Symptomatic acute occlusion of the internal carotid artery: Reappraisal of urgent vascular reconstruction based on current stroke imaging

(a) Perfusion-weighted image 4 hours after onset of stroke symptoms (Rankin 4) and before revascularization displays a perfusion deficit (red and green) of the right hemisphere, which represents “tissue at risk” for further infarction. (b) Perfusion-weighted image taken 1 week after successful revascularization of the right internal carotid artery demonstrates a perfusion deficit in the area of the definitive infarction (green), while the surrounding tissue recovered (blue). The patient remained clinically stable.

(a) Diffusion-weighted image 4 hours after onset of stroke symptoms and before revascularization of the right internal carotid artery displays white spots in the middle carotid artery perfusion area region as sign for definitely damaged brain tissue. (b) Diffusion-weighted image 1 week after successful revascularization displays an enlargement of the stroke area, which approximately has the same size as the zone of severe perfusion deficit (red color Fig 1, a), but is smaller than the total zone of impaired perfusion in the preoperative perfusion-weighted image (red and green in Fig 1, a).

Rankin scale scores before (gray) and after (black) carotid artery surgery.

Duplex subtraction angiography shows (a) an occlusion of the right internal carotid artery, (b) a perfusion of the right middle carotid artery, and (c) a retrograde perfusion of the “siphon.”

Magnetic resonance angiography taken 1 week after the surgical revascularization demonstrates restoration of blood flow in the right internal carotid artery.

Postoperative clinical course at discharge improved or deteriorated means change of 1 point or more in Rankin scale.