Successful Stenting Seven Days After Atherothrombotic Occlusion of the Intracranial Internal Carotid Artery

Real-time angiography in endovascular revascularization of intracranial atherosclerotic internal carotid artery stenosis under proximal balloon protection: "Retrograde suction-injection" technique and literature review

Intracranial angioplasty/stenting is a treatment option for patients with symptomatic intracranial atherosclerotic disease refractory to aggressive medical treatment. However, it carries a risk of procedure-related embolism as well as reperfusion hemorrhage and in-stent thrombosis. We have devised a new embolic protection system which can achieve both total ipsilateral internal carotid artery (ICA) embolic protection and real-time visualization of the target lesion during endovascular revascularization of intracranial atherosclerotic disease below the carotid T junction. Herein, we describe a case of medically refractory symptomatic intracranial atherosclerotic ICA stenosis successfully treated with this method.

Management of extracranial carotid artery disease

Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.

Analysis of reserve capacity and subsequent stenting in a case of subacute occlusion of the internal carotid artery

Introduction

While acute internal carotid artery (ICA) occlusions are increasingly being treated with carotid angioplasty and stenting (CAS), the utility of CAS in subacute stages is unclear.

Case Report

A 65-year-old patient with an acute left ICA occlusion and pre-existing occlusion on the right side presented with dysarthria and central right-sided facial palsy. Carbon dioxide (CO₂) reactivity within the left hemisphere was markedly reduced. Due to acute deterioration despite maximal conservative therapy CAS was performed 8 days after the initial event with an excellent result and symptoms subsided.

Conclusion

CAS in subacute ICA occlusion is possible. Patients should be selected carefully. Assessment of cerebrovascular CO₂ reactivity might provide valuable information.

Long-term Angiographic and Clinical Outcome Following Stenting by Flow Reversal Technique for Chronic Occlusions Older Than 3 Months of the Cervical Carotid or Vertebral Artery

BACKGROUND

Long-term angiographic and clinical outcome following stenting by flow reversal technique (FRT) for chronic occlusions (COs) of the cervical internal carotid artery (ICA) or vertebral artery (VA) is unknown.

OBJECTIVE

The aim of our retrospective study was to investigate the feasibility, safety, and long-term outcome of stenting by FRT for COs of the cervical ICA or VA.

METHODS

Included for analysis were patients (1) who underwent stenting for COs of the ICA or VA older than 3 months by FRT, and (2) who finished at least 1-year follow-up angiographic and clinical investigation. Criteria of stenting for CO in the ICA or VA were patients (1) who experienced minor strokes, a transient ischemic attack, or transient symptoms probably due to hemodynamic compromise or insufficiency, (2) angiographic complete occlusion of the ICA or VA, and (3) occlusion limited in the cervical area of the affected artery.

RESULTS

During the study period, 6 patients underwent stenting by FRT for cervical COs successfully, ICAs in 4 cases and VAs in 2 cases. The prestenting angiographically estimated occlusion length ranged from 50 to 130 mm. Total length of the deployed stents ranged from 30 to 108 mm. No complications occurred during the periprocedural period. Neither transient ischemic events nor restenosis has occurred during the follow-up period.

CONCLUSION

COs of the cervical carotid or vertebral arteries older than 3 months can be opened safely with FRT, and 1-year angiographic and long-term clinical outcome is favorable.

Case of “Slow” Stroke from Carotid Artery Occlusion Treated by Delayed but Cautious Endovascular Intervention

In a challenging case of carotid occlusion with slowly evolving stroke, we used brain imaging to facilitate endovascular revascularization resulting in the relief of the patient's symptoms. Patients with carotid occlusion and continued neurological worsening or fluctuations present enormous treatment challenges. These patients may present “slow” strokes with subacute infarcts that present significant challenges and risks during attempts at revascularization of the occluded artery. We present such a case in which we used multimodal imaging techniques, including MR-perfusion, to facilitate endovascular revascularization. Our approach of delayed but cautious intra-arterial thrombolytic therapy, guided by brain imaging, and followed by stent placement across the residual stenosis, enabled revascularization of the occluded artery without overt in-hospital complications.

Intracranial angioplasty and stent placement for direct cerebral revascularization of nonacute intracranial occlusions and near occlusions

OBJECT

The authors reviewed their experience in 7 cases of nonacute intracranial occlusions and near occlusions in which the patients underwent intracranial angioplasty and stent implantation for direct cerebral revascularization.

METHODS

Between 2005 and 2008, 4 men and 3 women underwent direct cerebral revascularization of nonacute intracerebral occlusions or near occlusions. Five patients had chronic angiographically documented occlusion and 2 patients had chronic angiographically documented near occlusions. The locations of the treated vessels included 2 supraclinoid internal carotid arteries, 4 middle cerebral arteries, and 1 vertebral artery. Prior to intervention, all patients were symptomatic and experienced strokes ipsilateral to their occlusions. In addition, all patients had clinical or radiographic evidence of ongoing hemodynamic compromise. Five patients underwent successful intracranial angioplasty and stent placement and 2 patients underwent successful intracranial balloon angioplasty alone. The mean time from documented vessel occlusion to treatment was 35 days. All patients had successful revascularization determined using the Thrombolysis in Cerebral Infarction (TICI) scale: TICI Score 3, 2b, and 2a in 4, 2, and 1 patient, respectively, and the mean residual stenosis was 38%.

RESULTS

After uneventful technical procedures, 1 patient suffered a perforator vessel stroke and 1 patient suffered a fatal hemorrhage. Mean modified Rankin Scale score of 2 (range 1-5) and mean Glasgow Outcome Scale score of 4 (range 1-6) were achieved during a mean clinical follow-up period of 399 days (range 1-840 days). Asymptomatic restenosis was documented in 4 patients, 1 underwent bypass retreatment, and 1 patient received repeated balloon angioplasty.

CONCLUSIONS

Combined intracranial angioplasty and stent placement is a potential treatment option in selected patients for the direct revascularization of nonacute intracranial occlusions and near occlusions. Whether this represents a substantial risk reduction compared with the best medical therapy or a long-lasting treatment option is unknown.

Intracranial internal carotid artery stenosis with vulnerable plaques successfully treated by stenting under cerebral protection

Percutaneous transluminal angioplasty with stenting (PTA/stenting) for intracranial atherosclerotic stenoses is usually performed without any protection devices. We report a unique case of atherothrombotic stenosis with the vulnerable plaque in the cavernous portion of the internal carotid artery (ICA), which was successfully treated by PTA/stenting under cerebral protection with the flow reversal system. A 68-year-old woman presented repetitive transient ischemic attacks in the right ICA territory. Cerebral angiography revealed 80% stenosis in the cavernous portion of the right ICA. High-resolution magnetic resonance imaging (HR-MRI) demonstrated lipid-rich plaques at this lesion. PTA/stenting was performed with a proximal protection device under flow reversal. A filter device captured much amount of atherothrombotic debris with lipid-rich macrophages and leukocytes, which was consistent with HR-MRI findings. Some selected cases of intracranial atherothrombotic ICA stenoses may need endovascular treatment with cerebral protection system. HR-MRI is useful to evaluate plaque characteristics even in the cavernous portion of the ICA.