Symptomatic Near-Occlusion of the Internal Carotid Artery: Excellent Clinical Outcome from Balloon Dilatation and Stent Deployment

A 76-year-old man with a past medical history of type 2 diabetes mellitus, arterial hypertension, and a hemicolectomy for colon carcinoma 38 years ago presented at the emergency room with latent left hemiparesis and an NIH Stroke Score of 1. One day before this presentation, he developed weakness and fine motor impairment of his left hand. Approximately 6 h later, his left leg became weak; this was followed by a fall 2 h later. Computed tomography (CT) and CT angiography performed on admission revealed an ischemic lesion in the right sensorimotor cortex, proximal occlusion of the right internal carotid artery (ICA), ulcerated plaque in the proximal left ICA, low-grade stenosis of the left middle cerebral artery, and ostial stenosis of the right vertebral artery. Contrast-enhanced magnetic resonance imaging (MRI)/MR angiography performed 2 days later revealed that the right ICA was patent, although its lumen had collapsed due to high-grade proximal atherosclerotic stenosishigh-grade proximal atherosclerotic stenosis. Oral dual antiplatelet therapydual antiplatelet therapy with aspirin at 1× 100 mg and ticagrelor at 2× 90 mg per day was initiated. Digital subtraction angiography performed 2 days later under local anesthesia confirmed near-occlusionnear-occlusion of the right ICA with collapse of the lumencollapse of the lumen at a point distal to the stenosis. After induction of general anesthesia, the region of stenosis was traversed with a microguidewire which facilitated balloon dilatation and stent deployment to reconstruct the right ICA lumen. The procedure was well tolerated. MRI performed 2 days later demonstrated several diffusion-weighted imaging microlesions. The diagnosis and management of near-occlusive stenosis (also known as pseudo-occlusion) of the ICA are reviewed.