ARTICLE IN PRESS

“Opening the Unopenable”: Endovascular Treatment in a
Patient with Three Months’ Internal Carotid Artery Occlusion
and Hemispheric Symptomatic Hypoperfusion
Guido Bigliardi, MD,* Maria Luisa Dell’Acqua, MD,* Stefano Vallone, MD,†
Filippo Barbi, MD,* Roberta Pentore, MD,* Livio Picchetto, MD,*
Paolo Carpeggiani, MD,† Paolo Nichelli, MD, PhD,* and Andrea Zini, MD*

Background: Internal carotid artery occlusion (ICAO) is defined as “untouchable”
by all specialists; no treatment is indicated because intervention risks (carotid endarterectomy (CEA) or endovascular treatment) are usually much more than benefits.1,2
We report the case of a patient admitted to our hospital with an atherothrombotic
ischemic stroke due to symptomatic acute ICAO, who developed a recurrent stroke
with hemispheric hypoperfusion and was treated in the emergency department
with ICAO revascularization after 60 days of occlusion finding. Case Description:
D.G., a 62-year-old man, came to our attention for a transient episode of left weakness and hypoesthesia. The electrocardiogram revealed a new diagnosis of atrial
fibrillation. CT angiography showed right ICAO; computed tomography and magnetic resonance imaging studies with perfusion imaging revealed a severe hemispheric
hypoperfusion. Full anticoagulation therapy was started, and antihypertensive therapy
was reduced to help collateral circulation. Some weeks later, the patient was readmitted to the stroke unit for 2 episodes of left-hand weakness. Cerebral angiography
confirmed right ICAO from the proximal tract to the siphon. After some days,
the patient suffered a femoral hemorrhagic lesion, with active bleeding, and was
treated with surgical intervention. On the following day, the patient presented
with left hemiplegia with hemianesthesia (National Institutes of Health Stroke Scale
score = 14). The patient was treated in the emergency department with a complex
endovascular treatment with complete recanalization of ICAO by positioning 3
stents through the intravenous infusion of abciximab. After intensive rehabilitation, at the 3- and 6-month follow-up evaluations, the patient regained autonomy.
Conclusion: In literature, treatment of chronic ICAO is not indicated. Endovascular
recanalization may be beneficial to patients with chronic cerebral hypoperfusion
due to ICAO, when all conservative medical therapies have failed. Key Words:
Stroke—internal carotid artery occlusion—hypoperfusion—stenting.
© 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

From the *Stroke Unit—Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena,
Italy; and †Neuroradiology Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
Received January 25, 2016; revision received April 20, 2016; accepted April 27, 2016.
Address correspondence to Guido Bigliardi, MD, Stroke Unit—Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S.
Agostino-Estense, AUSL Modena, Modena, Italy. E-mail: guido.bigliardi@gmail.com.
1052-3057/$ - see front matter
© 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.04.019

Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2016: pp ■■–■■

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ARTICLE IN PRESS
G. BIGLIARDI ET AL.

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Case Presentation
D.G., a 62-year-old man with a history of pharmacologically treated hypertension, smoking habit, and obesity
(BMI 33.4), came to our attention for a transient episode
of weakness and hypoesthesia in his left hand. A computed tomography (CT) scan showed an acute cerebral
ischemic lesion involving the right parietal lobe, and
CT angiography showed postbulbar right internal carotid
artery occlusion (ICAO) (Fig 1, a); CT perfusion revealed a right hemispheric hypoperfusion in mean transit
time maps (Fig 1, b) without modification in the cerebral blood volume. The electrocardiogram showed an
atrial fibrillation. The patient was admitted to the stroke
unit.
The first magnetic resonance imaging (MRI) study with
all-brain perfusion sequences and magnetic resonance angiography confirmed the presence of multiple subacute
ischemic areas on the right side and right ICAO;
hypoperfusion of the right cerebral hemisphere was also
confirmed. Anticoagulant therapy was started with lowmolecular-weight heparin and antihypertensive therapy
was reduced to help collateral circulation. The patient was
discharged with planned follow-up exams. After 1 month,
the result of the control Colordoppler exam was unchanged and therapy with a new oral anticoagulant was
started (dabigatran).
Some weeks later, the patient was readmitted to the
stroke unit following 2 transient episodes of weakness
in his left hand. The result of the brain CT scan was
unchanged.
The MRI study showed some small new ischemic lesions
in the right parietal and occipital lobes, right ICAO, and
hypoperfusion in the right cerebral hemisphere. We decided
to perform a diagnostic cerebral angiography that

confirmed right ICAO involving the proximal tract through
to the siphon; the internal carotid artery appeared to be
recanalized from the intracranial siphon and fed by external carotid collateral branches.
Seven days later, the patient suffered a hemorrhagic
lesion posteriorly to the right superficial femoral artery,
with active bleeding. After the angiological evaluation,
the patient was treated by the vascular surgeon and required blood transfusions after the intervention. On the
following day, early in the morning, the patient presented with left hemiplegia with hemianesthesia. A new
MRI study showed recent ischemic lesions in the peripheral territory of the middle cerebral artery, suggesting
failure of collateral circulation (Fig 1, c,d).
An emergency cerebral angiography was performed;
the interventional neuroradiologist positioned an 8F
concentric catheter with a distal balloon in the right
common carotid. A selective catheterization of the occluded ICA was performed with a microcatether Rebar
18 (Covidien) and microwire Synchro-14 (Stryker) from
the site of the occlusion up to the siphon, downstream
of the ophthalmic artery; injection of contrast medium
from the microcatheter confirmed patency of the distal
siphon and the presence of devices in the true lumen
of the vessel. A complete recanalization of the ICAO
(Fig 1, e,f) was obtained by the telescopic positioning of
2 stents Solitaire 5 × 30 (Covidien) in the cavernous and
intrapetrous tracts of the siphon, and of a carotic stent,
Precise 7 × 40 (Cordis), in the distal extracranial tract of
the internal carotid artery, with thromboaspiration and
blockage flow using an 8F balloon catheter. The presence of flow was documented by the injection of a
contrast medium, but initially appeared very slow. Complete recanalization of the vessel with optimal blood
flow was obtained through the infusion of abciximab

Figure 1. (a) CT angiography showed right ICAO
in the postbulbar tract. (b) CT perfusion mean transit
time maps showed a severe right hemispheric
hypoperfusion. (c and d) Magnetic resonance images
of acute and subacute ischemic lesions in diffusionweighted imaging (c) and apparent diffusion coefficient
(d) sequences. (e) Cerebral angiography confirmed right
ICAO, with intracranial collateral branches. (f) Final
sequence of cerebral angiography showed complete recanalization of the internal carotid artery by the
positioning of 3 stents. Abbreviations: CT, computed
tomography; ICAO, internal carotid artery occlusion.

ARTICLE IN PRESS
ENDOVASCULAR TREATMENT IN A PATIENT WITH ICAO

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Discussion

Figure 2. (a) Six months’ follow-up CT angiography showing patency
of the right ICA, with 2 Solitaire stents in cavernous and intrapetrous
tracts of right siphon and an extracranial Precise stent in the distal ICA.
(b) Twelve months’ follow-up CT perfusion mean transit time maps showed
normal right hemispheric perfusion. Abbreviations: CT, computed tomography;
ICA, internal carotid artery.

(ReoPro, Eli Lilly Italia Spa): a first bolus dose followed
by a second dose in continuous intravenous infusion
throughout the following 12 hours.
After intensive rehabilitation, at the 3- and 6-month
follow-up evaluations, the patient regained his autonomy and was able to walk without assistance. Ultrasound
and CT angiography controls (Fig 2, a) confirmed the
patency of the right internal carotid, and follow-up CT
perfusion showed improvement in the right cerebral hemisphere flow (Fig 2, b).

In literature, treatment of chronic ICAO is not indicated. Endovascular recanalization may be beneficial to
patients with chronic cerebral hypoperfusion due to ICAO,
and with recurrent clinical relevant episodes, when all
conservative medical therapies have failed.
The case in the present study underlines the importance of clinical and vascular follow-up assessments to
improve therapeutic chances in unstable stroke patients.
The description of endovascular procedure may be useful
for reproduction in common practice in similar situations.
This complex and delayed procedure inevitably requires the positioning of carotid stents. It is possible that
the success of the procedure is related to previous anticoagulant therapy (low-molecular-weight heparin and
dabigatran), which maintained the soft consistency of the
thrombus, facilitating advancement through the occlusion.

References
1. Shojima M, Nemoto S, Morita A, et al. Protected
endovascular revascularization of subacute and chronic
total occlusion of the internal carotid artery. AJNR Am J
Neuroradiol 2010;31:481-486.
2. Rostambeigi N, Khatri R, Hassan AE, et al. Duplex
ultrasound assisted endovascular revascularization of
chronic internal carotid artery occlusion: technical note.
J Vasc Interv Neurol 2013;6:42-46.