the natural history of acute cervical internal carotid artery ( ica ) occlusion with serious neurological symptom is unfavorable1 ) .
treatment for acute occlusion of the cervical ica includes intravenous administration of tissue plasminogen activator ( tpa ) , percutaneous transluminal angioplasty , carotid endarterectomy ( cea ) , and extracranial - to - intracranial ( ec - ic ) artery bypass . according to the current literature , the recanalization rate for carotid occlusion with systemic ( intravenous ) tpa alone ranges from 15% to 35% .
a good outcome has been documented for 20% to 44% of patients treated with intravenous tpa alone for acutely symptomatic ica occlusion4,17 ) . despite the proven benefit of cea in prevention of stroke recurrence in patients with a high - grade stenosis of the ica2,25 ) , few studies of emergency cea for improvement of their neurologic symptoms and no rigorous clinical trials regarding the efficacy of cea in an acute stroke stage have been reported3,18 ) .
a few studies have attempted to determine whether emergent ec - ic bypass surgery is an effective treatment for main trunk stenosis or occlusion in acute stage12 ) .
previous studies have supported carotid angioplasty and stenting ( cas ) as a technique for secondary prevention in the chronic stroke stage8,29 ) .
however , cas in the acute stage remains challenging because of the limited therapeutic window and risk of hyperperfusion syndrome after revascularization .
nevertheless , there have been some reports on the safety and effectiveness of emergency cas , even in the acute stage of ischemic stroke7,14,15,19,21,27,28,30 ) .
the purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent cas for acute stroke due to athero - thrombotic occlusion of the cervical ica .
medical records identified 17 patients who underwent emergent cas for treatment of acute stroke related to an athero - thrombotic cervical ica occlusion between 2009 and 2013 .
all patients underwent examination by computed tomographic ( ct ) perfusion imaging , followed by magnetic resonance ( mr ) imaging before conventional angiography .
the indication for emergent cas was determined by mismatch between the diffusion - weighted mr imaging finding of localized high intensity areas and the ct perfusion finding of decreased cbf related to the occluded ica .
patients who present within 4.5 hours of symptom onset and without contraindication to systemic thrombolysis are treated immediately with intravenous tpa ( 0.9 mg / kg ) and , unless immediate neurological improvement is observed , are then transferred rapidly to the angiography suite . in contrast , patients who present between 4.5 and 6 hours after symptom onset do not undergo systemic thrombolysis , but are transferred immediately to the neurointerventional suite .
patients matching the following criteria were included in our analysis : 1 ) onset of acute stroke symptom and arrival at the hospital within 6 hours , 2 ) national institutes of health stroke scale ( nihss ) score on admission 5 , 3 ) athero - thrombotic occlusion of the cervical ica confirmed by catheter - based angiography : as the balloon configuration during inflation and features of residual stenosis after predilatation or the stent configuration before balloon angioplasty , and 4 ) negative findings on brain ct or limited hypodensities involving less than one - third of the middle cerebral artery ( mca ) territory .
we excluded patients in whom a dissection of the ica was diagnosed due to the different nature of the disease .
tia was defined as an acute transient focal neurological deficit caused by vascular disease , which showed a complete reversal within 24 hours , and caused no acute lesion , as confirmed by diffusion - weighted mr imaging .
interventional procedures were performed in the neuroangiography room equipped with a digital subtraction angiography system ( axiom artis , siemens , germany ) .
all angiographic procedures were performed using a transfemoral approach under local anesthesia using an electrocardiogram , arterial oxygen saturation , and blood pressure monitoring .
four - vessel angiography was performed for estimation of collateral flow from the anterior and posterior communicating arteries , and to determine the presence of concomitant intracranial artery occlusion .
the interventional treatment consists of two steps : first , emergent cas for athero - thrombotic occlusion of the cervical ica , and second , intracranial recanalization . a loading dose of 300 mg clopidogrel plus 300 mg
prior to the therapeutic procedure , patients were administered a systemic heparinization and a bolus injection of heparin 3000 iu .
an additional 1000 iu bolus of heparin was administered every hour in order to maintain an act of > 200 seconds throughout the procedure .
coaxial catheter - flushing fluid was mixed with heparin at a concentration of 1000 iu of heparin per 1000 ml of saline . an 8 fr guiding catheter ( envoy ; cordis , miami lakes , fl , usa ) or 6 fr shuttle sheath was advanced to the common carotid artery , and it was connected to a continuous saline flush .
a 0.014-in microwire ( transend ; boston scientific , natick , ma , usa ) was placed into the petrous ica passing the occluded segment .
then , a self - expandable stent was advanced over the microwire and positioned across the occlusion . a stent deployment and balloon angioplasty
were performed with or without distal protection device ( spider device , ev3 , plymouth , mn , usa ) to prevent distal embolic event .
the entire length of the ica and the intracranial area was then imaged for determination of whether there was any further stenosis or occlusion of the ica or mca .
if there was no distal patency of the ica , we attempted restoration of distal flow using forced arterial suction thrombectomy using a 50-ml syringe .
if an additional occlusion was present in the terminal segment of the ica or mca , a 6 fr guiding catheter was advanced as far as possible into the recanalized ica .
the devices used for mechanical thrombectomy were the penumbra system ( penumbra inc . , alameda , ca , usa ) or the solitaire ab / fr ( ev3 europe sas , paris , france ) with or without additional intra - arterial thrombolysis with urokinase .
we initially attempted forced arterial suction thrombectomy using a penumbra reperfusion catheter , but switched to solitaire in difficult cases , which means failed thrombectomy despite several attempts at recanalization . immediately after the therapeutic procedure
, we obtained the detailed neurologic history and performed a complete examination of all patients .
the patients underwent non - enhanced brain ct imaging for evaluation of possible hemorrhagic complications .
following endovascular stent placement , patients were transferred to a stroke intensive care unit for strict control of blood pressure for prevention of hyperperfusion syndrome .
after the procedure , patients were administered aspirin 100 mg and clopidogrel 75 mg daily .
low - molecular - weight nadroparin calcium ( fraxiparine ; glaxosmithkline , marly - le - roi cedex , france ) 2850 iu was also administered subcutaneously three times per day for at least three days .
technical success of emergent cas was defined as restoration of ica flow with more than 50% recanalization of the cervical ica .
intracranial arterial recanalization was assessed using the thrombolysis in cerebral infarction ( tici ) scores and was recorded prospectively at the end of each case by the treating interventionalist11 ) .
angiographic success of intracranial arterial recanalization was defined as restoration of ica flow with normal or near - normal perfusion in the ipsilateral ica territory ( tici 2b flow ) . for clinical outcome evaluation ,
improvement of neurological function was defined as reduction of 4 points on the nihss at seven days after the procedure compared with baseline .
in addition , clinical functional outcome was assessed upon discharge from hospital or at the last clinical visit using the modified rankin scale ( mrs ) .
medical records identified 17 patients who underwent emergent cas for treatment of acute stroke related to an athero - thrombotic cervical ica occlusion between 2009 and 2013 .
all patients underwent examination by computed tomographic ( ct ) perfusion imaging , followed by magnetic resonance ( mr ) imaging before conventional angiography .
the indication for emergent cas was determined by mismatch between the diffusion - weighted mr imaging finding of localized high intensity areas and the ct perfusion finding of decreased cbf related to the occluded ica .
patients who present within 4.5 hours of symptom onset and without contraindication to systemic thrombolysis are treated immediately with intravenous tpa ( 0.9 mg / kg ) and , unless immediate neurological improvement is observed , are then transferred rapidly to the angiography suite . in contrast , patients who present between 4.5 and 6 hours after symptom onset do not undergo systemic thrombolysis , but are transferred immediately to the neurointerventional suite .
patients matching the following criteria were included in our analysis : 1 ) onset of acute stroke symptom and arrival at the hospital within 6 hours , 2 ) national institutes of health stroke scale ( nihss ) score on admission 5 , 3 ) athero - thrombotic occlusion of the cervical ica confirmed by catheter - based angiography : as the balloon configuration during inflation and features of residual stenosis after predilatation or the stent configuration before balloon angioplasty , and 4 ) negative findings on brain ct or limited hypodensities involving less than one - third of the middle cerebral artery ( mca ) territory .
we excluded patients in whom a dissection of the ica was diagnosed due to the different nature of the disease .
tia was defined as an acute transient focal neurological deficit caused by vascular disease , which showed a complete reversal within 24 hours , and caused no acute lesion , as confirmed by diffusion - weighted mr imaging .
interventional procedures were performed in the neuroangiography room equipped with a digital subtraction angiography system ( axiom artis , siemens , germany ) .
all angiographic procedures were performed using a transfemoral approach under local anesthesia using an electrocardiogram , arterial oxygen saturation , and blood pressure monitoring .
four - vessel angiography was performed for estimation of collateral flow from the anterior and posterior communicating arteries , and to determine the presence of concomitant intracranial artery occlusion .
the interventional treatment consists of two steps : first , emergent cas for athero - thrombotic occlusion of the cervical ica , and second , intracranial recanalization . a loading dose of 300 mg clopidogrel plus 300 mg
prior to the therapeutic procedure , patients were administered a systemic heparinization and a bolus injection of heparin 3000 iu .
an additional 1000 iu bolus of heparin was administered every hour in order to maintain an act of > 200 seconds throughout the procedure .
coaxial catheter - flushing fluid was mixed with heparin at a concentration of 1000 iu of heparin per 1000 ml of saline .
an 8 fr guiding catheter ( envoy ; cordis , miami lakes , fl , usa ) or 6 fr shuttle sheath was advanced to the common carotid artery , and it was connected to a continuous saline flush . a 0.014-in microwire ( transend ; boston scientific , natick , ma , usa ) was placed into the petrous ica passing the occluded segment . then , a self - expandable stent was advanced over the microwire and positioned across the occlusion . a stent deployment and balloon angioplasty
were performed with or without distal protection device ( spider device , ev3 , plymouth , mn , usa ) to prevent distal embolic event .
the entire length of the ica and the intracranial area was then imaged for determination of whether there was any further stenosis or occlusion of the ica or mca .
if there was no distal patency of the ica , we attempted restoration of distal flow using forced arterial suction thrombectomy using a 50-ml syringe . if an additional occlusion was present in the terminal segment of the ica or mca , a 6 fr guiding catheter was advanced as far as possible into the recanalized ica .
the devices used for mechanical thrombectomy were the penumbra system ( penumbra inc . , alameda , ca , usa ) or the solitaire ab / fr ( ev3 europe sas , paris , france ) with or without additional intra - arterial thrombolysis with urokinase .
we initially attempted forced arterial suction thrombectomy using a penumbra reperfusion catheter , but switched to solitaire in difficult cases , which means failed thrombectomy despite several attempts at recanalization . immediately after the therapeutic procedure
, we obtained the detailed neurologic history and performed a complete examination of all patients .
the patients underwent non - enhanced brain ct imaging for evaluation of possible hemorrhagic complications .
following endovascular stent placement , patients were transferred to a stroke intensive care unit for strict control of blood pressure for prevention of hyperperfusion syndrome . after the procedure , patients were administered aspirin 100 mg and clopidogrel 75 mg daily .
low - molecular - weight nadroparin calcium ( fraxiparine ; glaxosmithkline , marly - le - roi cedex , france ) 2850 iu was also administered subcutaneously three times per day for at least three days .
technical success of emergent cas was defined as restoration of ica flow with more than 50% recanalization of the cervical ica .
intracranial arterial recanalization was assessed using the thrombolysis in cerebral infarction ( tici ) scores and was recorded prospectively at the end of each case by the treating interventionalist11 ) .
angiographic success of intracranial arterial recanalization was defined as restoration of ica flow with normal or near - normal perfusion in the ipsilateral ica territory ( tici 2b flow ) . for clinical outcome evaluation ,
improvement of neurological function was defined as reduction of 4 points on the nihss at seven days after the procedure compared with baseline .
in addition , clinical functional outcome was assessed upon discharge from hospital or at the last clinical visit using the modified rankin scale ( mrs ) .
the 17 patients with acute stroke related to athero - thrombotic cervical ica occlusion were treated by emergent cas between 2009 and 2013 .
the mean age of the patients ( 15 men and 2 women ) was 70.57.7 years ( range , 54 - 82 years ) .
the patients ' mean nihss score on admission was 15.15.4 ( range , 6 - 23 ) .
six patients had contraindications to intravenous administration of tpa , however , the others received a standard 10% bolus of the maximum dose ( 0.9 mg / kg body weight ) .
the mean time from stroke onset to recanalization was 277110 minutes ( range , 120 - 460 minutes ) .
some difficulties were encountered during passage of the guidewire through the occluded segment ; it was possible in all cases . in six patients ,
no further vessel occlusion was detected after successful recanalization of the cervical ica ( fig .
the stent used was protg ( ev3 , plymouth , mn , usa ) in 15 patients and wallstent ( boston scientific , natick , ma , usa ) in two .
of 17 patients , 11 ( 11/17 , 64.7% ) showed an additional intracranial occlusion after flow restoration in the cervical ica ( fig .
2 ) : at the level of the terminal segment of the ica ( n=3 ) and at the level of the mca in eight patients . intracranial arterial recanalization to a tici 2b flow was achieved in four of 11 patients ( 36.4% ) . the overall recanalization rate ( cervical ica and intracranial artery ) was 10 of 17 patients ( 58.8% ) .
procedure - related complications developed in two patients ( 2/17 , 11.8% ) . in patient 3 , although a distal protection filter was used , distal embolism occurred after cas .
immediate thrombolysis using a combination of mechanical thrombectomy and intraarterial urokinase led to recanalization to a tici 2b flow .
however , afterward , relevant infarction was observed and his neurological status worsened . in one patient who suffered acute in - stent thrombosis ,
abciximab was administered intraarterially with a maintenance drip , yielding stent recanalization ; however , the patient subsequently developed massive intracranial hemorrhage ( ich ) and died ( patient 12 ) .
thus , procedure - related mortality was 5.9% ( 1/17 , patient 12 ) and morbidity was 5.9%
ten of 17 patients ( 58.8% ) showed improvement ( decrease in nihss score of 4 points compared with admission score ) during the hospital course at seven days after recanalization .
follow - up ct scan obtained immediately after each intervention showed occasional enhancement around the area of ischemia , which had resolved by the time the scan was repeated later .
the ich was symptomatic with neurologic deterioration , resulting in death ( patients 9 and 12 ) .
the other patient suffered an asymptomatic hemorrhage in the basal ganglia ( patient 2 ) .
one patient ( patient 13 ) died secondary to pneumonia and sepsis 21 days after the procedure . thus , there were three in - hospital deaths ( 3/17 , 17.6% ) , respectively . at the end of the observational period , nine patients showed a good clinical outcome , with an mrs score of 2 ( 9/17 , 52.9% ) , while the other eight ( 8/17 , 47.1% ) were dependent or dead ( mrs score , 3 - 6 ) .
all surviving patients were followed up for 6 - 21 months ( mean , 12.5 months ) .
no neurologic deterioration or ischemic event occurred during the follow - up period in all surviving patients .
a summary of characteristics and clinical outcomes according to existence of intracranial tandem lesion is shown in table 3 .
near - complete occlusion of the cervical ica was identified in half of patients without an intracranial tandem lesion , while in only one patient with an intracranial tandem lesion . a favorable outcome ( mrs 2 )
was obtained in four of the six patients with isolated cervical ica occlusion ( 66.7% ) and five of 11 patients with intracranial tandem occlusion ( 45.5% ) at the last follow up .
no patient with isolated cervical ica occlusion suffered from a symptomtic ich or in - hospital mortality , however , there were two cases of symptomtic ich ( 18.2% ) and three cases of in - hospital mortality ( 27.3% ) in the patients with intracranial tandem occlusion .
more favorable outcomes were achieved in patients without intracranial tandem lesion , compared to a patient population with intracranial tandem lesion .
the 17 patients with acute stroke related to athero - thrombotic cervical ica occlusion were treated by emergent cas between 2009 and 2013 .
the mean age of the patients ( 15 men and 2 women ) was 70.57.7 years ( range , 54 - 82 years ) .
the patients ' mean nihss score on admission was 15.15.4 ( range , 6 - 23 ) .
six patients had contraindications to intravenous administration of tpa , however , the others received a standard 10% bolus of the maximum dose ( 0.9 mg / kg body weight ) .
the mean time from stroke onset to recanalization was 277110 minutes ( range , 120 - 460 minutes ) .
some difficulties were encountered during passage of the guidewire through the occluded segment ; it was possible in all cases . in six patients ,
no further vessel occlusion was detected after successful recanalization of the cervical ica ( fig .
the stent used was protg ( ev3 , plymouth , mn , usa ) in 15 patients and wallstent ( boston scientific , natick , ma , usa ) in two .
of 17 patients , 11 ( 11/17 , 64.7% ) showed an additional intracranial occlusion after flow restoration in the cervical ica ( fig .
2 ) : at the level of the terminal segment of the ica ( n=3 ) and at the level of the mca in eight patients . intracranial arterial recanalization to a tici 2b flow was achieved in four of 11 patients ( 36.4% ) .
the overall recanalization rate ( cervical ica and intracranial artery ) was 10 of 17 patients ( 58.8% ) .
procedure - related complications developed in two patients ( 2/17 , 11.8% ) . in patient 3 , although a distal protection filter was used , distal embolism occurred after cas .
immediate thrombolysis using a combination of mechanical thrombectomy and intraarterial urokinase led to recanalization to a tici 2b flow . however , afterward , relevant infarction was observed and his neurological status worsened . in one patient who suffered acute in - stent thrombosis ,
abciximab was administered intraarterially with a maintenance drip , yielding stent recanalization ; however , the patient subsequently developed massive intracranial hemorrhage ( ich ) and died ( patient 12 ) .
thus , procedure - related mortality was 5.9% ( 1/17 , patient 12 ) and morbidity was 5.9% ( 1/17 , patient 3 ) , respectively .
ten of 17 patients ( 58.8% ) showed improvement ( decrease in nihss score of 4 points compared with admission score ) during the hospital course at seven days after recanalization .
follow - up ct scan obtained immediately after each intervention showed occasional enhancement around the area of ischemia , which had resolved by the time the scan was repeated later .
the ich was symptomatic with neurologic deterioration , resulting in death ( patients 9 and 12 ) .
the other patient suffered an asymptomatic hemorrhage in the basal ganglia ( patient 2 ) .
one patient ( patient 13 ) died secondary to pneumonia and sepsis 21 days after the procedure .
thus , there were three in - hospital deaths ( 3/17 , 17.6% ) , respectively . at the end of the observational period
, nine patients showed a good clinical outcome , with an mrs score of 2 ( 9/17 , 52.9% ) , while the other eight ( 8/17 , 47.1% ) were dependent or dead ( mrs score , 3 - 6 ) .
all surviving patients were followed up for 6 - 21 months ( mean , 12.5 months ) .
no neurologic deterioration or ischemic event occurred during the follow - up period in all surviving patients .
a summary of characteristics and clinical outcomes according to existence of intracranial tandem lesion is shown in table 3 .
near - complete occlusion of the cervical ica was identified in half of patients without an intracranial tandem lesion , while in only one patient with an intracranial tandem lesion . a favorable outcome ( mrs 2 )
was obtained in four of the six patients with isolated cervical ica occlusion ( 66.7% ) and five of 11 patients with intracranial tandem occlusion ( 45.5% ) at the last follow up . no patient with isolated cervical ica occlusion suffered from a symptomtic ich or in - hospital mortality , however , there were two cases of symptomtic ich ( 18.2% ) and three cases of in - hospital mortality ( 27.3% ) in the patients with intracranial tandem occlusion .
more favorable outcomes were achieved in patients without intracranial tandem lesion , compared to a patient population with intracranial tandem lesion .
the natural history of acute cervical ica occlusion with serious neurologic symptoms is unfavorable1 ) . for these types of lesions ,
treatment with standard intravenous thrombolysis alone leads to a good clinical outcome in only 17% of cases with a death rate of as high as 55%18 ) . currently , there is no consensus treatment for patients with acute ischemic stroke presenting with severe clinical symptoms due to athero - thrombotic occlusion of the cervical ica .
acute cervical ica occlusion resulting in ischemic stroke is different from other forms of acute occlusion of cerebral vessels .
occluded segments in other cerebral vessels , such as the mca and the terminal segment of the ica , usually consist of an occlusive embolus in a normal vessel23 ) .
the ecass iii showed that intravenous tpa is effective in treatment of acute ischemic stroke if given to patients within 4.5 hours of stroke symptom onset .
however , the recanalization rates achieved with intravenous tpa for large vessel arterial occlusion are low , ranging from 4% to 32% , depending on the vessel ( 4% for ica occlusions and
in addition , cervical ica occlusion is associated with a high incidence of intracranial tandem occlusions .
rubiera et al.26 ) reported on the presence of a tandem lesion ( ica and mca ) as an independent predictor of poor outcome after intravenous thrombolysis . according to linfante et al.,17 ) a significant difference
was observed between the proportion of recanalization in mca - only occlusions ( 15 of 17 recanalized , 88% ) at three days after tpa compared with that in ica - mca tandem occlusions ( five of 16 recanalized , 31% ) .
improvement in clinical outcome showed a close association with resumption of mca flow , and most ica occlusions did not recanalize after intravenous tpa therapy .
the pathophysiologic processes involved in occlusion of the extracranial ica are similar to processes observed in acute occlusion of the coronary arteries .
the occluded segment of the ica consists of a predominantly atherosclerotic plaque and a superimposed thrombus .
therefore , large contributions of atherosclerotic plaque and platelet activation do not provide an ideal substrate for thrombolytics alone23,24 ) . in acute myocardial infarction ,
the recanalization rate for carotid occlusion with intravenous tpa alone is very low , ranging from 15% to 35% .
a good outcome has been documented for 20% to 44% of patients treated with intravenous tpa alone for acutely symptomatic ica occlusion .
nevertheless , there is currently an interest in " early " cea after intravenous tpa for prevention of further stroke .
however , cea is not suited for patients in an emergency situation such as acute stroke because control of the intracranial extension of the clot is extremely limited . surgical bypass may be a natural resolution for ica occlusion , however , a large international randomized ec - ic bypass trial failed to show any benefit22 ) .
recently , there has been a surge of interest in endovascular interventions for acute ica occlusion5,6,10,13,15,19,20,21 ) .
we have summarized the reported studies in which more than 10 patients with acute cervical ica occlusion were treated with cas in table 4 .
imai et al.13 ) treated 17 patients with either occlusion or a high - grade stenosis of the ica with emergent cas .
median nihss scores before emergency stent placement and at seven days were 12 and 5 , respectively ( p<0.01 ) .
eleven patients ( 65% ) showed favorable outcomes ( mrs score , 0 - 2 ) at 90 days .
dabitz et al.5 ) reported on their experience with 10 patients with an average nihss score of 21 using a combination of cas and intra - arterial thrombolysis for treatment of the cervical ica occlusion ; 70% had an mrs of 2 after 20 weeks .
hauck et al.10 ) reported that 17 of 22 patients ( 77.3% ) underwent successful revascularization with cas and 50% of patients showed good outcomes ( mrs 2 ) after a median follow - up of three months .
patients with complete cervical ica occlusion but partial distal preservation of the vessel were most likely to benefit from the intervention .
papanagiotou et al.21 ) treated 22 patients with acute atherosclerotic extracranial ica occlusion with emergent cas and intraarterial thrombolysis using mechanical thrombectomy .
fourteen of 22 patients ( 63% ) underwent successful overall revascularization and nine patients ( 41% ) had an mrs of 2 at 90 days .
dalyai et al.6 ) reported on their experience with 17 patients using a combination of cas and intraarterial thrombolysis for treatment of proximal ica occlusion .
the results of our study combined with the results of these series indicate that this approach is also feasible for athero - thrombotic occlusion of the cervical ica .
after cas of an ica occlusion , an additional occlusion may be present in the terminal segment of the ica or the mca . in our study ,
acute cervical ica occlusion presented frequently ( 64.7% ) as a tandem lesion with intracranial extension of the clot , usually into the mca branches or the carotid terminus . in the event of additional intracranial occlusion , further recanalization measures should be taken .
however , the angiographic result was somewhat disappointing , with achievement of a recanalization rate of 36.4% .
revascularization of intracranial artery occlusion requires a significant amount of time ; however , the therapeutic time window is narrow because of less collateral flow from the anterior communicating artery and/or posterior communicating artery , compared with that for isolated cervical ica occlusion . in some cases ,
we should have stopped further revascularization of intracranial artery occlusion because of exceeding the therapeutic time window .
we found that patients without a tandem occlusion were more likely to show rapid neurologic improvement within the first seven days after cas and a mrs 2 at follow - up ( table 3 ) ; this has also been previously reported in the literature10,19,21 ) . however , due to the risk of reperfusion injury , such as hyperperfusion syndrome or hemorrhagic transformation , successful recanalization does not always result in a favorable outcome .
although the incidence of hyperperfusion syndrome after cas is 5% to 7% , it is expected to be higher in emergent recanalization of the cervical ica .
symptomatic ich rate of 12% ( n=2 ) in the current study is similar to the previously reported rates for cas in acute stroke ( 6% to 18%)6,13,15,20,21 ) . due to
the aggressive anticoagulation required , the risk of ich is expected to be higher in acute cas compared with mechanical recanalization studies . in our series , there was one case of acute in - stent thrombosis ; prompt use of intraarterial abciximab yielded thrombolysis , however , subsequently developed massive ich and died .
the diffusion / perfusion mismatch indicative of ischemic penumbra is useful for selection of patients who might benefit from recanalization . in our series , emergent endovascular recanalization of the cervical ica and distal branches was technically successful in 58.8% ( 10 patients ) overall . at the last follow - up , good clinical outcome ( mrs 2 ) with endovascular intervention was observed in nine of 17 patients ( 52.9% ) overall and in seven patients ( 7/10 , 70.0% ) in whom revascularization was successful .
our observation that endovascular revascularization of an acutely occluded ica at the cervical level has a fairly high chance of success exceeding the rate of recanalization with intravenous tpa alone is similar to the findings of several previous reports in the literature .
the current study showed that patients with cervical ica occlusion with acute stroke presentation could benefit from endovascular revascularization , although these findings should be confirmed in a larger study with multivariate logistic regression analysis .
emergent cas for acute stroke due to athero - thrombotic occusion of the cervical ica showed a good technical feasibility and favorable clinical outcome .
in particular , emergent cas is more beneficial in patients with isolated cervical ica occlusion .
treatment of intracranial tandem occlusions is an issue that must be resolved in order to achieve a favorable outcome .
 objectivethe purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting ( cas ) for acute stroke due to athero - thrombotic occlusion of the cervical internal carotid artery ( ica).methodsreview of medical records identified 17 patients who underwent emergent cas for treatment of athero - thrombotic occlusion of the cervical ica with acute stroke between 2009 and 2013 . 
 eleven patients ( 64.7% ) presented with concomitant intracranial artery occlusion , which was treated primarily by mechanical thrombectomy after cas.resultssuccessful revascularization of the cervical ica with emergent cas was achieved in all patients . 
 after cas , intracranial recanalization with thrombolysis in cerebral infarction 2b flow was achieved in four of the 11 patients ( 36.4% ) . the overall recanalization rate ( cervical ica and intracranial artery ) was 10 of 17 patients ( 58.8% ) . 
 symptomatic intracranial hemorrhage occurred in two patients ( 11.8% ) , resulting in death . 
 ten patients ( 58.8% ) showed improvement ( decrease in nihss score of 4 points ) at seven days after recanalization . 
 nine patients ( 52.9% ) showed a favorable outcome ( mrs 2 ) at the last follow - up . 
 a favorable outcome ( mrs 2 ) was obtained in four of the six patients with isolated cervical ica occlusion ( 4/6 , 66.7% ) and five of 11 patients with intracranial tandem occlusion ( 5/11 , 45.5%).conclusionemergent cas for acute stroke due to athero - thrombotic occusion of the cervical ica showed a good technical feasibility and favorable clinical outcome . 
INTRODUCTION
MATERIALS AND METHODS
Patient population and inclusion criteria
Endovascular procedure
Emergent CAS for cervical ICA occlusion
Intlicranial recanalization
Analysis
RESULTS
Patient population and angiographic outcome
Clinical outcome
DISCUSSION
CONCLUSION