Carotid Endarterectomy or Stenting for Evolving Stroke Secondary to Carotid Artery Atherosclerosis

Peter Kan, David Orion, Adnan H. Siddiqui, Elad I. Levy and L. Nelson Hopkins

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.

Carotid Artery Stenting in Acute Cervical Carotid Occlusion

In comparison to thrombolytics and CEA, CAS can be used to treat acute carotid occlusion in all locations (including intracranial) and from all etiologies (including dissections). The initial results reported have been very encouraging. Miyamoto and colleagues reported a favorable outcome (modified Rankin scale [mRS] score ≤1) and complete revascularization in all five patients treated with CAS for isolated cervical ICA occlusion. Dabitz’s group, in another study of 10 patients with either isolated cervical or tandem ICA occlusions, reported a cervical ICA recanalization rate of 100% with CAS, and 70% of patients returned with an mRS score of 2 or less after 20 weeks. Sugg and coworkers, in a study of 14 patients with either isolated cervical or tandem ICA occlusions, reported recanalization in 64% of patients, with good outcomes in 64% of patients. Nedeltchev and coworkers, in a larger study with 25 patients treated with CAS for acute cervical ICA occlusion, reported successful recanalization in 84% of patients. At 3 months, 56% of patients had a favorable outcome.

Similarly, in another study with 25 patients who presented with acute cervical ICA occlusions, Jovin and associates reported successful revascularization with CAS in 92% of patients. Two groups of patients were identified in the study: patients who presented with an acute stroke and patients who presented with milder fluctuating neurologic symptoms. Jovin and associates found that patients in the first group were younger and more likely to have a tandem lesion and a higher baseline National Institutes of Health Stroke Scale (NIHSS) score. In contrast, patients in the second group were older, usually presented with a less severe stroke, and were more likely to show early clinical improvement after CAS, defined as a reduction of the NIHSS score by at least 4 points and an mRS score of 2 or lower at the 30-day follow-up evaluation.

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