title: Endovascular treatment in proximal and intracranial carotid occlusion 9 hours after symptom onset.
abstract: BACKGROUND
  A debate is emerging over whether the treatment time window in acute stroke can be extended beyond 6 h if penumbral tissue can be identified. Treatment decisions are very difficult in cases of tandem proximal carotid occlusion with arterioarterial intracranial embolism. We enter this debate with the present report on a case of atherosclerotic proximal carotid occlusion and resulting periocclusional carotid T embolism that was successfully treated 9 h after symptom onset.
  
  
  METHODS
  The case of a 68-year-old man with fluctuating symptoms of right-hemispheric stroke is presented (NIHSS score 12-20 on admission). CT angiography demonstrated proximal carotid occlusion and periocclusional embolism of the entire internal carotid artery (ICA) including the carotid T segment. Penumbral tissue was diagnosed by nonenhanced and perfusion CT imaging 7.5 h after symptom onset. Treatment was initiated 9 h after symptom onset by passing the proximal occlusion with a microcatheter and local administration of recombinant tissue plasminogen activator (rt-PA) into the carotid T segment at the level of posterior communicating artery (PCoA) origin.
  
  
  RESULTS
  Recanalization of the ICA and middle cerebral artery was accomplished within 1 h by flow establishment via the PCoA. The atherosclerotic proximal ICA occlusion was not stented due to the risk of embolism from remnant thrombi in the petrous and cavernous ICA segments. Follow-up MRI showed only mild haemorrhagic infarct transformation of the initial infarct core. The patient was discharged from hospital 18 days after treatment with NIHSS score 5.
  
  
  CONCLUSIONS
  If penumbral tissue can be conclusively identified, endovascular treatment in proximal and intracranial tandem occlusion can be successful, even in treatments initiated 6-9 h after stroke onset. If the intracranial flow after recanalization can be established via the circle of Willis, the underlying proximal ICA occlusion may not require treatment.
authors.affiliation: Department of Neurology, Asklepios Clinic Altona, Hamburg, Germany. m.jakubowska@asklepios.com
authors.forename: Malgorzata M
authors.initials: MM
authors.lastname: Jakubowska
authors.forename: Peter
authors.initials: P
authors.lastname: Michels
authors.forename: Axel
authors.initials: A
authors.lastname: Müller-Jensen
authors.forename: Andreas
authors.initials: A
authors.lastname: Leppien
authors.forename: Bernd
authors.initials: B
authors.lastname: Eckert
mesh_terms: D000368:Aged; D002341:Carotid Artery Thrombosis / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy*; D002343:Carotid Artery, Internal; D004334:Drug Administration Schedule; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology; D020766:Intracranial Embolism / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology; D008279:Magnetic Resonance Imaging; D008297:Male; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator