Cognitive and cerebral hemodynamic effects of endovascular recanalization of chronically occluded cervical internal carotid artery: single-center study and review of the literature

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  • 1 Departments of Neurosurgery,
  • | 3 Neurology, and
  • | 6 Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa;
  • | 2 Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois;
  • | 4 Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania;
  • | 5 Departments of Neurosurgery and Radiology, University of Miami, Florida;
  • | 7 Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan;
  • | 8 Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
  • | 9 Departments of Epidemiology,
  • | 10 Neurology, and
  • | 11 Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa
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Revascularization of a symptomatic, medically refractory, cervical chronically occluded internal carotid artery (COICA) using endovascular techniques (ETs) has surfaced as a viable alternative to extracranial-intracranial bypass. The authors aimed to assess the safety, success, and neurocognitive outcomes of recanalization of COICA using ETs or hybrid treatment (ET plus carotid endarterectomy) and to identify candidate radiological markers that could predict success.


The authors performed a retrospective analysis of their prospectively collected institutional database and used their previously published COICA classification to assess the potential benefits of ETs or hybrid surgery to revascularize symptomatic patients with COICA. Subjects who had undergone CT perfusion (CTP) imaging and Montreal Cognitive Assessment (MoCA) testing, both pre- and postprocedure, were included. The authors then performed a review of the literature on patients with COICA to further evaluate the success and safety of these treatment alternatives.


The single-center study revealed 28 subjects who had undergone revascularization of symptomatic COICA. Five subjects had CTP imaging and MoCA testing pre- and postrevascularization and thus were included in the study. All 5 patients had very large penumbra involving the entire hemisphere supplied by the ipsilateral COICA, which resolved postoperatively. Significant improvement in neurocognitive outcome was demonstrated by MoCA testing after treatment (preprocedure: 19.8 ± 2.4, postprocedure: 27 ± 1.6; p = 0.0038). Moreover, successful revascularization of COICA led to full restoration of cerebral hemodynamics in all cases. Review of the literature identified a total of 333 patients with COICA. Of these, 232 (70%) showed successful recanalization after ETs or hybrid surgery, with low major and minor complication rates (3.9% and 2.7%, respectively).


ETs and hybrid surgery are safe and effective alternatives to revascularize patients with symptomatic COICA. CTP imaging could be used as a radiological marker to assess cerebral hemodynamics and predict the success of revascularization. Improvement in CTP parameters is associated with significant improvement in neurocognitive functions.


ACA = anterior cerebral artery; CBF = cerebral blood flow; CBV = cerebral blood volume; CEA = carotid endarterectomy; COICA = chronically occluded internal carotid artery; CTP = CT perfusion; DSA = digital subtraction angiography; EC-IC = extracranial-intracranial; ET = endovascular technique; MoCA = Montreal Cognitive Assessment; MTT = mean transit time; NIHSS = National Institutes of Health Stroke Scale; OEF = oxygen extraction fraction; STA-MCA = superficial temporal artery–middle cerebral artery; TTP = time to peak.

Supplementary Materials

    • Supplemental Figure (PDF 421 KB)

Illustration from Duan et al. (pp 1174–1181).

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Contributor Notes

Correspondence David M. Hasan: University of Iowa Hospitals and Clinics, Iowa City, IA.

INCLUDE WHEN CITING Published online March 29, 2019; DOI: 10.3171/2019.1.JNS183337.

Disclosures Dr. Samaniego has been a consultant for Microvention and a proctor for Medtronic.


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