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Published on: May 31, 2024
Endovascular Revascularization of Multi Segment Chronically Occluded ICA
Nicholas Mulchan1, Phillip Yeun2, Jennifer Frontera1
1Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA.
Insights
A novel endovascular technique successfully treated chronic internal carotid artery (ICA) occlusion using multiple stents. This approach reconstructed the ICA, leading to significant symptom improvement and penumbra recovery in a stroke patient.
Area of Science:
- Vascular Surgery
- Interventional Neurology
- Endovascular Therapy
Background:
- Chronic internal carotid artery (ICA) occlusion presents a significant challenge in stroke management.
- Traditional treatment options for ICA occlusion are limited, especially for extensive intracranial occlusions.
Observation:
- A 55-year-old male with bilateral ICA occlusion experienced persistent stroke symptoms despite medical management.
- Advanced imaging revealed bilateral ICA occlusions with significant hypoperfusion and neurological deficits.
Findings:
- A novel endovascular approach successfully reconstructed the left ICA using seven consecutive coronary-carotid stents from the ophthalmic to the cervical segment.
- Post-procedure, the patient exhibited marked symptom improvement, with imaging confirming penumbra recovery and infarct stability.
Implications:
- This case demonstrates the feasibility and efficacy of a multi-stent technique for complex ICA reconstructions.
- This approach offers a potential new treatment strategy for select patients with chronic ICA occlusions and associated stroke symptoms.
Abstract:
This case report describes a novel endovascular method for treating chronically occluded internal carotid artery (COICA). The patient is a 55-year-old male with vascular risk factors who presented to an outside institution with right-sided weakness and dysarthria, was diagnosed as having a stroke, and discharged with medical management. The patient's symptoms failed to improve throughout the week prompting him to visit another outside institution, where computed tomography (CT) angiography showed bilateral occlusion of the ICAs at their origins extending intracranially. The patient was then transferred to our hospital, where head CT revealed bilateral acute infarcts predominantly in the left centrum ovale/corona radiata and left temporoparietal region. CT perfusion showed a large area of hypoperfusion in the entire left hemisphere as well as part of the right hemisphere (mismatch volume of 438-526 mL). The patient had significant neurological deficits despite sustained high perfusion pressure, so the following morning, the patient was taken for angiography showing complete occlusion of the left ICA with support mostly from the left external carotid artery (ECA)/ophthalmic collateralization. The microcatheter was able to be advanced to the level of the ophthalmic segment of the left ICA, so the decision was made to proceed with stenting from the left ophthalmic ICA to the cervical ICA. Seven consecutive coronary-carotid stents were placed to essentially reconstruct the left ICA. Post-stenting, the patient was treated with an Integrilin drip and transitioned to Aspirin and Brilinta the following morning. The patient's symptoms markedly improved after the procedure. CT perfusion, as well as diffusion magnetic resonance imaging (MRI), revealed recovery of the patient's penumbra and stability of the existing infarcts despite the delayed nature of revascularization respectively. This is a rarely reported study in literature describing the successful deployment of multiple stents in recreating the ICA from its extracranial to intracranial portion.
