1. Acute Carotid Occlusions
SOFIA - BEC 2012
Treatment of
Acute Carotid Occlusions
K. Mathias*, A. Ranft*, G. Rudel**
*Department of Radiology
**Department of Neurology
Klinikum Dortmund / Germany

3. Symptomatic Carotid Stenosis
Emergency-CEA in crescendo-TIA and
progressive stroke
Perioperative CEA risk of major stroke and death
- TIA %
- progressive stroke 17.0%
c-TIA, 12 studies, 176 patients

4. Whom do we treat ? Stroke Symptoms Ischemic Stroke 80-85%
Hemorrhagic Stroke
15-20%
Cerebral Bleeding
2/3
Subarachnoidal
Bleeding 1/3
Adapted from PA Scott and WG Barsan: Stroke, transient ischemic attack, and other central focal conditions. In: J Tintinalli: Emergency Medicine: A Comprehensive Study Guide; McGraw-Hill; 2000:14302/3

5. Stent & Suction Thrombectomy
Solitaire® EV3
In the meanwhile at least 6 companies work on stent retriever systems
ACI → Solitaire® 6 mm
M1 segment → Solitaire® 4 mm
M2 segment → Solitaire® 4 mm
Vertebral/basilar artery → Solitaire® 4 mm
Distal branches → Thrombolysis

6. Two Types of Occlusions
Carotid-T occlusion
Carotid bifurcation occlusion

7. Technique of Carotid Thrombectomy
thrombus is crossed by guidewire and
micro-catheter
the tip of the micro-catheter is placed
just beyond the occlusion
the guidewire is exchanged for the
Solitaire FR stent retriever
the stent retriever is positioned
at the level of the thrombus

8. Technique of Carotid Thrombectomy
the micro-catheter is pulled back deploying
the stent retriever
blood flow may begin
the carotid is blocked by balloon inflation
after 4-5 min the Solitaire is pulled back slowly
simultaneously an underpressure is produced
by suction until the thrombus is caught in the
aspiration catheter (50 ml syringe)

9. Carotis-T Occlusion Guidewire is exchanged for the stent retriever,
microcatheter is pulled back to deploy the stent
Guidewire & microcatheter
cross the occlusion

10. J. B. m-52 Hemiplegic left side for 6 hrs CT
Carotis-T Occlusion
J. B. m-52 Hemiplegic left side for 6 hrs CT

11. J. B. m-52 Hemiplegic for 6 hrs Perfusion
Carotis-T Occlusion
J. B. m-52 Hemiplegic for 6 hrs Perfusion

12. J. B. m-52 Hemiplegic for 6 hrs CTA
Carotis-T Occlusion
J. B. m-52 Hemiplegic for 6 hrs CTA

13. J. B. m-52 Hemiplegic for 6 hrs Before and after TE
Carotis-T Occlusion
J. B. m-52 Hemiplegic for 6 hrs Before and after TE

14. J. B. m-52 Hemiplegic for 6 hrs CT n 24h
Carotis-T Occlusion
J. B. m-52 Hemiplegic for 6 hrs CT n 24h

15. Acute Stroke - Carotid-T Occlusion
D.C. m-43 Acute Stroke - Normal CT findings

16. Acute Stroke - Carotid-T Occlusion
D.C. m-43 hemiplegic ICA occlusion distal to the bifurcation
After TE normal flow and full clinical recovery

17. Acute Stroke - Carotid-T Occlusion
D.C. m-43 hemiplegic Control CT after 24h
Clinically silent infarctions

18. Carotid Bifurcation Occlusion

19. Acute Stroke - Carotid Occlusion
Perfusions study: still good blood volume
Transit time
Flow
Blood volume
M. O. m-64

20. Acute Stroke - Carotid Occlusion CEA?
CAS preferrable in the acute situation*
CT-Angio 4w after CAS & TE
*Own experiences with more than 220 thrombectomies of carotid and cerebral arteries

21. Acute Stroke - Carotid Occlusion CEA?
M. O. m-64
Residual thrombus after first TE - good result after second TE with the Solitaire Stent Retriever

22. Thrombectomy ICA D.E. f-62 Hemiplegic for 4 hours
CTA right ICA & MCA occluded

23. Thrombectomy ICA Bifurcational disease or carotid-T occlusion ?
D.E. f-62 Hemiplegic for 4 hours
CAS & TE

24. Some ICA spasm after TE & CAS - MCA cleaned
Thrombectomy ICA
Some ICA spasm after TE & CAS - MCA cleaned
D.E. f-62

25. Thrombektomie
Solitaire® 6 mm

26. D.E. f-62 Hemiplegic for 4 hours No stroke demarcated
Thrombectomy ICA
D.E. f-62 Hemiplegic for 4 hours No stroke demarcated

27. E. B. f-66 Aphasic and hemiplegic for 5 hrs FU CT/MRI after 24 hrs
Thrombectomy ICA
E. B. f-66 Aphasic and hemiplegic for 5 hrs FU CT/MRI after 24 hrs

28. B.G. f-66 Aphasic and hemiplegic for 4 hrs Perfusion Study
Thrombectomy ICA
B.G. f-66 Aphasic and hemiplegic for 4 hrs Perfusion Study

29. B.G. f-66 Aphasic and hemiplegic for 4 hrs CTA
Thrombectomy ICA
B.G. f-66 Aphasic and hemiplegic for 4 hrs CTA

30. B.G. f-66 Aphasic and hemiplegic for 4 hrs Opacification of ICA stump
Thrombectomy ICA
B.G. f-66 Aphasic and hemiplegic for 4 hrs Opacification of ICA stump

31. B.G. f-66 Aphasic and hemiplegic for 4 hrs CT n 24 Std.
Thrombectomy ICA
B.G. f-66 Aphasic and hemiplegic for 4 hrs CT n 24 Std.

32. B.G. f-66 Aphasic and hemiplegic for 4 hrs MRT after 6 days
Thrombectomy ICA
B.G. f-66 Aphasic and hemiplegic for 4 hrs MRT after 6 days

33. Thrombectomy - Results all
Patients* %
Age ±22
time window Std
technical success %
- no infarction %
- minor stroke %
- major stroke %
mortality (30 d) %
*Own results

34. Thrombectomy Results ICA
Patients* %
Age ±18
Time window Std
Technical success %
with CAS %
only TE
*Own results

35. Thrombectomy Results ICA
Patients %
No infarction %
Minor stroke* %
Major stroke** %
ICB (NIH >4) %
Own results *mRS <2; **mRS >2

36. Keep in mind ... Early recanalization improves the outcome
dramatically
Functional imaging is more important than
the time window
a short “Door to CT to Angio” time must be
achieved
there is no “I” team ... close cooperation
is essential!