Symptomatic Acute Proximal Internal Carotid Occlusion with Patent Intracranial Vasculature: Endovascular Revascularization with Balloon Angioplasty and Stenting

Acute ischemic stroke due to isolated internal carotid artery (ICA) occlusion is uncommon. Patients with this condition were excluded from the major clinical trials that showed the efficacy of mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in the anterior circulation. These patients exhibit various clinical states, ranging from asymptomatic to transient ischemic attacks to acute severe stroke syndromes. Asymptomatic occlusions present a low risk of stroke; however, the recurrence of ischemic events in patients with symptomatic ICA occlusion ranges from 10–18% annually. The clinical presentation and recurrent stroke risk in an individual patient depend on various vascular risk factors, including hemodynamic alterations, occlusive patterns, and the robustness of collateral reserve capacity. From a therapeutic point of view, acute ICA occlusion responds poorly to intravenous thrombolysis. Endovascular management of acute proximal ICA occlusions was only recently evaluated. Despite some conflicting results, the recent success of endovascular procedures continues to expand the horizons and improve the management of ICA occlusion, and supports urgent endovascular revascularization of symptomatic patients. We present the case of a 77-year-old previously independent man with a history of arterial hypertension, who was admitted due to a mild left-hemisphere wake-up stroke with a baseline National Institutes of Health Stroke (NIHSS) score of 4. Noncontrast cranial CT was unremarkable with an Alberta Stroke Program Early CT Score (ASPECTS) of 10. CT angiography showed occlusion of the left ICA in the proximal cervical segment, a patent left middle cerebral artery (MCA) supplied by the contralateral ICA through the anterior communicating artery (AcomA), and absence of the posterior communicating arteries (PcomAs). MRI diffusion-weighted imaging (DWI) revealed watershed infarcts in the left frontal and parietal lobe periventricular white matter. The patient was admitted to the stroke unit. Dual antiplatelet therapy, high-dose statin, and intravenous fluids were started. Despite the treatment, the patient demonstrated marked clinical instability, with an NIHSS score ranging from 4–8 during the first 12 h after admission. To prevent further neurological deterioration, the patient underwent urgent endovascular revascularization of the proximal left ICA occlusion using stent-assisted left ICA angioplasty. The procedure was uneventful, and an excellent angiographic and clinical result was obtained. The patient improved neurologically, with an NIHSS of 2 after the endovascular treatment. Post-procedure noncontrast cranial CT was unremarkable. The patient had an uncomplicated subsequent clinical course with a remarkably rapid recovery and almost complete reversal of his symptoms. This chapter describes the revascularization strategy for the management of a symptomatic acute proximal ICA occlusion. We explain our standard procedure, its rationale, and its limitations and present the ongoing controversies and debates.