Letter by Nedeltchev et al Regarding Article, “Short-Term Outcomes After Symptomatic Internal Carotid Artery Occlusion”
To the Editor:
In a recent article in Stroke,(1 Burke et al compared the short-term outcome of patients with symptomatic internal carotid artery (ICA) occlusion with that of patients with varying degrees of ICA stenosis. Symptomatic ICA occlusion had worse outcomes than moderate or severe stenosis. Given the poor short-term prognosis, the authors conclude that more aggressive management may be warranted for patients with acute symptomatic ICA occlusion.
As pointed out in the article, patients with acute symptomatic ICA occlusion may have a hemodynamic compromise and therefore be at higher risk of an unfavorable outcome. Urgent revascularization procedures such as thrombectomy and stenting can restore the blood supply to the ischemic penumbra and thus improve the outcome. In addition, these interventions would remove the source of embolism (ie, the fresh thrombus in the ICA) and prevent stroke recurrence.
To reduce the risk of both hemodynamic compromise and stroke recurrence in patients with acute symptomatic ICA occlusion, we developed a protocol for endovascular treatment that consists of thrombectomy, stenting of the proximal segment of the ICA, and intra-arterial thrombolysis.2 The intervention is performed within the therapeutic time window of 6 hours and during a single angiographic session.
We treated 25 consecutive patients with acute symptomatic ICA occlusion.2 In 21 patients (84%), the ICA was recanalized successfully. In 4 patients, both the passage of the guidewire through the occluded ICA and the recanalization failed. We compared the functional outcome of these patients with that of 31 patients, who received antiplatelet drugs or heparin only. At 3 months, 56% of the endovascular group and 26% of the medical group had a favorable outcome. Mortality was 20% in the endovascular and 16% in the medical group.
Our experience corroborates the conclusion of Burke et al that further studies are needed to determine the value of urgent revascularization techniques in patients with acute symptomatic ICA occlusion.
Krassen Nedeltchev, MD
Department of Neurology
Luca Remonda, MD
Department of Neuroradiology
Gerhard Schroth, MD
University of Bern
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- © 2012 American Heart Association, Inc.