What are the treatment options for a suspected right Internal Carotid Artery (ICA) stroke?

Treatment Options for Right Internal Carotid Artery (ICA) Stroke

For patients with suspected right ICA stroke, immediate brain imaging followed by appropriate reperfusion therapy (IV thrombolysis within 4.5 hours and/or mechanical thrombectomy within 6-24 hours depending on imaging findings) is recommended to reduce mortality and improve functional outcomes.

Initial Assessment and Imaging

• All patients with suspected acute stroke should undergo brain imaging (head CT or brain MRI) without delay upon hospital arrival and before receiving any specific treatment 1
• Non-invasive vascular imaging (CT angiography) should be performed to assess for large vessel occlusion, particularly in patients with clinically suspected ICA occlusion 1
• A stroke severity rating scale (e.g., NIHSS) should be used in the emergency department to quantify deficit and guide treatment decisions 1
• Basic laboratory tests should be obtained but should not delay initiation of reperfusion therapy: blood glucose, complete blood count, electrolytes, coagulation studies, and cardiac biomarkers 1

Acute Reperfusion Therapy

Intravenous Thrombolysis

• IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 min with initial 10% as bolus) is recommended for eligible patients within 4.5 hours of symptom onset or last known well 1
• Only blood glucose assessment must precede IV alteplase initiation 1
• Patients with acute hypertension should have BP lowered below 185/110 mmHg before IV thrombolysis 1
• In patients with ICA occlusion, IV thrombolysis results in significant reduction in dependency despite increased risk of intracranial bleeding 2
• For patients with unclear time of onset >4.5 hours from last known well, IV alteplase may be beneficial if MRI shows DWI-FLAIR mismatch 1

Mechanical Thrombectomy

• Mechanical thrombectomy is strongly recommended for patients with ICA occlusion who meet the following criteria 1:
  • Age ≥18 years
  • Pre-stroke mRS score of 0-1
  • NIHSS score ≥6
  • ASPECTS ≥6
  • Treatment can be initiated (groin puncture) within 6 hours of symptom onset
• Mechanical thrombectomy is also recommended between 6-24 hours in patients with sizable mismatch between ischemic core and hypoperfusion area on advanced imaging 1
• Mechanical thrombectomy has shown higher recanalization rates (69% vs 38%) and better functional outcomes (34% vs 12%) compared to intra-arterial thrombolysis for intracranial ICA occlusions 3
• Eligible patients should receive IV thrombolysis even if mechanical thrombectomy is being considered 1
• Do NOT wait to evaluate response to IV thrombolysis before proceeding with catheter angiography for mechanical thrombectomy 1

Surgical Management for Symptomatic ICA Stenosis

• For patients with symptomatic 70%-99% ICA stenosis, carotid endarterectomy (CEA) is recommended if the 30-day risk of procedural death/stroke is <6% 1
• If CEA is indicated, it should be performed within 14 days of symptom onset 1
• Revascularization is not recommended for patients with ICA lesions <50% 1
• For extracranial ICA occlusions, stenting has shown higher recanalization rates (87% vs 48%) and better functional outcomes (68% vs 15%) compared to intra-arterial thrombolysis 3

Acute In-Hospital Management

• Patients should be admitted to a specialized stroke unit or intensive care unit if critically ill 1
• Cardiac monitoring is recommended for at least the first 24 hours to screen for atrial fibrillation and other arrhythmias 1
• Blood pressure should be maintained below 180/105 mmHg for at least 24 hours after acute reperfusion treatment 1
• Aspirin administration is recommended within 24-48 hours after stroke onset (delayed until >24 hours after IV thrombolysis) 1
• Supplemental oxygen should be provided to maintain oxygen saturation ≥94% 1
• Body temperature should be monitored and fever (>38°C) should be treated 1

Management of Massive Stroke with Cerebral Edema

• Serial neurological examinations and repeat head CT should be performed to identify worsening brain swelling 1
• Patients with massive strokes should be immediately intubated if they develop neurological deterioration with respiratory insufficiency 1
• Decompressive hemicraniectomy is indicated within 48 hours of symptom onset in patients with massive hemispheric infarction and worsening neurological condition 1

Secondary Prevention

• In patients with symptomatic ICA stenosis not undergoing revascularization, dual antiplatelet therapy (DAPT) with low-dose aspirin and clopidogrel (75 mg) is recommended for the first 21 days, followed by clopidogrel 75 mg or long-term aspirin 1, 4
• DAPT reduces stroke recurrence after minor stroke/TIA when initiated within 24 hours of symptom onset 1, 4
• After ICA stent implantation, DAPT with aspirin and clopidogrel is recommended for at least 1 month 1
• After ICA revascularization, long-term single antiplatelet therapy is recommended 1

Follow-up Care

• Once-yearly follow-up is recommended to check for cardiovascular risk factors and treatment compliance 1
• After ICA revascularization, surveillance with Doppler ultrasound is recommended within the first month 1
• During follow-up, neurological symptoms, cardiovascular risk factors, and treatment adherence should be assessed at least yearly 1

Special Considerations

• Patients with right ICA stroke may present with left-sided hemiparesis, left-sided sensory deficits, left visual field defects, and potentially neglect syndrome or spatial-perceptual deficits
• Treatment decisions should be made by a multidisciplinary team including a neurologist with stroke expertise 1
• The technical goal of mechanical thrombectomy should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b/3 1