Aggressive revascularization of acute internal carotid artery occlusion in patients with NIHSS > 20 and poor collateral circulation: Preliminary report

Background: Acute occlusion of internal carotid artery (ICA) is a clinical catastrophic entity with mortality as high as 50%. With innovative devices and technology, we want to clarify the benefit and risk of interventional treatment for those patients. Methods and results: From 2005 to 2009, 62 patients were enrolled and 7 patients were diagnosed as total ICA occlusion with severe neurological deficit and poor collateral circulation received endovascular interventions. Intra-arterial thrombolysis was performed in all the 7 patients. Besides, angioplasty was done in 2 patients, stenting in 3, and thrombosuction in 1. The average NIHSS was 23.3 (standard deviation = 3.6) before revascularization, was 14.2(standard deviation = 6.8) on day 7. Three patients had symptomatically hemorrhagic transformation and one developed severe brain edema after procedure. Decompressive craniotomy has been conducted in 3, who survived thereafter. One patient died for refusal of decompressive craniotomy. The 30-day modified Rankin scale was 1 in 1, 2 in 1, 3 in 1, and 4 in 3. All of our patients had distal residual lesions at anterior or middle cerebral artery area, and delayed recanalization was noted in 4. Conclusions: Endovascular therapy was promising as a hyperacute management for patients of ICA total occlusion leading to survival rate more than 80% and significant neurological recovery in 50% of our patients. Distal residual lesions were common in patients of total carotid occlusion after aggressive revascularization. Although the mechanism was not clear, delayed re-canalization was common in such patients.