title: "Opening the Unopenable": Endovascular Treatment in a Patient with Three Months' Internal Carotid Artery Occlusion and Hemispheric Symptomatic Hypoperfusion.
abstract: BACKGROUND
  Internal carotid artery occlusion (ICAO) is defined as "untouchable" by all specialists; no treatment is indicated because intervention risks (carotid endarterectomy (CEA) or endovascular treatment) are usually much more than benefits.(1,2) We report the case of a patient admitted to our hospital with an atherothrombotic ischemic stroke due to symptomatic acute ICAO, who developed a recurrent stroke with hemispheric hypoperfusion and was treated in the emergency department with ICAO revascularization after 60 days of occlusion finding.
  
  
  METHODS
  D.G., a 62-year-old man, came to our attention for a transient episode of left weakness and hypoesthesia. The electrocardiogram revealed a new diagnosis of atrial fibrillation. CT angiography showed right ICAO; computed tomography and magnetic resonance imaging studies with perfusion imaging revealed a severe hemispheric hypoperfusion. Full anticoagulation therapy was started, and antihypertensive therapy was reduced to help collateral circulation. Some weeks later, the patient was readmitted to the stroke unit for 2 episodes of left-hand weakness. Cerebral angiography confirmed right ICAO from the proximal tract to the siphon. After some days, the patient suffered a femoral hemorrhagic lesion, with active bleeding, and was treated with surgical intervention. On the following day, the patient presented with left hemiplegia with hemianesthesia (National Institutes of Health Stroke Scale score = 14). The patient was treated in the emergency department with a complex endovascular treatment with complete recanalization of ICAO by positioning 3 stents through the intravenous infusion of abciximab. After intensive rehabilitation, at the 3- and 6-month follow-up evaluations, the patient regained autonomy.
  
  
  CONCLUSIONS
  In literature, treatment of chronic ICAO is not indicated. Endovascular recanalization may be beneficial to patients with chronic cerebral hypoperfusion due to ICAO, when all conservative medical therapies have failed.
authors.affiliation: Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy. Electronic address: guido.bigliardi@gmail.com.
authors.forename: Guido
authors.initials: G
authors.lastname: Bigliardi
authors.affiliation: Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Maria Luisa
authors.initials: ML
authors.lastname: Dell'Acqua
authors.affiliation: Neuroradiology Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Vallone
authors.affiliation: Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Barbi
authors.affiliation: Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Pentore
authors.affiliation: Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Livio
authors.initials: L
authors.lastname: Picchetto
authors.affiliation: Neuroradiology Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Carpeggiani
authors.affiliation: Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Nichelli
authors.affiliation: Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Zini
mesh_terms: D002340:Carotid Artery Diseases / Q000150:complications* / Q000000981:diagnostic imaging; D002343:Carotid Artery, Internal; D002548:Cerebral Revascularization / Q000379:methods*; D000072226:Computed Tomography Angiography; D006429:Hemiplegia / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged
keywords: Stroke; hypoperfusion; internal carotid artery occlusion; stenting