What is the treatment for a stroke caused by clots in the neck?

Treatment of Stroke Caused by Clots in the Neck

For acute ischemic stroke caused by extracranial (neck) vessel occlusion, immediate treatment consists of intravenous alteplase (rtPA) within 4.5 hours if eligible, combined with urgent endovascular thrombectomy for large vessel occlusion, as this dual approach maximizes reperfusion and improves mortality and disability outcomes. 1, 2, 3

Immediate Diagnostic Evaluation

The first priority is rapid imaging to confirm ischemic stroke and exclude hemorrhage:

• Non-contrast CT head is mandatory before any reperfusion therapy to rule out intracranial hemorrhage, which is an absolute contraindication to thrombolysis 1, 2
• CTA of the neck and head should be obtained immediately to identify the location and extent of vessel occlusion in the extracranial carotid or vertebral arteries 1
• CTA of the neck is the fastest method to assess extracranial vasculature and is essential for endovascular surgical planning, including assessment of vessel tortuosity that affects thrombectomy approach 1

Critical pitfall: Do not delay treatment with time-consuming MRI sequences when CT/CTA can be obtained rapidly—every 30-minute delay in recanalization decreases the probability of good functional outcome by 8-14% 1, 3

Acute Reperfusion Therapy

Intravenous Thrombolysis

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) if the patient presents within 4.5 hours of symptom onset and meets eligibility criteria 2, 3:

• Blood pressure must be <185/110 mmHg before administration 3
• No evidence of hemorrhage on imaging 2, 3
• Use validated stroke severity scale (NIHSS) to assess deficit 3

The American College of Chest Physicians strongly recommends IV rtPA within 3 hours, with extended window to 4.5 hours for selected patients 2, 3

Endovascular Thrombectomy

For large vessel occlusion in the neck (extracranial carotid or vertebral artery), proceed immediately to endovascular therapy 1:

• Combined approach using stent-retrievers and aspiration is most effective for achieving rapid first-pass complete reperfusion 1
• Mechanical thrombectomy can be performed up to 6-12 hours from symptom onset for basilar artery occlusion 3
• Emergency angioplasty and stenting of extracranial internal carotid artery occlusion has shown favorable outcomes (56% vs 26% with medical therapy alone) 1

The 2020 JACC guidelines emphasize that treatment delays and patient overselection should be avoided given the time-dependent nature and poor natural history of large vessel occlusion stroke 1

Specific Management for Neck Vessel Occlusions

Extracranial Carotid Dissection

If the stroke is caused by carotid or vertebral artery dissection in the neck:

• Antithrombotic treatment for at least 3-6 months is reasonable, though the relative efficacy of antiplatelet therapy versus anticoagulation remains unclear 1
• Most dissections heal over time; anatomic healing with recanalization occurs in the majority of patients 1
• For patients with recurrent ischemic events despite optimal medical therapy, endovascular stenting may be considered 1

Combined Intravenous and Intra-arterial Approach

For proximal neck vessel occlusions with large clot burden, combined IV and intra-arterial therapy allows immediate IV thrombolysis while mobilizing the angiography team 1:

• Initiate IV alteplase in the emergency department
• Rapidly transport to angiography suite for additional intra-arterial therapy if needed
• This addresses the concern that delays to intra-arterial therapy alone may negate benefits 1

Blood Pressure Management

In patients receiving thrombolytic therapy, maintain blood pressure <185/110 mmHg 3:

• For patients NOT receiving reperfusion therapy, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg 3
• This represents a critical difference from hemorrhagic stroke management 2

Early Supportive Care

Within the first 24-48 hours:

• Administer aspirin 160-325 mg within 48 hours if the patient did not receive thrombolysis 2, 3
• Maintain oxygen saturation ≥94% 3
• Monitor and treat blood glucose to maintain <300 mg/dL 3
• Begin rehabilitation assessment within 48 hours and initiate therapy once medically stable 3
• Prophylactic LMWH or intermittent pneumatic compression for VTE prevention in patients with restricted mobility 4

Imaging for Treatment Planning

The degree of vascular tortuosity in neck vessels directly correlates with time from groin puncture to recanalization and must factor into surgical approach decisions, including consideration of radial artery or direct carotid puncture access 1

For patients with renal insufficiency or contrast allergy, MRA without contrast can identify arterial occlusions, though this should not delay treatment in the hyperacute setting 1

Key Contraindications

Absolute contraindications to thrombolysis include:

• Active intracranial hemorrhage 2, 4
• Evidence of hemorrhagic transformation on imaging 4
• Blood pressure that cannot be controlled below 185/110 mmHg 3