What is the management and treatment for a patient with a left Internal Carotid Artery (ICA) complete occlusion causing left cortical stroke?

Management of Left Internal Carotid Artery Complete Occlusion Causing Left Cortical Stroke

For patients with left internal carotid artery (ICA) complete occlusion causing left cortical stroke, mechanical thrombectomy with stent retrievers is the preferred treatment when initiated within 6 hours of symptom onset, particularly for patients with pre-stroke mRS 0-1 and ASPECTS ≥6. 1

Initial Assessment and Management

• All patients should undergo immediate brain imaging (CT/MRI) and vascular imaging (CT angiography) to confirm ICA occlusion and assess for concomitant intracranial large vessel occlusion 2
• Stroke severity should be quantified using NIHSS to guide treatment decisions 2
• Eligible patients should receive IV thrombolysis (alteplase 0.9 mg/kg) within 4.5 hours of symptom onset, even if endovascular treatment is being considered 1
• Do not wait to evaluate response to IV thrombolysis before proceeding with catheter angiography for mechanical thrombectomy 2

Endovascular Treatment Options

• Mechanical thrombectomy with stent retrievers is strongly recommended for patients with ICA occlusion who meet criteria (age ≥18, pre-stroke mRS 0-1, NIHSS ≥6, ASPECTS ≥6) within 6 hours of symptom onset 1, 2
• The technical goal of thrombectomy should be a TICI grade 2b/3 angiographic result to maximize probability of good functional outcome 1
• Use of a proximal balloon guide catheter or large-bore distal-access catheter in conjunction with stent retrievers may be beneficial 1
• For tandem lesions (extracranial ICA occlusion with ipsilateral intracranial occlusion), mechanical thrombectomy of the intracranial occlusion is recommended 1, 3

Management of Extracranial ICA Occlusion

• For isolated extracranial ICA occlusion, stenting shows higher recanalization rates (87% vs 48%) and better functional outcomes (68% vs 15%) compared to intra-arterial thrombolysis 3
• Angioplasty and stenting of proximal cervical atherosclerotic stenosis or complete occlusion at the time of thrombectomy may be considered, though the usefulness is not fully established 1
• Caution is warranted with urgent stenting as it typically requires antiplatelet therapy, which may increase risk of intracranial hemorrhage 1

Extended Time Window Treatment

• For patients presenting between 6-24 hours after symptom onset, mechanical thrombectomy may still be beneficial if there is a sizable mismatch between ischemic core and hypoperfusion area on advanced imaging 2

Acute In-Hospital Management

• Admit patients to a specialized stroke unit or intensive care unit if critically ill 2
• Monitor cardiac rhythm for at least 24 hours to screen for atrial fibrillation 2
• Maintain blood pressure below 180/105 mmHg for at least 24 hours after reperfusion treatment 2
• Initiate aspirin within 24-48 hours after stroke onset (delayed until >24 hours after IV thrombolysis) 2
• Monitor for and treat cerebral edema, particularly in large strokes 2

Management of Massive Stroke with Cerebral Edema

• Perform serial neurological examinations and repeat head CT to identify worsening brain swelling 2
• Consider decompressive hemicraniectomy within 48 hours of symptom onset in patients with massive hemispheric infarction and worsening neurological condition 2

Secondary Prevention

• For patients with symptomatic ICA occlusion not undergoing revascularization, dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended for the first 21 days, followed by long-term single antiplatelet therapy 2, 4
• After ICA stent implantation, DAPT is recommended for at least 1 month 2, 4
• Aggressive risk factor modification including blood pressure control, lipid management, and smoking cessation is essential 2

Follow-up Care

• Once-yearly follow-up is recommended to check for cardiovascular risk factors and treatment compliance 2
• After ICA revascularization, surveillance with Doppler ultrasound is recommended within the first month 2, 4

Important Considerations and Caveats

• Distal residual occlusion (DRO) is an independent predictor of favorable clinical outcomes in patients with acute ICA occlusion undergoing endovascular treatment 5
• Carotid endarterectomy may be considered for recent symptomatic ICA occlusion within 2 weeks of symptom onset in selected patients, though this approach is less common with modern endovascular techniques 6
• The risk of distal embolization should be considered when performing mechanical thrombectomy in cases without intracranial large vessel occlusion 7