| Oct 17, 2005 | Shelley Wood |
Pittsburgh, PA - Angioplasty with stenting to revascularize occluded extracranial internal carotid arteries (ICAs) can safely restore blood flow in patients with acute occlusion and may be associated with early neurological improvement, a new study shows [1]. The nonrandomized results should be considered pilot data warranting further study, the authors say.
As lead author Dr Tudor G Jovin (University of Pittsburgh, PA) told heartwire, acute ischemic stroke due to extracranial internal carotid artery occlusion can be fatal in as many as 20% of patients, yet there is little in the way of accepted treatment.
"Your average community hospital would probably not do much with these patients, just put them on heparin and hope for the best," he explained. "Putting people on pressors or sending them to surgery is not really standard of care. It's done at very few centers, which are very advanced in the approach to stroke."
Jovin et al's study appears in the November 2005 issue of Stroke.
Investigators report 30-day outcomes for 25 patients who underwent cerebral angiography followed by revascularization when possible. The patients were either acute-stroke patients (presenting within six hours of symptoms) or patients who presented subacutely with neurologic fluctuations due to internal carotid artery occlusion.
In total, 23 of the 25 patients were successfully revascularized. Acute-stroke patients were more likely to be younger and to have tandem intracranial occlusions, whereas patients in the subacute-stroke group were more likely to experience improvement in National Institutes of Health Stroke Score (NIHSS) at 24 hours and a modified Rankin Score (mRS) <2 at 30 days.
Neurologic improvements
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While the results are short-term and represent the experience of a single center, Jovin believes they are promising and novel. Although operators now have considerable experience stenting for carotid stenosis, they have been apprehensive about stenting a total extracranial carotid occlusion due to concerns of thrombi dislodging distally when the occlusion is crossed and uncertainty about the length of the occlusion.
"We are not used to thinking in terms of opening an occluded vessel affecting the brain. We're about 10 years behind cardiologists in their approach to blocked or narrowed vessels, and I think they are probably going to say, well, this isn't a big deal, we're already doing that in the heart," Jovin commented. "But the thinking for the brain vessels has not been there, and there's a bit more at stake. And the big concern has been: what do we have downstream from this blockage? The conventional wisdom has been that you have a big clot in the vessel that extends from the blockage up to the brain. And we found that that's not the case. What we found is that the vessel is actually completely blocked for a very short segment, and when you open that segment with a stent, you can actually open the whole vessel."
The next step says, Jovin, is a randomized trial comparing extracranial ICA stenting to standard of care. An endovascular strategy, he adds, would be a welcome alternative to pressor drugs, since acute-stroke patients with ICA occlusions are typically elderly with hypertension, heart disease, and other contraindications to blood-pressure-elevating drugs. While surgery may also yield similar neurological improvements, an endovascular approach provides operators with the advantage of defining the length of the occlusion before the intervention.
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