Symptomatic acute occlusion of the internal carotid artery: Reappraisal of urgent vascular reconstruction based on current stroke imaging

Objective We hypothesized that a subgroup of patients with frank stroke due to sudden occlusion of the internal carotid artery could safely undergo surgery to restore carotid patency and to rescue brain tissue not yet irreversibly damaged if current stroke diagnostic methods were applied. Methods From November 1997 to March 2007, 1810 patients underwent carotid endarterectomy of the internal carotid artery for occlusive disease at our department. Within the same period, 5369 patients were examined at our stroke unit, and 502 from this cohort underwent internal carotid artery reconstruction. A subgroup of 35 patients (28 men, 7 women; mean age, 61 ± 10 years) underwent urgent surgical revascularization due to an acute internal carotid artery occlusion ≤72 hours (mean 25 ± 17 hours) after the onset of stroke symptoms and ≤36 hours (mean 16 ± 10 hours) after admission to our stroke unit. Our diagnostic workup consisted of extracranial intracranial duplex sonography, cerebral computed tomography, digital subtraction angiography, magnetic resonance imaging, and angiography, including diffusion- and perfusion-weighted imaging, to discriminate between viable and irreversibly damaged brain tissue. The study excluded patients who presented an impaired level of consciousness, occlusion of the intracranial internal carotid artery, occlusion of the ipsilateral middle cerebral artery, or infarction more than one-third of the territory perfused by the middle cerebral artery. Imaging showed signs of recent ischemic infarction in all 35 cases. On admission, eight patients (23%) scored 0 to 2 points and 27 (77%) scored 3 to 5 points in Rankin scale. Results Confirmed by postoperative Doppler and duplex sonography at discharge, internal carotid artery patency could be achieved in 30 of 35 cases (86%). Intracranial hemorrhage occurred in two patients (6%) and reinfarction in another two (6%). Two patients died during their hospital stay (30-day mortality, 6%). Compared with the preoperative neurologic status, rates of clinical improvement (≥1 point in Rankin scale), stability, and deterioration were 57%, 31%, and 6%, respectively. Conclusions Restoration of blood flow in an acutely occluded internal carotid artery can only be achieved in the acute stage. Our pilot study demonstrated that a thorough diagnostic workup allows selection of patients who may benefit from urgent revascularization of acute internal carotid artery occlusion in the stage of an acute stroke. A prospective randomized multicenter trial comparing surgery with conservative medical treatment is needed.