Endovascular therapy in 201 patients with acute symptomatic occlusion of the internal carotid artery

Fischer, Urs; Mono, M.-L.; Schroth, G.; Jung, S.; Mordasini, P.; El-Koussy, M.; Weck, A.; Brekenfeld, C.; Findling, O.; Galimanis, A.; Heldner, Mirjam Rachel; Arnold, M.; Mattle, H.P.; Gralla, J. (2013). Endovascular therapy in 201 patients with acute symptomatic occlusion of the internal carotid artery. European journal of neurology, 20(7), pp. 1017-1024. Oxford: Blackwell Science 10.1111/ene.12094

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Background and purpose

Endovascular therapy is used increasingly for treatment of acute symptomatic internal carotid artery (ICA) occlusion, although randomized trials are lacking. Predictors of outcome are therefore of special interest.

Methods

From 1992 to 2010 we treated 201 patients with acute ICA occlusion with intra-arterial pharmacological thrombolysis (32), endovascular mechanical therapy (78) or a combination of both (91). All data were assessed prospectively.

Results

There were 76/38% patients with tandem occlusions [ICA plus middle (MCA) or anterior cerebral arteries (ACA)], 18/9% without concomitant occlusions of major intracranial arteries (ICA plus branch occlusion) and 107/53% with functional ICA-T occlusions (ICA plus MCA and ACA). Median baseline National Institute of Health Stroke Scale (NIHSS) score was 17. Good recanalization (Thrombolysis in Myocardial Infarction 2–3) was achieved in (157/201) 78% patients and good reperfusion (Thrombolysis in Cerebral Infarction 2–3) in (151/182) 83%. Better recanalization rates were obtained with mechanical approaches, with/without thrombolytics (78/91 = 86% and 64/78 = 82%) compared with pharmacological thrombolysis only (15/32 = 47%; P < 0.001). Twelve patients (6%) suffered symptomatic intracranial haemorrhages. The 3-month outcome was favourable [modified Rankin score (mRS) 0–2] in 54/28% patients and moderate (mRS 0–3) in 90/46%; 60/31% patients died. Only 17/16% patients with functional ICA-T occlusions had favourable outcomes compared with 32/44% with tandem occlusions and 5/31% with ICA plus cerebral branch occlusions (P = 0.001). In multivariate analysis age [odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.93–0.98], NIHSS on admission (OR = 0.9, 95% CI = 0.83–0.98) and functional ICA-T occlusion (OR = 0.35, 95% CI = 0.16–0.77) were non-modifiable predictors, and vessel recanalization was the only modifiable predictor of outcome (OR = 9.30, 95% CI = 2.03–42.63).

Conclusions

The outcome of acute symptomatic ICA occlusion is poor. However, recanalization is associated with better outcome, and recanalization rates with mechanical techniques were superior to merely pharmacological recanalization attempts.

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