Isolated carotid occlusion - Ep.1/2: When to treat? - SLICE Worldwide 2023

"Isolated carotid occlusion" When to treat?

A 55-year-old patient, smoker, started experiencing symptoms at 11:30 AM with changes in vision in the left eye and clumsiness in the right hand. He arrives at the Comprehensive stroke center with NIHSS 0 after two hours and 30 minutes of symptoms.

During admission, ischemic lesions were seen in the border area and MRA diagnosed a dissection of the left internal carotid artery with a subocclusive thrombus.

There was a great discussion about the best therapeutic option and some experts opted for heparin and others thought that double antiplatelet therapy would be the best option as the patient would eventually be prepared for endovascular treatment. Furthermore, there are some studies showing the benefit of dual antiplatelet therapy in relation to aspirin.

The patient was placed on full heparinization and on the third day he presented some ocular symptoms once again and a new MRI was performed with a new ischemic lesions in the basal ganglia and the MRA with occlusion of the left internal carotid artery and a new dissection of the right internal carotid artery.

Furthermore, the literature demonstrated that there is a 20% risk of worsening in the first 7 days in patients with isolated carotid occlusion, despite the series mixing patients with dissection and thrombi.1,2

Endovascular treatment was then indicated and on the day of treatment the patient presented with aphasia. We can see the presentation of an innovative product called Zeit Halo, which monitors brain activity and can detect ischemic changes during sleep.

And after treatment with angioplasty of the left internal carotid, the patient presented symptoms of the right internal carotid and was referred for treatment of the right internal carotid.

We can also see a great discussion about what would be the best medical treatment strategy between anticoagulation or dual antiplatelet therapy in these cases.

And summarizing all the discussions in cases of isolated internal carotid occlusion:

1) high NIHSS; disabling deficit or Hypoperfusion = REVASCULARIZATION

2)CTA or CTP with hypoperfusion but with NIHSS < 5 or minor deficits = first medical treatment and neurological surveillance.

An important tip is for patients with isolated carotid occlusion and low NIHSS to be referred to a comprehensive stroke center. In these patients in group 2, we must monitor with NIHSS every 20 minutes, optimizing blood pressure and MRI if in doubt.

If you present warning signs:

1) Clinical fluctuation

2) New Silent injuries Revascularization with endovascular treatment is indicated.

• Further reading: 

1. Ossama Khazaal et al Early Neurologic Deterioration with Symptomatic Isolated Internal Carotid Artery Occlusion: A Cohort Study, Systematic Review, and Meta Analysis Stroke: Vascular and Interventional Neurology 2022;2:e000219

2. Ter Schiphorst A, Gaillard N, Dargazanli C, Mourand I, Corti L, Charif M, Ayrignac X, Lippi A, Bouly S, Thibault L, Sablot D, Blanchet-Fourcade G, Landragin N, Costalat V, Duflos C, Arquizan C. Symptomatic isolated internal carotid artery occlusion with initial medical management: a monocentric cohort. J Neurol. 2021 Jan;268(1):346-355.