Importance of perioperative management for emergency carotid artery stenting within 24 h after intravenous thrombolysis for acute ischemic stroke: Case report

• We report a patient treated successfully via endovascular surgery within 24 h after intravenous thrombolysis using recombinant tissue plasminogen activator for acute cervical internal carotid artery occlusion.
• Emergency carotid artery stenting for the acute internal carotid artery occlusion may be considered a safe procedure in preventing early stroke recurrence in selected patients.
• When trying to perform emergency carotid artery stenting within 24 h after intravenous recombinant tissue plasminogen activator administration, several issues require attention, such as the decisions regarding the type of stent and embolic protection device, the selection of antiplatelet therapy and the methods of preventing hyper perfusion syndrome.
• We administered aspirin and clopidogrel for the prevention of subacute thrombosis, and we used dexmedetomidine for preventing hyperperfusion syndrome, so that we also obtained a good result.

IntroductionWe report a patient treated successfully via endovascular surgery within 24 h after intravenous thrombolysis using recombinant tissue plasminogen activator for acute cervical internal carotid artery occlusion.Presentation of caseA 68-year-old man was admitted to our hospital. Neurological examination revealed severe left-sided motor weakness. Magnetic resonance imaging showed no cerebral infarction, but magnetic resonance angiography revealed complete occlusion of the right internal carotid artery. Systemic intravenous injection of recombinant tissue plasminogen activator was performed within 4 h after the onset. But, magnetic resonance angiography still revealed complete occlusion. Revascularization of the right cervical internal carotid artery was performed via endovascular surgery. The occluded artery was successfully recanalized using the Penumbra System® and stent placement at the origin of the internal carotid artery. Immediately after surgery, dual antiplatelet therapy (aspirin and clopidogrel) was initiated, and then cilostazol was added on the following day. Carotid ultrasonography and three-dimensional computed tomographic angiography at 14 days revealed no further obstruction to flow.DiscussionWhen trying to perform emergency carotid artery stenting within 24 h after intravenous recombinant tissue plasminogen activator administration, several issues require attention, such as the decisions regarding the type of stent and embolic protection device, the selection of antiplatelet therapy and the methods of preventing hyperperfusion syndrome.ConclusionEmergency carotid artery stenting for the acute internal carotid artery occlusion may be considered a safe procedure in preventing early stroke recurrence in selected patients.