“Internal cross-clamping” for symptomatic internal carotid artery thrombus

Report of two cases

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✓Both carotid endarterectomy and carotid artery stent placement with filter embolic protection present a higher risk for patients with internal carotid artery (ICA) lesions containing intraluminal thrombus. Despite the risk associated with intervention, patients with symptomatic intraluminal thrombus who were enrolled in the North American Symptomatic Endarterectomy Trial did better with surgical than medical treatment. We describe the novel use of an endovascular “internal cross-clamping” technique in two patients with symptomatic intraluminal thrombus in the ICA. A 57-year-old woman presented with a history of multiple episodes of left upper-extremity numbness, mild dysarthria, and agraphia occurring over the previous 24 hours. Cranial magnetic resonance imaging revealed a scattered watershed infarction of the right hemisphere and a critical stenosis of the right ICA. An 81-year-old man awoke with hemiplegia and inability to follow commands after undergoing a complicated carotid endarterectomy. Computed tomographic perfusion imaging demonstrated an increased time to peak in the left middle cerebral territory, and emergent angiography demonstrated both intimal flaps and thrombus in the endarterectomy bed. The lesions in both patients were treated with endovascular stent placement using both proximal and distal flow occlusion—a functional “internal cross-clamping”—for embolic protection. To our knowledge, this is the first report of internal trapping and stent placement for symptomatic carotid stenosis containing intraluminal thrombus. This treatment strategy should be added to the armamentarium of endovascular surgeons in selected patients with symptomatic carotid intraluminal thrombus.

Abbreviations used in this paper:CA = carotid artery; CCA = common CA; CEA = carotid endarterectomy; ECA = external CA; ICA = internal CA; MR = magnetic resonance; NASCET = North American Symptomatic Carotid Endarterectomy Trial.

Article Information

Address correspondence to: L. Nelson Hopkins, M.D., University at Buffalo Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, 3 Gates Circle, Buffalo, New York 14209.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Left: Axial MR image showing a small right frontal infarction. Right: An MR angiogram showing a critical right ICA stenosis.

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    Case 1. Cervical angiograms obtained before (left) and after (right) stent placement. The critical stenosis and flame-shaped intraluminal thrombus are evident in the pretreatment image.

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    Case 1. An MR image obtained after stent placement, showing no new areas of stroke.

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    Case 2. Preoperative MR angiographic image demonstrating severe stenosis of the origin of the left ICA and distal tortuosity.

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    Case 2. Computed tomography perfusion image demonstrating increased time to peak in the left middle cerebral artery territory and in the posterior watershed region (arrow).

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    Case 2. Angiograms obtained before (left) and after (right) stent placement. Initial lateral projection (left) of a left CCA injection shows irregular appearance of endarterectomy bed with intimal flaps and thrombus (arrow). Lateral projection obtained after stent placement shows excellent coverage of the endarterectomy bed and good luminal reconstruction.

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