Management of patients with isolated acute cervical carotid artery occlusion and normal neurological exam: Technical note and case series

• Published in: Interdisciplinary neurosurgery : Advanced techniques and case management 2020-03, Vol.19, p.100600, Article 100600
• Main Authors: Weinberg, Joshua H., Chalouhi, Nohra, Sweid, Ahmad, Tjoumakaris, Stavropoula, Gooch, Michael Reid, Rosenwasser, Robert H., Jabbour, Pascal, Zarzour, Hekmat
• Format: Article
• Language: English
• Subjects: Carotid artery occlusion; Endovascular; Normal neurological exam; Perfusion imaging; Proximal flow arrest
• ISSN: 2214-7519; 2214-7519
• DOI: 10.1016/j.inat.2019.100600

•Order CTP in all patients with normal neuro exam after experiencing neuro deficits.•CTP can help identify patients at risk for stroke due to collateral failure.•If CT perfusion shows mismatch, give patients the option of intervention.•MTT ≥ 200% or Tmax > 6 s is the optimal penumbra threshold predicting infarction.•A technique using proximal flow arrest minimizes risk of shower emboli. Limited data exists on the management and outcome of patients with isolated acute cervical internal carotid artery (cICA) occlusion presenting with normal neurologic exam after experiencing a period of neurological deficits. These patients are at risk for progressive neurologic deterioration but have not yet progressed to stroke. Current management is no intervention due to intervention risk of embolization. We aim to determine the optimal management of patients with isolated acute cICA occlusion presenting with a normal neurological exam after experiencing neurological deficits. Data was collected on 3 patients with acute cICA occlusion that presented with a normal neurological exam to our institution. Patient 1 was treated according to standard protocol, while patients 2 and 3 were treated according to the management discussed. Associations between perfusion imaging studies and clinical outcome were analyzed to determine stroke risk. A revascularization technique to minimize risk of distal embolization is described. A total of 3 consecutive patients with acute cICA occlusion were successfully revascularized. Patients 2 and 3 (66.67%) were neurologically intact post-operatively, while patient 1 (33.33%) had residual hemiparesis. It seems that MTT ≥ 200% or Tmax > 6 s is the optimal penumbra threshold predicting infarction and neurologic deterioration. There were no embolic complications as a result of endovascular therapy (EVT). Cerebral perfusion imaging of patients presenting with normal neurological exam after experiencing neurological deficits is warranted to help identify patients at risk for stroke due to collateral failure. These patients should be monitored in the ICU for neurologic deterioration and given the option of intervention if mismatch is noted on CT perfusion imaging. Perfusion studies identifying penumbra and delayed MTT ≥ 200% or Tmax > 6 s are indicators for possible collateral failure. In patients undergoing intervention, we suggest a technique using proximal flow arrest to minimize risk of shower emboli. Further studies are needed to verify our findi