Evaluation of stenosis using Magnetic resonance angiography for acute cervical internal carotid artery occlusion initially treated by angioplasty alone: a case series

Evaluation of stenosis using Magnetic resonance angiography for acute cervical internal carotid artery occlusion initially treated by angioplasty alone: a case series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Evaluation of stenosis using Magnetic resonance angiography for acute cervical internal carotid artery occlusion initially treated by angioplasty alone: a case series Masahiro Nakahara, Atsushi Fujita, Satoshi Inoue, Naoya Takeda, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4768425/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The optimal treatment strategy for acute ischemic stroke following cervical internal carotid artery occlusion of atherosclerotic lesions remains unclear. We retrospectively investigated the changes in imaging findings of the stenotic lesion after performing angioplasty alone. The most stenotic lesion on magnetic resonance angiography was significantly improved. No re-occlusion or stroke deterioration occurred in the perioperative period. Considering the risk of hemorrhagic complications at the acute phase, performing angioplasty alone may be useful. Additionally, the stenotic lesion can be evaluated using magnetic resonance angiography, with early consideration of additional treatment, if necessary. Acute ischemic stroke Angioplasty Atherosclerotic carotid artery disease Carotid artery stenting Figures Figure 1 Figure 2 Introduction The optimal treatment strategies for acute ischemic stroke (AIS) due to cervical internal carotid artery (ICA) occlusion of an atherosclerotic lesion remain unknown. If cervical angioplasty alone is performed, it may increase the risk of re-occlusion and recurrence of ischemic stroke. In this study, we retrospectively investigated changes in imaging findings of stenotic lesions after performing angioplasty alone. Methods Patient selection Between 2017 and 2024, we included patients who underwent angioplasty alone for AIS due to atherosclerotic cervical ICA occlusion. Patients with ICA lesions other than atherosclerotic disease (e.g., dissection or cardioembolism) were excluded. This study was approved by our institutional review board (Junshin Hospital ethics committee, #2023-002). Acute procedure Intravenous tissue plasminogen activator (tPA) was administered following the Japanese guidelines. [ 6 ] We performed mechanical thrombectomy (MT) using a stent retriever or aspiration catheter, along with angioplasty for cervical ICA occlusion. Prior to angioplasty, we administered a loading dose of aspirin (200−300 mg) via a nasogastric tube, and ozagrel (80 mg) intravenously, except in patients where intravenous tPA was administered. Additional intracranial MT was performed if necessary. Acute carotid artery stenting was avoided as much as possible after considering the residual and progression of the stenotic lesion. Final digital subtraction angiography (DSA) confirmed good recanalization, and we measured the diameter of the most stenotic lesion. Post-procedural course Patients continued receiving aspirin (100 mg) and a statin. Magnetic resonance imaging (MRI) was performed to assess the stenotic lesion. To achieve optimal visual contrast at the cervical ICA level, the window width and level were adjusted to 450 and 280, respectively. Additional treatment was scheduled after a week or more, and carotid artery stenting or endarterectomy was performed based on the operator’s discretion. Patients who underwent stenting were administered dual antiplatelet therapy for 10−14 days prior. In patients in whom stenting was performed, we measured the preoperative diameter of the stenotic lesion on DSA (lateral view). Statistical analysis All statistical analyses were performed with statistical software (EZR; Saitama Medical Center, Jichi Medical University, Saitama, Japan; a graphical user interface for R [The R Foundation for Statistical Computing, Vienna, Austria]) [ 4 ]. We analyzed the diameter of the most stenotic lesion from both magnetic resonance angiography (MRA) and DSA using a paired t-test. A p-value < 0.05 was considered statistically significant. Results We performed MT in 262 patients with AIS with large vessel occlusion from April 2017 to March 2024. Of these, 11 patients with acute cervical ICA occlusion due to atherosclerotic disease were treated. Of these, seven patients who underwent angioplasty alone for ICA were included in this study. Patient baseline characteristics are presented in Table 1. The mean age was 73 years, and all patients were male. The mean National Institutes of Health Stroke Scale score at admission was 19. Intracranial artery occlusion was observed in six patients. Intravenous tPA was administered in two patients. Angioplasty was performed in six patients, and thrombosis aspiration was performed in one patient at the cervical ICA. Additional intracranial MT was performed in five patients, while final good recanalization was achieved in all patients. The diameter of the most stenotic lesion was assessed using MRA and DSA (Table 2). MRA showed a significant improvement in the diameter of the most stenotic lesion before the second procedure (2.5 ± 0.5 mm) compared with after the acute procedure (2.0 ± 0.6 mm; p = 0.01) (Fig. 1 a). In patients in whom stenting was performed, DSA at the lateral view showed no significant difference in the diameter of the residual stenotic lesion at the second procedure (2.1 ± 0.7 mm) compared with that at the acute procedure (1.9 ± 0.6 mm; p = 0.57) (Fig. 1 b). Improvement was noted in three of five patients. The mean period between the acute procedure and the second procedure was 23 days, and no patients experienced re-occlusion or deterioration of the ischemic stroke. Two patients exhibited asymptomatic hemorrhage within infarcted tissue, which did not enlarge during the waiting period. No patients exhibited hemorrhagic complications after the second procedure. Case description (Case 4) A 70-year-old man was admitted with left hemiparesis and dysarthria, and presented with a National Institutes of Health Stroke Scale score of 11. MRI showed occlusion of the right cervical ICA and the middle cerebral artery with ischemic change (Fig. 2 a−c). Initial DSA revealed persistent occlusion of the cervical ICA (Fig. 2 d). Thus, we performed angioplasty, which achieved recanalization. Additional MT for the remaining intracranial occlusion was performed, which achieved good recanalization. Carotid DSA confirmed the diameter of the residual stenotic lesion to be 2.3 mm (Fig. 2 e). MRI at 3 days after the procedure showed a diameter of the most stenotic lesion of 3.0×3.0 mm (Fig. 2 h) At 14 days’ recovery, the diameter measured 3.2×3.2 mm (Fig. 2 i), while at 25 days’ recovery it had increased to 3.2×3.6 mm (Fig. 2 j). Additional carotid artery stenting was performed at 35 days after the acute procedure. Initial DSA revealed a stenotic lesion diameter of 1.8 mm (Fig. 2 f). Final DSA confirmed successful dilatation (Fig. 2 g), and the patient was discharged home with mild left hemiparesis. Discussion We conducted a retrospective investigation of changes in imaging findings of stenotic lesions after angioplasty in patients with AIS caused by atherosclerotic cervical ICA occlusion. MRA indicated a significant improvement in the diameter of the most stenotic lesion. Among patients in whom additional stenting was performed, DSA showed improvement in the diameter of the residual stenotic lesion compared with the acute and second procedures in three of five patients. No patients experienced re-occlusion or deterioration of the ischemic stroke. The optimal management for residual ICA stenosis remains uncertain, and includes whether it is best managed with stenting or angioplasty alone during the initial procedure. Anadani et al. reported that patients treated with acute stenting for tandem occlusion strokes had higher odds of a favorable 90-day outcome, despite higher odds of intracerebral hemorrhage (ICH), because in that study most hemorrhages were asymptomatic [ 2 ]. Diana et al. reported that emergent stenting was associated with a higher rate of good functional outcome compared with no-stenting in patients with AIS due to tandem occlusion, despite a significantly increased risk of symptomatic ICH [ 3 ]. In that study, emergent stenting was also associated with a lower re-stenosis rate and higher recanalization rate. Pop et al. also reviewed stent patency and delayed stent thrombosis for emergent stenting [ 7 ], and found a significantly higher stent occlusion rate in patients who received aspirin alone (28.3%) compared with those who received both aspirin and clopidogrel (8.8%). Thus, the authors recommended that patients receive dual-antiplatelet whenever possible to avoid stent thrombosis. Conversely, Akpinar et al. postulated that delayed stenting might prevent ICH due to early use of antiplatelet agents [ 1 ]. In the present study, angioplasty alone was performed during the acute phase, which was followed by postoperative aspirin administration. Good recanalization was obtained, and only localized hemorrhage within the infarct was observed in two patients. Considering the risk of hemorrhagic complications, angioplasty alone during the acute procedure may be a useful treatment strategy. The risk of ICH decreases when patients undergo angioplasty alone, as they can be managed with single platelet therapy. However, there is concern regarding the risk of thrombosis and ICA re-occlusion. Several studies have reported a risk of stent occlusion of 5.4%−19.1% in patients undergoing emergent stenting [ 5 , 7 – 9 ]. Eker et al. also demonstrated a treatment strategy for atherosclerotic tandem occlusion in AIS, with a rate of stent/ICA occlusion within 7 days after emergent stenting of 10.3%, and a trend toward higher rates (33.3%) after angioplasty alone. In the present study, no patients experienced cervical ICA re-occlusion or deterioration of the ischemic stroke, and all patients were managed electively. The diameter of the most stenotic lesion on MRA and DSA also showed a tendency to improve compared with the acute phase. These findings suggest that MRA is useful for assessing the stenotic lesion. We recommend that angioplasty be performed alone during the acute phase, while increasing the dose of antiplatelet drugs or early additional endovascular treatment should be considered in patients with stenosis progression. Conclusions We present the changes in imaging findings of stenotic lesions following angioplasty alone for AIS due to atherosclerotic ICA occlusion. No cervical ICA re-occlusion or deterioration of the ischemic stroke were observed in the perioperative period. The diameter of the stenotic lesion assessed by MRA and DSA showed a gradual trend toward improvement. Considering the risk of hemorrhagic complication in the acute phase, performing angioplasty alone for cervical ICA may be useful. Additionally, the stenotic lesion can be evaluated using MRA, with early consideration of additional treatment if necessary. Abbreviations AIS Acute ischemic stroke DSA Digital subtraction angiography ICA Internal carotid artery ICH Intracerebral hemorrhage MRI Magnetic resonance imaging MRA Magnetic resonance angiography MT Mechanical thrombectomy tPA Tissue plasminogen activator Declarations Acknowledgements We thank Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. Competing interests None. Informed consent Informed consent was obtained from patients for publication of this study and the accompanying images. Author Contribution All authors reviewed the manuscript. References Akpinar CK, Gürkaş E, Aytac E (2017) Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions. Interv Neuroradiol 23(4):405–411 Anadani M, Marnat G, Consoli A et al (2021) Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled Analysis From the TITAN and ETIS Registries. Stroke 52(10):3097–3105 Diana F, Romoli M, Toccaceli G et al (2023) Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis. J Neurointerv Surg 15(5):428–432 Kanda Y (2013) Investigation of the freely available easy-to-use software EZR for medical statistics. Bone Marrow Transpl 48(3):452–458 Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F (2015) Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 57(6):589–598 Miyamoto S, Ogasawara K, Kuroda S et al (2022) Japan Stroke Society Guideline 2021 for the Treatment of Stroke. Int J Stroke 17(9):1039–1049 Pop R, Zinchenko I, Quenardelle V et al (2019) Predictors and Clinical Impact of Delayed Stent Thrombosis after Thrombectomy for Acute Stroke with Tandem Lesions. AJNR Am J Neuroradiol 40(3):533–539 Sadeh-Gonik U, Tau N, Friehmann T et al (2018) Thrombectomy outcomes for acute stroke patients with anterior circulation tandem lesions: a clinical registry and an update of a systematic review with meta-analysis. Eur J Neurol 25(4):693–700 Steglich-Arnholm H, Holtmannspötter M, Kondziella D, Wagner A, Stavngaard T, Cronqvist ME, Hansen K, Højgaard J, Taudorf S, Krieger DW (2015) Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms. J Neurol 262(12):2668–2675 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.xlsx Table2.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4768425","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":339397970,"identity":"e6a24a0f-c300-47c4-b752-e6b1fa699b50","order_by":0,"name":"Masahiro Nakahara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtklEQVRIiWNgGAWjYFACNmaGCgYbIIOx8QDxWs4wpIG0NJCk5TCYSZwWc/ZjyQYHc87brW0/DLSlxiaaoBbLnrTDCQe33U7ediYRqOVYWm4DIS0GB9KbD38EajE7ANTC2HCYCC3nnzcfOLjtXLLZ+YfEarkBdtgBO7MbRNty4xnQ+9uSE8xuAG1JIMov59OMJQ5us7M3O5/+8MGHGhvCWmAgEawygVjlIGBPiuJRMApGwSgYYQAAEipNz43uxVQAAAAASUVORK5CYII=","orcid":"","institution":"Junshin Hospital","correspondingAuthor":true,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Nakahara","suffix":""},{"id":339397972,"identity":"8b4a67fd-6b79-4258-85b2-8d8328e37167","order_by":1,"name":"Atsushi Fujita","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Atsushi","middleName":"","lastName":"Fujita","suffix":""},{"id":339397974,"identity":"756505ae-c81c-4ab9-8efd-e232e17b591a","order_by":2,"name":"Satoshi Inoue","email":"","orcid":"","institution":"Junshin Hospital","correspondingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Inoue","suffix":""},{"id":339397975,"identity":"91e080f1-1eed-44c1-bcd7-0c5ae4031f4e","order_by":3,"name":"Naoya Takeda","email":"","orcid":"","institution":"Junshin Hospital","correspondingAuthor":false,"prefix":"","firstName":"Naoya","middleName":"","lastName":"Takeda","suffix":""},{"id":339397977,"identity":"d55f0713-5ad8-45c1-bccf-d87c015d68ba","order_by":4,"name":"Eiji Kurihara","email":"","orcid":"","institution":"Junshin Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eiji","middleName":"","lastName":"Kurihara","suffix":""},{"id":339397978,"identity":"189d969b-92e1-426f-8697-0101e3d81b68","order_by":5,"name":"Takashi Sasayama","email":"","orcid":"","institution":"Kobe University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Sasayama","suffix":""}],"badges":[],"createdAt":"2024-07-19 15:20:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4768425/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4768425/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62800715,"identity":"cf30aebb-6a84-4a94-8ae3-0315b5f57b7a","added_by":"auto","created_at":"2024-08-19 15:51:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":52260,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Diameter of the most stenotic lesion on magnetic resonance angiography. A = after the acute procedure; B = before the second procedure. (b) The diameter of the most stenotic lesion on digital subtraction angiography. A = at the acute procedure; B = at the second procedure. Data are presented as box plots with lower and upper boundaries at the 25\u003csup\u003eth\u003c/sup\u003e and 75\u003csup\u003eth\u003c/sup\u003e percentiles. The median is indicated by the line subdividing the box. The whiskers encompass all other observations except those \u0026gt;1.5 times the interquartile range above or below the box boundaries\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-4768425/v1/4aed8110e1ba361f80a17b67.png"},{"id":62801143,"identity":"638d67ab-0195-44d1-a13c-7d5ad38a05b5","added_by":"auto","created_at":"2024-08-19 15:59:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":284301,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Magnetic resonance diffusion-weighted imaging and (b, c) angiography performed at patient admission showing occlusion of the right cervical Internal carotid artery (ICA) with ischemic change. (d) Initial digital subtraction angiography (DSA) at the acute procedure showing occlusion of the right cervical ICA. (e) Final DSA at the acute procedure confirming good recanalization and residual stenosis. (f) Initial DSA at the second procedure revealing the residualstenosis. (g) Final DSA after stent placement confirming good dilatation. The most stenotic lesion of the ICA (arrow head) on Magnetic resonance angiography for the 3 days (h), 14 days (i), and 25 days (j) after the procedure\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-4768425/v1/0c6fd08b855331f0bd570966.png"},{"id":70933067,"identity":"c7d588bd-a013-493e-b27a-85b0fef3ee5c","added_by":"auto","created_at":"2024-12-09 10:32:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":670052,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4768425/v1/abe762ef-20d2-4ebb-afa5-44b2ce0ae8d8.pdf"},{"id":62800713,"identity":"e9cd588c-3e3e-498c-aee7-709e2605a889","added_by":"auto","created_at":"2024-08-19 15:51:59","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":11562,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4768425/v1/dce822960f9bd056640375b2.xlsx"},{"id":62800714,"identity":"a9ffe110-bb7e-49dd-85d1-c510652bc7cf","added_by":"auto","created_at":"2024-08-19 15:51:59","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":10602,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4768425/v1/1ceceec2abefc7b8b9175b2b.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of stenosis using Magnetic resonance angiography for acute cervical internal carotid artery occlusion initially treated by angioplasty alone: a case series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe optimal treatment strategies for acute ischemic stroke (AIS) due to cervical internal carotid artery (ICA) occlusion of an atherosclerotic lesion remain unknown. If cervical angioplasty alone is performed, it may increase the risk of re-occlusion and recurrence of ischemic stroke. In this study, we retrospectively investigated changes in imaging findings of stenotic lesions after performing angioplasty alone.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection\u003c/h2\u003e \u003cp\u003eBetween 2017 and 2024, we included patients who underwent angioplasty alone for AIS due to atherosclerotic cervical ICA occlusion. Patients with ICA lesions other than atherosclerotic disease (e.g., dissection or cardioembolism) were excluded. This study was approved by our institutional review board (Junshin Hospital ethics committee, #2023-002).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAcute procedure\u003c/h2\u003e \u003cp\u003e Intravenous tissue plasminogen activator (tPA) was administered following the Japanese guidelines. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] We performed mechanical thrombectomy (MT) using a stent retriever or aspiration catheter, along with angioplasty for cervical ICA occlusion. Prior to angioplasty, we administered a loading dose of aspirin (200\u0026minus;300 mg) via a nasogastric tube, and ozagrel (80 mg) intravenously, except in patients where intravenous tPA was administered. Additional intracranial MT was performed if necessary. Acute carotid artery stenting was avoided as much as possible after considering the residual and progression of the stenotic lesion. Final digital subtraction angiography (DSA) confirmed good recanalization, and we measured the diameter of the most stenotic lesion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePost-procedural course\u003c/h2\u003e \u003cp\u003ePatients continued receiving aspirin (100 mg) and a statin. Magnetic resonance imaging (MRI) was performed to assess the stenotic lesion. To achieve optimal visual contrast at the cervical ICA level, the window width and level were adjusted to 450 and 280, respectively. Additional treatment was scheduled after a week or more, and carotid artery stenting or endarterectomy was performed based on the operator\u0026rsquo;s discretion. Patients who underwent stenting were administered dual antiplatelet therapy for 10\u0026minus;14 days prior. In patients in whom stenting was performed, we measured the preoperative diameter of the stenotic lesion on DSA (lateral view).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed with statistical software (EZR; Saitama Medical Center, Jichi Medical University, Saitama, Japan; a graphical user interface for R [The R Foundation for Statistical Computing, Vienna, Austria]) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. We analyzed the diameter of the most stenotic lesion from both magnetic resonance angiography (MRA) and DSA using a paired t-test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe performed MT in 262 patients with AIS with large vessel occlusion from April 2017 to March 2024. Of these, 11 patients with acute cervical ICA occlusion due to atherosclerotic disease were treated. Of these, seven patients who underwent angioplasty alone for ICA were included in this study. Patient baseline characteristics are presented in Table\u0026nbsp;1. The mean age was 73 years, and all patients were male. The mean National Institutes of Health Stroke Scale score at admission was 19. Intracranial artery occlusion was observed in six patients. Intravenous tPA was administered in two patients. Angioplasty was performed in six patients, and thrombosis aspiration was performed in one patient at the cervical ICA. Additional intracranial MT was performed in five patients, while final good recanalization was achieved in all patients.\u003c/p\u003e \u003cp\u003eThe diameter of the most stenotic lesion was assessed using MRA and DSA (Table\u0026nbsp;2). MRA showed a significant improvement in the diameter of the most stenotic lesion before the second procedure (2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 mm) compared with after the acute procedure (2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 mm; p\u0026thinsp;=\u0026thinsp;0.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). In patients in whom stenting was performed, DSA at the lateral view showed no significant difference in the diameter of the residual stenotic lesion at the second procedure (2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 mm) compared with that at the acute procedure (1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 mm; p\u0026thinsp;=\u0026thinsp;0.57) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Improvement was noted in three of five patients.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe mean period between the acute procedure and the second procedure was 23 days, and no patients experienced re-occlusion or deterioration of the ischemic stroke. Two patients exhibited asymptomatic hemorrhage within infarcted tissue, which did not enlarge during the waiting period. No patients exhibited hemorrhagic complications after the second procedure.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCase description (Case 4)\u003c/h2\u003e \u003cp\u003eA 70-year-old man was admitted with left hemiparesis and dysarthria, and presented with a National Institutes of Health Stroke Scale score of 11. MRI showed occlusion of the right cervical ICA and the middle cerebral artery with ischemic change (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea\u0026minus;c). Initial DSA revealed persistent occlusion of the cervical ICA (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed). Thus, we performed angioplasty, which achieved recanalization. Additional MT for the remaining intracranial occlusion was performed, which achieved good recanalization. Carotid DSA confirmed the diameter of the residual stenotic lesion to be 2.3 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee). MRI at 3 days after the procedure showed a diameter of the most stenotic lesion of 3.0\u0026times;3.0 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eh) At 14 days\u0026rsquo; recovery, the diameter measured 3.2\u0026times;3.2 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ei), while at 25 days\u0026rsquo; recovery it had increased to 3.2\u0026times;3.6 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ej). Additional carotid artery stenting was performed at 35 days after the acute procedure. Initial DSA revealed a stenotic lesion diameter of 1.8 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef). Final DSA confirmed successful dilatation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eg), and the patient was discharged home with mild left hemiparesis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe conducted a retrospective investigation of changes in imaging findings of stenotic lesions after angioplasty in patients with AIS caused by atherosclerotic cervical ICA occlusion. MRA indicated a significant improvement in the diameter of the most stenotic lesion. Among patients in whom additional stenting was performed, DSA showed improvement in the diameter of the residual stenotic lesion compared with the acute and second procedures in three of five patients. No patients experienced re-occlusion or deterioration of the ischemic stroke.\u003c/p\u003e \u003cp\u003eThe optimal management for residual ICA stenosis remains uncertain, and includes whether it is best managed with stenting or angioplasty alone during the initial procedure. Anadani et al. reported that patients treated with acute stenting for tandem occlusion strokes had higher odds of a favorable 90-day outcome, despite higher odds of intracerebral hemorrhage (ICH), because in that study most hemorrhages were asymptomatic [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Diana et al. reported that emergent stenting was associated with a higher rate of good functional outcome compared with no-stenting in patients with AIS due to tandem occlusion, despite a significantly increased risk of symptomatic ICH [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In that study, emergent stenting was also associated with a lower re-stenosis rate and higher recanalization rate. Pop et al. also reviewed stent patency and delayed stent thrombosis for emergent stenting [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and found a significantly higher stent occlusion rate in patients who received aspirin alone (28.3%) compared with those who received both aspirin and clopidogrel (8.8%). Thus, the authors recommended that patients receive dual-antiplatelet whenever possible to avoid stent thrombosis. Conversely, Akpinar et al. postulated that delayed stenting might prevent ICH due to early use of antiplatelet agents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In the present study, angioplasty alone was performed during the acute phase, which was followed by postoperative aspirin administration. Good recanalization was obtained, and only localized hemorrhage within the infarct was observed in two patients. Considering the risk of hemorrhagic complications, angioplasty alone during the acute procedure may be a useful treatment strategy.\u003c/p\u003e \u003cp\u003eThe risk of ICH decreases when patients undergo angioplasty alone, as they can be managed with single platelet therapy. However, there is concern regarding the risk of thrombosis and ICA re-occlusion. Several studies have reported a risk of stent occlusion of 5.4%\u0026minus;19.1% in patients undergoing emergent stenting [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Eker et al. also demonstrated a treatment strategy for atherosclerotic tandem occlusion in AIS, with a rate of stent/ICA occlusion within 7 days after emergent stenting of 10.3%, and a trend toward higher rates (33.3%) after angioplasty alone. In the present study, no patients experienced cervical ICA re-occlusion or deterioration of the ischemic stroke, and all patients were managed electively. The diameter of the most stenotic lesion on MRA and DSA also showed a tendency to improve compared with the acute phase. These findings suggest that MRA is useful for assessing the stenotic lesion. We recommend that angioplasty be performed alone during the acute phase, while increasing the dose of antiplatelet drugs or early additional endovascular treatment should be considered in patients with stenosis progression.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe present the changes in imaging findings of stenotic lesions following angioplasty alone for AIS due to atherosclerotic ICA occlusion. No cervical ICA re-occlusion or deterioration of the ischemic stroke were observed in the perioperative period. The diameter of the stenotic lesion assessed by MRA and DSA showed a gradual trend toward improvement. Considering the risk of hemorrhagic complication in the acute phase, performing angioplasty alone for cervical ICA may be useful. Additionally, the stenotic lesion can be evaluated using MRA, with early consideration of additional treatment if necessary.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acute ischemic stroke\u003c/p\u003e\n\u003cp\u003eDSA\u0026nbsp; \u0026nbsp;\u0026nbsp;Digital subtraction angiography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICA\u0026nbsp; \u0026nbsp; \u0026nbsp;Internal carotid artery\u003c/p\u003e\n\u003cp\u003eICH\u0026nbsp; \u0026nbsp; \u0026nbsp;Intracerebral hemorrhage\u003c/p\u003e\n\u003cp\u003eMRI\u0026nbsp; \u0026nbsp; \u0026nbsp;Magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eMRA\u0026nbsp; \u0026nbsp;Magnetic resonance angiography\u003c/p\u003e\n\u003cp\u003eMT\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Mechanical thrombectomy\u003c/p\u003e\n\u003cp\u003etPA\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Tissue plasminogen activator\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from patients for publication of this study and the accompanying images.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAkpinar CK, G\u0026uuml;rkaş E, Aytac E (2017) Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions. Interv Neuroradiol 23(4):405\u0026ndash;411\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnadani M, Marnat G, Consoli A et al (2021) Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled Analysis From the TITAN and ETIS Registries. Stroke 52(10):3097\u0026ndash;3105\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiana F, Romoli M, Toccaceli G et al (2023) Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis. J Neurointerv Surg 15(5):428\u0026ndash;432\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanda Y (2013) Investigation of the freely available easy-to-use software EZR for medical statistics. Bone Marrow Transpl 48(3):452\u0026ndash;458\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F (2015) Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 57(6):589\u0026ndash;598\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyamoto S, Ogasawara K, Kuroda S et al (2022) Japan Stroke Society Guideline 2021 for the Treatment of Stroke. Int J Stroke 17(9):1039\u0026ndash;1049\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePop R, Zinchenko I, Quenardelle V et al (2019) Predictors and Clinical Impact of Delayed Stent Thrombosis after Thrombectomy for Acute Stroke with Tandem Lesions. AJNR Am J Neuroradiol 40(3):533\u0026ndash;539\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeh-Gonik U, Tau N, Friehmann T et al (2018) Thrombectomy outcomes for acute stroke patients with anterior circulation tandem lesions: a clinical registry and an update of a systematic review with meta-analysis. Eur J Neurol 25(4):693\u0026ndash;700\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteglich-Arnholm H, Holtmannsp\u0026ouml;tter M, Kondziella D, Wagner A, Stavngaard T, Cronqvist ME, Hansen K, H\u0026oslash;jgaard J, Taudorf S, Krieger DW (2015) Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms. J Neurol 262(12):2668\u0026ndash;2675\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute ischemic stroke, Angioplasty, Atherosclerotic carotid artery disease, Carotid artery stenting","lastPublishedDoi":"10.21203/rs.3.rs-4768425/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4768425/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe optimal treatment strategy for acute ischemic stroke following cervical internal carotid artery occlusion of atherosclerotic lesions remains unclear. We retrospectively investigated the changes in imaging findings of the stenotic lesion after performing angioplasty alone. The most stenotic lesion on magnetic resonance angiography was significantly improved. No re-occlusion or stroke deterioration occurred in the perioperative period. Considering the risk of hemorrhagic complications at the acute phase, performing angioplasty alone may be useful. Additionally, the stenotic lesion can be evaluated using magnetic resonance angiography, with early consideration of additional treatment, if necessary.\u003c/p\u003e","manuscriptTitle":"Evaluation of stenosis using Magnetic resonance angiography for acute cervical internal carotid artery occlusion initially treated by angioplasty alone: a case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-19 15:51:54","doi":"10.21203/rs.3.rs-4768425/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8f86a377-c57d-4a1f-a601-dd13404862e1","owner":[],"postedDate":"August 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-09T10:23:54+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-19 15:51:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4768425","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4768425","identity":"rs-4768425","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}