Acute Ischemic Stroke in the Setting of Cervical Carotid Occlusion: A Proposed Management Strategy

BackgroundOcclusion of the extracranial internal carotid artery, whether a result of atherothrombosis or dissection, is a challenging cause of ischemic stroke, characterized by a dismal natural history and a poor response to systemic thrombolysis.MethodsReview of the literature and proposal of a management strategy.ResultsIn most patients, symptoms are caused by a coexistent intracranial occlusion, and treatment of the latter dictates the final outcome. However, a smaller subset of patients present with acute cerebral hemodynamic insufficiency requiring recanalization of the extracranial vessel. Careful analysis of the initial angiograms, particularly the extent and pattern of collateral flow, will usually give the clue as to the mechanism of stroke. The distal lesion can often be accessed by advancing a microcatheter, either through collateral channels or through the proximal occlusion itself.ConclusionsIn all cases, the importance of prompt and timely recanalization through aggressive intra-arterial therapy cannot be overemphasized.