The feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to proximal internal carotid artery (ICA) stenosis or occlusion are still controversial. In this study we analyzed our experience with eCAS in patients with AIS. Twenty-two eCAS procedures for proximal ICA stenosis or occlusion were performed in 22 patients at our institution between January 2011 and November 2013. The mean time from stroke symptom onset to presentation was 204 min (range 50-630 min) and the mean initial score on the National Institutes of Health Stroke Scale (NIHSS) was 12.55 (range 5-23). Ten patients had total occlusion of the proximal ICA and the remaining 12 patients had near total occlusion or severe stenosis (mean degree 90.7%, range 80-100%). Eleven patients also had tandem occlusion on the more distal intracranial arteries. Successful stent insertion was achieved in all patients and additional thrombectomy using a Solitaire stent or Penumbra aspiration catheter achieved a Thrombolysis In Cerebral Infarction grade of more than 2a in all patients with distal tandem occlusion. Procedure-related complications occurred in one patient (cerebral hyperperfusion syndrome) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0-18). The mean modified Rankin Scale score at 3 months was 1±1.67 (range 0-6). eCAS in patients with AIS due to proximal ICA stenosis or occlusion appears to be a technically feasible and effective method for achieving good clinical outcomes.

Arteriograms performed in the Interventional Management of Stroke studies were analyzed for external carotid artery embolus. Two cases were identified and diagnosed as thromboembolic due to a cardiac origin. This is an uncommon but useful finding on angiography which is helpful for further management. It is hypothesized that finding embolus within the external carotid artery on angiography in stroke patients with internal carotid artery occlusion allows confident ascription to a proximal, usually cardiac, source.

Intracranial ICA dissection is a rare pathology that frequently results in severe morbidity or mortality in young patients. This study examined the suitability of early surgical treatment. We present and analyze 6 of our own cases and 39 other cases reported after 1980. The clinical courses were classified into 3 types: A, single attack and severe outcome; B, single attack and mild to moderate outcome; and C, recurrent attacks and various outcomes. Type A patients (n = 11) usually deteriorated quickly and severely so that early surgical treatment was not possible. Most type B patients (n = 12) did not require surgical intervention because of relatively stable courses. Only some type C patients (n = 10) are candidates for early surgery to prevent progressive deterioration. Twelve cases were unclassified because of insufficient information. We encountered 3 cases of type C, and emergency bypass surgery with parent ICA occlusion was planned in 2 patients. The surgery was successful with good prognosis in 1 patient; but the ICA and its branches were already occluded in the other patient, which precluded completion of bypass surgery and resulted in severe hemiparesis. Intraoperative findings and histologic examination of the MCA confirmed arterial dissection. Young patients with intracranial ICA dissection manifesting as mild ischemic stroke should be considered for early bypass surgery with occlusion of the dissected ICA if any sign of progression or recurrence occurs after the onset.