Background: The endovascular management of acute extracranial carotid artery (EcCA) occlusion is unclear, as hypotension, a known phenomenon with carotid revascularization (CR), may exacerbate stroke symptoms. Most studiesinclude patients with tandem intracranial occlusions requiring thrombectomy, and even in those cases, there remains variability in regards to the order and manner of endovascular therapy (e.g. extra- vs intracranial revascularization first.
Objective: We sought to compare the clinical and radiographic differences in EcCA patients who did or did not undergo proximal CR.
Methods: We identified patients screened for possible intervention with acute EcCA occlusion from our prospective stroke database from 1/2014-8/2016and abstracted their demographic, clinical, and radiographic data. We compared differences between groups using chi-square analysis.
Results: Thirty-four patients had EcCA: (10, 29% sole EcCA; 24, 71% tandem occlusions; these included 19 of our 143 (13%) patients undergoing acute stroke intervention (16 with tandem lesions, 3 without). Nine of the 16 tandem occlusion patients underwent specific CR, whereas in four we were unable to cross the EcCA, and in 3 only targeted the intracranial occlusion. The mean age was 69±14 years among 19 males and 15 females, with no intergroup differences. Most (19, 56%) received IV tPA in the whole group as well as the CR subset (7, 58%), who were loaded with antiplatelet agents afterwards; 11 underwent stent placement and 1 angioplasty alone. Although there were trends towards higher baseline and discharge National Institutes of Health Stroke scale scores (NIHSSS) among the CR group (19 vs 16 and 21 vs 18) and median discharge modified Rankin scales (5 vs 4), these were not significant (p>0.05). There were 5 deaths in both groups. As a comparison to the rest of our thrombectomy cohort, there was no significant difference in discharge NIHSSS (11 vs 13) among patients undergoing CR though there proportionately more deaths (25, 18%, no CRvs 5, 42%, CR, p<0.05).
Conclusion: These data suggest that EcCA patients should be informed of possible greater risk of mortality during acute stroke intervention. Further analyses may better identify practice standards to improve outcomes in this population.