracranial pressure can be monitored by pulsatility index which reflects blood flow resistance in cerebral vessels. Transcranial Doppler ultrasonography is also the unique modality for detection of micro emboli in high-risk patients. Also, it can be used for evaluation of circulatory arrest with subsequent confirmation of brain death

Conclusion

Transcranial Doppler ultrasonography is the only diagnostic modality that provides a reliable assessment of cerebral blood flow patterns in real time. The physiological information obtained from TCD is complementary to the anatomical details obtained from other neuroimaging modalities. TCD is relatively cheap, can be performed bedside, and allows monitoring in acute emergency settings.

Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement

Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.

How Are We Monitoring Brain Injuries in Patients With Left Ventricular Assist Device? A Systematic Review of Literature

Despite the common occurrence of brain injury in patients with left ventricular assist device (LVAD), optimal neuromonitoring methods are unknown. A systematic review of PubMed and six electronic databases from inception was conducted until June 5, 2019. Studies reporting methods of neuromonitoring while on LVAD were extracted. Of 5,190 records screened, 37 studies met the inclusion criteria. The neuromonitoring methods include Transcranial Doppler ultrasound for emboli monitoring (TCD-e) (n = 13) and cerebral autoregulation (n = 3), computed tomography and magnetic resonance imaging (n = 9), serum biomarkers (n = 7), carotid ultrasound (n = 3), and near-infrared spectroscopy (n = 2). Of 421 patients with TCD-e, thromboembolic events (TEs) were reported in 79 patients (20%) and microembolic signals (MES) were detected in 105 patients (27%). Ischemic stroke was more prevalent in patients with MES compared to patients without MES (43% vs.13%, p < 0.001). Carotid ultrasound for assessing carotid stenosis was unreliable after LVAD implantation. Elevated lactate dehydrogenase (LDH) levels were associated with TEs. Significant heterogeneity exists in timing, frequency, and types of neuromonitoring tools. TCD-e and serial LDH levels appeared to have potential for assessing the risk of ischemic stroke. Future prospective research incorporating protocolized TCD-e and LDH may assist in monitoring adverse events in patients with LVAD.

The Use of Near-Infrared Spectroscopy and/or Transcranial Doppler as Non-Invasive Markers of Cerebral Perfusion in Adult Sepsis Patients With Delirium: A Systematic Review

Background:

Several studies have previously reported the presence of altered cerebral perfusion during sepsis. However, the role of non-invasive neuromonitoring, and the impact of altered cerebral perfusion, in sepsis patients with delirium remains unclear.

Methods:

We performed a systematic review of studies that used near-infrared spectroscopy (NIRS) and/or transcranial Doppler (TCD) to assess adults (≥18 years) with sepsis and delirium. From study inception to July 28, 2020, we searched the following databases: Ovid MedLine, Embase, Cochrane Library, and Web of Science.

Results:

Of 1546 articles identified, 10 met our inclusion criteria. Although NIRS-derived regional cerebral oxygenation was consistently lower, this difference was only statistically significant in one study. TCD-derived cerebral blood flow velocity was inconsistent across studies. Importantly, both impaired cerebral autoregulation during sepsis and increased cerebrovascular resistance were associated with delirium during sepsis. However, the heterogeneity in NIRS and TCD devices, duration of recording (from 10 seconds to 72 hours), and delirium assessment methods (e.g., electronic medical records, confusion assessment method for the intensive care unit), precluded meta-analysis.

Conclusion:

The available literature demonstrates that cerebral perfusion disturbances may be associated with delirium in sepsis. However, future investigations will require consistent definitions of delirium, delirium assessment training, harmonized NIRS and TCD assessments (e.g., consistent measurement site and length of recording), as well as the quantification of secondary and tertiary variables (i.e., Cox, Mxa, MAP_OPT), in order to fully assess the relationship between cerebral perfusion and delirium in patients with sepsis.

Prehospital Detection of Life-Threatening Intracranial Pathology: An Unmet Need for Severe TBI in Austere, Rural, and Remote Areas

Severe traumatic brain injury (TBI) is a leading cause of death and disability worldwide, especially in low- and middle-income countries, and in austere, rural, and remote settings. The purpose of this Perspective is to challenge the notion that accurate and actionable diagnosis of the most severe brain injuries should be limited to physicians and other highly-trained specialists located at hospitals. Further, we aim to demonstrate that the great opportunity to improve severe TBI care is in the prehospital setting. Here, we discuss potential applications of prehospital diagnostics, including ultrasound and near-infrared spectroscopy (NIRS) for detection of life-threatening subdural and epidural hemorrhage, as well as monitoring of cerebral hemodynamics following severe TBI. Ultrasound-based methods for assessment of cerebrovascular hemodynamics, vasospasm, and intracranial pressure have substantial promise, but have been mainly used in hospital settings; substantial development will be required for prehospital optimization. Compared to ultrasound, NIRS is better suited to assess certain aspects of intracranial pathology and has a smaller form factor. Thus, NIRS is potentially closer to becoming a reliable method for non-invasive intracranial assessment and cerebral monitoring in the prehospital setting. While one current continuous wave NIRS-based device has been FDA-approved for detection of subdural and epidural hemorrhage, NIRS methods using frequency domain technology have greater potential to improve diagnosis and monitoring in the prehospital setting. In addition to better technology, advances in large animal models, provider training, and implementation science represent opportunities to accelerate progress in prehospital care for severe TBI in austere, rural, and remote areas.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Accuracy of Transcranial Doppler Ultrasound Compared with Magnetic Resonance Angiography in the Diagnosis of Intracranial Artery Stenosis

Background  One of the most common causes of acute cerebral infarction (ACI) is intracranial artery stenosis (ICAS). The goal of our study was to evaluate the accuracy of transcranial Doppler (TCD) compared with magnetic resonance angiography (MRA) for diagnosing ICAS in patients with ACI. Materials and Methods  Consecutive patients presenting with ACI to the neurology department underwent both MRA and TCD examination within 6 hours of difference. To calculate the agreement between the results of MRA and TCD, kappa coefficient test was used. Sensitivity, specificity, and positive and negative TCD predictive values have been calculated in comparison with MRA. Results  A total of 115 patients was included. There were 77 males (66.95%) and 38 females (33.04%). The mean age of patients was 68.32 ± 10.66 years (range 29-80). The agreement between TCD and MRA in detecting stenosis was 0.56 for anterior circulation artery (ACA), and 0.40 for posterior circulation artery. For the detection of ICAS, sensitivity, specificity, positive predictive value, and negative predictive values were 85.9, 90.0, 98.2, and 50.0% for anterior cerebral artery and 73.5, 86.7, 96.2, and 40.0% for posterior cerebral artery, respectively. Conclusions  Moderate agreement of anterior circulation stenosis and fair agreement for posterior circulation stenosis was found between TCD and MRA in the evaluation of ICAS. In anterior circulation, the diagnostic accuracy of TCD is higher compared with the posterior circulation.

Dynamic assessment of cerebral blood flow and intracranial pressure during inversion table tilt using ultrasonography

CONTEXT

Inversion tables are used as treatment for back pain, but there is a lack of agreement on systemic effects of inversion.

OBJECTIVE

To assess intracranial pressure (ICP) and cerebral blood flow using ultrasonography during inversion table tilt.

METHODS

Optic nerve sheath diameter (ONSD), heart rate (HR), blood pressure, internal carotid artery (ICA) and middle cerebral artery (MCA) blood flow of participants were measured in 3 positions: supine before inversion, during inversion with head down, and supine post-inversion. ONSD was evaluated with ocular ultrasonography and blood flow (ICA and MCA) with Doppler ultrasonography.

RESULTS

The ONSD changed significantly between the supine position, at 3 min of inversion, and after returning to supine position (all P < .001). The post-inversion HR was less than pre-inversion (P = .03) and 3-min inversion HR (P = .003). There were significant changes in ICA and MCA flow caused by inversion, which affected blood flow velocity, resistance, and pulsatility index (all P ≤ .005).

CONCLUSION

Inversion caused significant changes in ICP and blood flow. Thus, increased chance of complications may exist when using inversion as a therapeutic tool or during surgical procedures in patients with previous history of elevated ICP. These results demonstrate that inversion therapy should be used with caution.

Evaluation of Application Value of Transcranial Doppler (TCD) in the Inspection of Cerebral Vasospasm After the Treatment of Intracranial Aneurysm

Abstract: Objective This study aimed to explore the application value of transcranial doppler (TCD) in the inspection of cerebral vasospasm (CVS) after the treatment of intracranial aneurysm.

Methods: 105 cases of patients with confirmed intracranial aneurysm were divided into two groups based on the two different treatments - craniotomy and aneurysmal clipping or interventional emboli-zation therapy. TCD was applied to monitor the conditions of CVS of 105 cases, and case study re-search method was used to analyze and conclude the TCD inspection data of patients with intracrani-al aneurysm detected after operation.

Results: The sensitivity of TCD in the detection of CVS was 83% and the specificity was 88%. Fur-ther, the incidence rate of CVS in the group treated with interventional embolization therapy was higher than that of the group treated with aneurysm clipping.

Conclusions: TCD, which can be used to guide the adjustment of treatment and avoid complications, is an effective method in monitoring CVS after the treatment of intracranial aneurysm.

Reliability of Hand-Held Transcranial Doppler with M-mode Ultrasound in Middle Cerebral Artery Measurement

Purpose

To determine the intra- and interrater agreement of mean flow velocity (MFV) and pulsatility index (PI) measurement in middle cerebral arteries, assessed by transcranial Doppler (TCD) with M-mode.

Methods

Masked experienced neurosonologists performed TCD with M-mode using handheld probe in healthy adult volunteers. The Bland–Altman method for concordance and intraclass correlation coefficient were used.

Results

Seventy-seven healthy volunteers and seven raters participated (3 on regular TCD shift and 4 off-shift). The intrarater absolute mean difference between measurements was 5.5 cm/s [95% confidence interval (CI), 4.7–6.3] for MVF and 0.073 (95% CI, 0.063–0.083) for PI. The difference between MFV measurements was significantly higher in off-shift raters (p = 0.015). The interrater absolute mean difference between measurements was 6.5 cm/s (95% CI, 5.5–7.5) for MVF and 0.065 (95% CI, 0.059–0.071) for PI. No influence was found for the middle cerebral artery side, volunteer’s sex, or age, and there was no significant difference between raters. The intraclass correlation coefficient was 82.2% (95% CI 77.8–85.6) and 72.9% (95% CI 67.4–77.6) for MFV and PI, respectively.

Conclusions

There exists good intra- and interrater agreement in MFV and PI measurements using M-mode TCD. These results support the use of this noninvasive tool and are important for clinical and investigational purposes.

Cerebral Blood Flow Autoregulation in Sepsis for the Intensivist: Why Its Monitoring May Be the Future of Individualized Care

Cerebral blood flow (CBF) autoregulation maintains consistent blood flow across a range of blood pressures (BPs). Sepsis is a common cause of systemic hypotension and cerebral dysfunction. Guidelines for BP management in sepsis are based on historical concepts of CBF autoregulation that have now evolved with the availability of more precise technology for its measurement. In this article, we provide a narrative review of methods of monitoring CBF autoregulation, the cerebral effects of sepsis, and the current knowledge of CBF autoregulation in sepsis. Current guidelines for BP management in sepsis are based on a goal of maintaining mean arterial pressure (MAP) above the lower limit of CBF autoregulation. Bedside tools are now available to monitor CBF autoregulation continuously. These data reveal that individual BP goals determined from CBF autoregulation monitoring are more variable than previously expected. In patients undergoing cardiac surgery with cardiopulmonary bypass, for example, the lower limit of autoregulation varied between a MAP of 40 to 90 mm Hg. Studies of CBF autoregulation in sepsis suggest patients frequently manifest impaired CBF autoregulation, possibly a result of BP below the lower limit of autoregulation, particularly in early sepsis or with sepsis-associated encephalopathy. This suggests that the present consensus guidelines for BP management in sepsis may expose some patients to both cerebral hypoperfusion and cerebral hyperperfusion, potentially resulting in damage to brain parenchyma. The future use of novel techniques to study and clinically monitor CBF autoregulation could provide insight into the cerebral pathophysiology of sepsis and offer more precise treatments that may improve functional and cognitive outcomes for survivors of sepsis.

Age-Dependent Effects of Haptoglobin Deletion in Neurobehavioral and Anatomical Outcomes Following Traumatic Brain Injury

Cerebral hemorrhages are common features of traumatic brain injury (TBI) and their presence is associated with chronic disabilities. Recent clinical and experimental evidence suggests that haptoglobin (Hp), an endogenous hemoglobin-binding protein most abundant in blood plasma, is involved in the intrinsic molecular defensive mechanism, though its role in TBI is poorly understood. The aim of this study was to investigate the effects of Hp deletion on the anatomical and behavioral outcomes in the controlled cortical impact model using wildtype (WT) C57BL/6 mice and genetically modified mice lacking the Hp gene (Hp(-∕-)) in two age cohorts [2-4 mo-old (young adult) and 7-8 mo-old (older adult)]. The data obtained suggest age-dependent significant effects on behavioral and anatomical TBI outcomes and recovery from injury. Moreover, in the adult cohort, neurological deficits in Hp(-∕-) mice at 24 h were significantly improved compared to WT, whereas there were no significant differences in brain pathology between these genotypes. In contrast, in the older adult cohort, Hp(-∕-) mice had significantly larger lesion volumes compared to WT, but neurological deficits were not significantly different. Immunohistochemistry for ionized calcium-binding adapter molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP) revealed significant differences in microglial and astrocytic reactivity between Hp(-∕-) and WT in selected brain regions of the adult but not the older adult-aged cohort. In conclusion, the data obtained in the study provide clarification on the age-dependent aspects of the intrinsic defensive mechanisms involving Hp that might be involved in complex pathways differentially affecting acute brain trauma outcomes.

Brachial-ankle pulse wave velocity and ankle-brachial index are complementary tools for transcranial Doppler ultrasonography in early diagnosis of intracranial arterial stenosis/occlusion in patients with acute ischemic stroke

The aim of this study was to explore whether brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI) are suitable to serve as complementary tools for TCD in early diagnosis of intracranial arterial stenosis/occlusion in patients with acute ischemic stroke (AIS). A total of 52 patients with AIS onset and 52 age-matched healthy controls were included in this study. All participants received TCD detection, and baPWV and ABI were measured. Computed topography (CT)/magnetic resonance imaging (MRI) was applied to confirm diagnosis. TCD data from all participants was collected and reviewed to diagnose stenosis and occlusion of the major intracranial arteries. Receiver operating characteristic (ROC) analysis and logistic regression analysis were used to assess and compare the diagnostic accuracy of the various diagnostic approaches. We found that a combination of TCD with either baPWV or ABI, or a combination of the three provided a significantly higher area under the curve (AUC) in detecting stenosis or occlusion in various intracranial arteries, excluding the anterior cerebral artery (ACA), when compared to TCD alone, thereby demonstrating that these combined approaches provide improved diagnostic accuracy. In conclusion, our findings suggest that both baPWV and ABI are suitable complementary tools for TCD in early diagnosis of intracranial arterial stenosis/occlusion in AIS patients and that these combinations may assist in facilitating the diagnostic process associated with this disease.

A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury

The incidence of traumatic brain injury (TBI) in the United States was 3.5 million cases in 2009, according to the Centers for Disease Control and Prevention. It is a contributing factor in 30.5% of injury-related deaths among civilians. Additionally, since 2000, more than 260,000 service members were diagnosed with TBI, with the vast majority classified as mild or concussive (76%). The objective assessment of TBI via imaging is a critical research gap, both in the military and civilian communities. In 2011, the Department of Defense (DoD) prepared a congressional report summarizing the effectiveness of seven neuroimaging modalities (computed tomography [CT], magnetic resonance imaging [MRI], transcranial Doppler [TCD], positron emission tomography, single photon emission computed tomography, electrophysiologic techniques [magnetoencephalography and electroencephalography], and functional near-infrared spectroscopy) to assess the spectrum of TBI from concussion to coma. For this report, neuroimaging experts identified the most relevant peer-reviewed publications and assessed the quality of the literature for each of these imaging technique in the clinical and research settings. Although CT, MRI, and TCD were determined to be the most useful modalities in the clinical setting, no single imaging modality proved sufficient for all patients due to the heterogeneity of TBI. All imaging modalities reviewed demonstrated the potential to emerge as part of future clinical care. This paper describes and updates the results of the DoD report and also expands on the use of angiography in patients with TBI.

Hybrid treatment of symptomatic chronic isolated carotid bifurcation

Total chronic occlusion of the common carotid artery with patent internal and external carotid arteries can induce cerebral embolism and hypoperfusion. We report a hybrid approach that was used to treat 2 patients presented with symptomatic chronic occlusion of the common carotid artery and ipsilateral internal carotid stenosis. Antegrade recanalization and retrograde stenting of the common carotid artery was performed in both patients associated to carotid bulb endarterectomy. Fresh thrombus observed in the distal common carotid stump was responsible for the embolic cerebral lesions and patients' previous symptoms. Patients remain asymptomatic at the 23rd- and 18th-month follow-up, respectively.