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.
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.
Authors: T Kucinski; C Koch; B Eckert; V Becker; H Krömer; C Heesen; U Grzyska; H J Freitag; J Röther; H Zeumer Journal: Neuroradiology Date: 2002-12-07 Impact factor: 2.804
Authors: A Furlan; R Higashida; L Wechsler; M Gent; H Rowley; C Kase; M Pessin; A Ahuja; F Callahan; W M Clark; F Silver; F Rivera Journal: JAMA Date: 1999-12-01 Impact factor: 56.272
Authors: Marta Rubiera; Marc Ribo; Raquel Delgado-Mederos; Esteban Santamarina; Pilar Delgado; Joan Montaner; José Alvarez-Sabín; Carlos A Molina Journal: Stroke Date: 2006-08-03 Impact factor: 7.914
Authors: Osama O Zaidat; Jose I Suarez; Concepcion Santillan; Jeffrey L Sunshine; Robert W Tarr; Vanessa H Paras; Warren R Selman; Dennis M D Landis Journal: Stroke Date: 2002-07 Impact factor: 7.914
Authors: J Röther; P D Schellinger; A Gass; M Siebler; A Villringer; J B Fiebach; J Fiehler; O Jansen; T Kucinski; V Schoder; K Szabo; G J Junge-Hülsing; M Hennerici; H Zeumer; K Sartor; C Weiller; W Hacke Journal: Stroke Date: 2002-10 Impact factor: 7.914