Endovascular treatment in proximal and intracranial carotid occlusion 9 hours after symptom onset

Neuroradiology. 2008 Jul;50(7):599-604. doi: 10.1007/s00234-008-0385-7. Epub 2008 Apr 29.

Abstract

Introduction: A debate is emerging over whether the treatment time window in acute stroke can be extended beyond 6 h if penumbral tissue can be identified. Treatment decisions are very difficult in cases of tandem proximal carotid occlusion with arterioarterial intracranial embolism. We enter this debate with the present report on a case of atherosclerotic proximal carotid occlusion and resulting periocclusional carotid T embolism that was successfully treated 9 h after symptom onset.

Methods: The case of a 68-year-old man with fluctuating symptoms of right-hemispheric stroke is presented (NIHSS score 12-20 on admission). CT angiography demonstrated proximal carotid occlusion and periocclusional embolism of the entire internal carotid artery (ICA) including the carotid T segment. Penumbral tissue was diagnosed by nonenhanced and perfusion CT imaging 7.5 h after symptom onset. Treatment was initiated 9 h after symptom onset by passing the proximal occlusion with a microcatheter and local administration of recombinant tissue plasminogen activator (rt-PA) into the carotid T segment at the level of posterior communicating artery (PCoA) origin.

Results: Recanalization of the ICA and middle cerebral artery was accomplished within 1 h by flow establishment via the PCoA. The atherosclerotic proximal ICA occlusion was not stented due to the risk of embolism from remnant thrombi in the petrous and cavernous ICA segments. Follow-up MRI showed only mild haemorrhagic infarct transformation of the initial infarct core. The patient was discharged from hospital 18 days after treatment with NIHSS score 5.

Conclusion: If penumbral tissue can be conclusively identified, endovascular treatment in proximal and intracranial tandem occlusion can be successful, even in treatments initiated 6-9 h after stroke onset. If the intracranial flow after recanalization can be established via the circle of Willis, the underlying proximal ICA occlusion may not require treatment.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Carotid Artery Thrombosis / complications
  • Carotid Artery Thrombosis / diagnostic imaging
  • Carotid Artery Thrombosis / drug therapy*
  • Carotid Artery, Internal
  • Drug Administration Schedule
  • Fibrinolytic Agents / administration & dosage*
  • Humans
  • Infarction, Middle Cerebral Artery / diagnostic imaging
  • Infarction, Middle Cerebral Artery / drug therapy*
  • Infarction, Middle Cerebral Artery / etiology
  • Intracranial Embolism / diagnostic imaging
  • Intracranial Embolism / drug therapy*
  • Intracranial Embolism / etiology
  • Magnetic Resonance Imaging
  • Male
  • Thrombolytic Therapy / methods*
  • Tissue Plasminogen Activator / administration & dosage*
  • Tomography, X-Ray Computed

Substances

  • Fibrinolytic Agents
  • Tissue Plasminogen Activator