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Updated: Aug 19, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Emergent carotid endarterectomy and mechanical thrombectomy in tandem occlusion
Danielle Hebert1, Theresa A Elder2, Joseph G Adel3
1Department of General Surgery, Central Michigan University College of Medicine, Michigan, United States.
Insights
Emergent carotid endarterectomy (CEA) is a viable option for acute ischemic stroke patients with tandem occlusions when endovascular approaches fail. This surgical method successfully restored blood flow, leading to good patient recovery.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Neuroradiology
Background:
- Acute tandem occlusions present significant challenges in stroke management, leading to poorer patient outcomes.
- Current treatment typically involves mechanical thrombectomy and carotid stenting.
- This case highlights a rare scenario where endovascular access was not feasible.
Purpose of the Study:
- To describe a successful surgical revascularization strategy for tandem occlusions.
- To present an alternative management for cases refractory to endovascular techniques.
- To emphasize the role of emergent carotid endarterectomy in specific stroke scenarios.
Main Methods:
- A patient with an uncrossable extracranial internal carotid artery (ICA) occlusion was treated.
- The procedure was converted to an emergent carotid endarterectomy (CEA).
- Intraoperative mechanical thrombectomy (MT) was performed after CEA before closure.
Main Results:
- The patient experienced a successful revascularization.
- Postoperative recovery was favorable, with discharge at NIHSS 2.
- Thirty-day follow-up showed resolution of deficits with modified Rankin Scale (mRS) 1.
Conclusions:
- Emergent CEA is a crucial consideration for acute ischemic stroke with tandem occlusions.
- This approach is indicated when endovascular crossing of the cervical occlusion is impossible.
- Successful surgical intervention can lead to favorable neurological outcomes.
Background:
Acute tandem occlusions, or occlusions of the extracranial portion of the internal carotid artery (ICA) with concurrent thromboembolism of the intracranial ICA or middle cerebral artery, poses a major clinical challenge, with patients suffering worse outcomes compared to those with single occlusions. Management of these lesions generally includes a combination of mechanical thrombectomy (MT) of the intracranial occlusion and stenting of the extracranial carotid lesion. In this manuscript, we describe a successful surgical method for achieving revascularization of tandem occlusions in the rare circumstance that the proximal lesion cannot be crossed endovascularly to gain intracranial access.
Methods:
Despite using our institution's standard protocol for achieving revascularization of such lesions, the extracranial occlusion could not be crossed endovascularly, and the case was converted to an emergent carotid endarterectomy (CEA) in the operating room. Once the endarterectomy was complete, intraoperative MT was performed before cervical incision closure to revascularization.
Results:
The patient recovered well postoperatively and was discharged with NIHSS of 2 due to minor facial palsy and minor dysarthria. Thirty-day follow-up revealed resolution of the prior neurologic deficits and an mRS of 1.
Conclusion:
Emergent CEA should be considered in the rare circumstance of being unable to cross the cervical occlusion during management of acute ischemic stroke with tandem occlusion.
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