Internal Carotid Artery Stenosis [Neurosurgery Wiki]

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====== Internal Carotid Artery Stenosis ======



The prevalence of asymptomatic carotid occlusion is not known, and the incidence of ipsilateral stroke in neversymptomatic
carotid occlusion is negligible
((Powers WJ, Derdeyn CP, Fritsch SM, et al. Benign
prognosis of never-symptomatic carotid occlusion.
Neurology. 2000; 54:878–882)).
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When an [[internal carotid artery]] (ICA) occludes, a patient may develop [[cerebral infarction]] (CI). Ishikawa et al investigated whether CI caused by ICA occlusion (ICAO) is associated with collateral flow through the anterior and posterior communicating arteries (ACoA and PCoA).

In 100 patients with ICAO, they investigated CI and white matter disease by performing an MRI and the anatomy of the ACoA and PCoA were investigated by performing magnetic resonance angiography. All patients were divided into the symptomatic CI group or the no-CI group. The collateral flow pathway was estimated by the anterior cerebral artery (ACA)-PCoA score and the collateral flow volume after ICAO was estimated by the middle cerebral artery (MCA) flow score, based on how well the MCA was visualized.

Of 100 patients with ICAO, the symptomatic CI group included 36 patients. ACA-PCoA score and white matter disease grades were significantly higher in the CI group (indicating poor collateral flow). More than 80% of patients with an ACA-PCoA score of 4 (poor collateral) experienced symptomatic CI. Thirty-one symptomatic CI patients (86%) had an MCA flow score of 1 or 2 (decreased MCA flow).

The ACA-PCoA score and white matter disease grade may suggest an increased risk of CI following ICAO
((Ishikawa M, Sugawara H, Nagai M, Kusaka G, Tanaka Y, Naritaka H. Collateral
Flow and White Matter Disease in Patients with Internal Carotid Artery Occlusion.
Eur Neurol. 2016 Dec 8;77(1-2):56-65. [Epub ahead of print] PubMed PMID:
27924799.
)).
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Clinical Significance of the Circle of Willis in Patients with Symptomatic Internal Carotid Artery Occlusion
((Park BJ, Kim KM, Lee WJ, Chun IK, Kim I, Lee SJ, Kim S. Clinical Significance 
of the Circle of Willis in Patients with Symptomatic Internal Carotid Artery
Occlusion. World Neurosurg. 2018 Apr 24. pii: S1878-8750(18)30824-6. doi:
10.1016/j.wneu.2018.04.104. [Epub ahead of print] PubMed PMID: 29702309.
)).

===== Treatment =====

10–15% of patients presenting with [[internal carotid artery]] territory stroke or [[transient ischemic attack]]s (TIA) are
found to have [[internal carotid artery occlusion]]. This amounts to an estimated 61,000 first ever strokes and 19,000
TIAs per year in the United States. Prevention of subsequent stroke in symptomatic patients with
carotid artery occlusion remains a difficult challenge. The overall rate of subsequent stroke is 7% per
year for all stroke and 5.9% per year for ischemic stroke ipsilateral to the occluded carotid artery
((Hankey GJ, Warlow CP. Prognosis of symptomatic
carotid artery occlusion: an overview. Cerebrovasc
Dis. 1991; 1:245–256)).

These risks persist even despite treatment with antiaggregants and anticoagulants
((Grubb RL,Jr, Derdeyn CP, Fritsch SM, et al.
Importance of hemodynamic factors in the prognosis
of symptomatic carotid occlusion. JAMA.
1998; 280:1055–1060)).

[[Mechanical Thrombectomy for Internal Carotid Artery Stenosis]]

===== Case reports =====
Deshpande and Giri presented a unique [[case]] of a middle-aged gentleman, who recovered from asymptomatic [[Covid-19]] infection and presented again with delayed [[stroke]]. He had [[vision loss]] secondary to [[internal carotid artery occlusion]] in the absence of neurological symptoms. This is the first case that describes cerebrovascular [[stroke]] due to delayed [[large vessel occlusion]] secondary to Covid-19 infection presenting as [[monocular vision loss]]
((Deshpande G, Giri P. Acute monocular [[vision loss]] as presenting symptom of delayed stroke from internal carotid occlusion in COVID-19. Indian J Ophthalmol. 2021 May;69(5):1325-1327. doi: 10.4103/ijo.IJO_439_21. PMID: 33913892.)).