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Carotid Endarterectomy or Stenting for Evolving Stroke Secondary to Carotid Artery Atherosclerosis
Stroke is the third leading cause of death and the most common cause of long-term neurologic disability worldwide. Each year, 795,000 Americans suffer a stroke, of which 80% are ischemic. Carotid atherosclerotic disease is implicated in 15% to 30% of all ischemic strokes. For decades, carotid endarterectomy (CEA) has been the standard treatment for carotid artery atherosclerosis, but carotid artery stenting (CAS) has emerged as a less invasive treatment alternative. Typically, treatment of symptomatic cervical carotid artery disease, whether with CEA or CAS, is not performed in the acute setting of evolving stroke, with the exception of acute cervical carotid occlusion. Acute occlusion of the cervical internal carotid artery (ICA) is responsible for 6.5% of ischemic strokes and can lead to significant neurologic deficits with a poor prognosis if adequate collaterals are absent.
Carotid endarterectomy has been advocated mainly in the past as an urgent method of revascularization but is associated with a high complication rate. Recent data suggest endovascular treatment with CAS is perhaps a safer and a more effective method of emergent carotid revascularization. In this chapter, we review the treatment options (thrombolytics, CEA, and CAS) for acute stroke caused by carotid artery occlusion secondary to atherosclerosis and the associated results. We then present our own experience with CAS in the treatment of acute ischemic stroke caused by acute cervical ICA occlusion, highlighting the role of CAS in the treatment of evolving stroke secondary to carotid disease.
Thrombolysis and Carotid Endarterectomy in Acute Cervical Carotid Occlusion
Intravenous (IV) tissue plasminogen activator (tPA) was approved by the Food and Drug Administration for the treatment of acute ischemic stroke within 3 hours. However, the recanalization rates for proximal vessel occlusions were generally disappointing: 10% for ICA occlusion and 30% for proximal middle cerebral artery (MCA) occlusion. Among 20 patients with cervical and terminal ICA occlusions treated with IV tPA, Christou and colleagues reported complete, partial, and non-recanalization rates of 10%, 16%, and 74%, respectively. Similarly, Linfante and coworkers reported a complete or partial recanalization rate of 31% in 17 patients with tandem cervical ICA–MCA occlusions treated with IV tPA. Other studies have suggested slightly better outcomes. Wunderlich’s group reported a recanalization rate of 40% in 42 patients with acute carotid terminus occlusions treated with IV tPA, whereas Thomalla and colleagues reported a recanalization rate of 42% in 14 patients with tandem ICA–MCA occlusion after IV tPA. Regarding the outcomes of IV tPA and acute carotid occlusion, Rubiera and coworkers reported that only 18% of patients with an acute tandem cervical ICA–MCA lesion were functionally independent after IV tPA at 3 months. On the basis of this literature, it appears that recanalization with IV tPA does not occur in most patients who present with an acute ischemic stroke secondary to cervical carotid occlusion.
Carotid endarterectomy is a surgical option for emergent revascularization of the occluded carotid artery. However, as early as 1965, DeBakey and colleagues recognized the limitation of CEA in the treatment of acute stroke because of the frequent intracranial extension of the thrombotic lesion beyond the cervical region. In addition, Bond’s group, in a systematic review, reported a 19.2% perioperative risk of CEA in patients with evolving stroke compared with a 3.2% risk in patients treated with CEA in a more delayed fashion. Nevertheless, there are still advocates of early CEA in patients presenting with acute stroke and ICA occlusion. Weis-Muller and coworkers reported their experience with 35 patients who underwent urgent CEA for acute ICA occlusion up to 72 hours after symptom onset. In their study, the rate of intracerebral hemorrhage, recurrent stroke, and mortality were 6% each. Revascularization was achieved in 86% of patients, and clinical improvement was encountered in 57% (31% of patients were stable and 6% had deterioration). However, the study excluded patients with major stroke, altered level of consciousness, or intracranial carotid occlusion, suggesting that the role of CEA in the treatment of acute stroke and carotid occlusion is limited to patients with cervical ICA occlusion secondary to atherosclerosis and minor neurologic deficits.
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