Stent-Assisted Endovascular Thrombolysis Versus Intravenous Thrombolysis in Internal Carotid Artery Dissection With Tandem Internal Carotid and Middle Cerebral Artery Occlusion

Background and Purpose— Tandem internal carotid and middle cerebral artery occlusion independently predicts poor outcome after intravenous thrombolysis. Recanalization of internal carotid artery dissection by stent-assisted angioplasty has recently been proposed when anticoagulation fails to prevent a new ischemic event. We recently reported a case of tandem internal carotid and middle cerebral artery occlusion with dissection of the internal carotid artery successfully treated with endovascular stent-assisted thrombolysis. Methods— We compared clinical outcomes in consecutive patients presenting with tandem internal carotid and middle cerebral artery occlusion with internal carotid artery dissection within 3 hours of symptom onset who were eligible for intravenous thrombolysis, treated by either endovascular stent-assisted thrombolysis or intravenous recombinant tissue-type plasminogen activator (rtPA) when an endovascular therapist was unavailable. National Institutes of Health Stroke Scale scores were obtained at baseline and after 24 hours. The modified Rankin Scale score was used to assess outcomes at 3 months. Arterial recanalization was assessed by magnetic resonance imaging. Results— Of 10 patients screened, 6 were treated with endovascular therapy and 4 with intravenous rtPA. Before treatment, mean National Institutes of Health Stroke Scale scores were high and comparable in the 2 groups (17 and 16, respectively). In the endovascular group, all patients achieved middle cerebral artery recanalization with subsequent dramatic improvement versus only 1 patient with middle cerebral artery recanalization in the intravenous rtPA group. At 3 months, 4 patients in the endovascular group had a favorable outcome (modified Rankin Scale score=0). In the intravenous rtPA group, 3 patients had a poor outcome (modified Rankin Scale score≥3). Conclusions— Endovascular stent-assisted thrombolysis is a promising treatment in tandem internal carotid and middle cerebral artery occlusion due to internal carotid artery dissection and compares favorably with intravenous rtPA.

[1]  C. Molina,et al.  Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion: An Independent Predictor of Poor Outcome After Systemic Thrombolysis , 2006, Stroke.

[2]  J. Hauw,et al.  Predictors for malignant middle cerebral artery infarctions , 2006, Neurology.

[3]  C. Derdeyn,et al.  Angioplasty and stenting in carotid dissection with or without associated pseudoaneurysm. , 2005, AJNR. American journal of neuroradiology.

[4]  S. Schwab,et al.  IV thrombolysis in patients with acute stroke due to spontaneous carotid dissection , 2005, Neurology.

[5]  A. Alexandrov,et al.  Early Recanalization Rates and Clinical Outcomes in Patients With Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion and Isolated Middle Cerebral Artery Occlusion , 2005, Stroke.

[6]  R. Sacco,et al.  Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. , 2004, Chest.

[7]  W. Hacke,et al.  Hemorrhagic Transformation of Ischemic Brain Tissue: Asymptomatic or Symptomatic? , 2001, Stroke.

[8]  J. Honnorat,et al.  Intravenous tPA in acute ischemic stroke related to internal carotid artery dissection , 2000, Neurology.

[9]  A M Malek,et al.  Endovascular management of extracranial carotid artery dissection achieved using stent angioplasty. , 2000, AJNR. American journal of neuroradiology.

[10]  M. Debouverie,et al.  [Cerebral ischemic accidents in young subjects. A prospective study of 296 patients aged 16 to 45 years]. , 1999, Revue neurologique.

[11]  B. Starnes,et al.  Treatment of symptomatic cervical carotid dissections with endovascular stents. , 1999, Neurosurgery.

[12]  L. Tatu,et al.  Stroke patterns of internal carotid artery dissection in 40 patients. , 1998, Stroke.

[13]  J. Marler,et al.  Measurements of acute cerebral infarction: a clinical examination scale. , 1989, Stroke.

[14]  C. Fisher,et al.  Spontaneous Dissection of Cervico-Cerebral Arteries , 1978, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques.

[15]  J. Swieten Interobserver Agreement for the Assessment of Handicap in Stroke Patients , 2005 .

[16]  R. Bloch,et al.  Interobserver agreement for the assessment of handicap in stroke patients. , 1988, Stroke.