|Year : 2019 | Volume
| Issue : 2 | Page : 65-68
A case of bilateral internal carotid artery complete occlusion
Mrugal Doshi, Arti Muley, Sunil Kumar, Sukhaswarup Kanojiya
Department of Medicine, SBKS MIRC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
|Date of Submission||30-May-2019|
|Date of Decision||11-Nov-2019|
|Date of Acceptance||13-Nov-2019|
|Date of Web Publication||02-Jan-2020|
Dr. Mrugal Doshi
1/B, Vidhyadhar Society, Vasna Road, Vadodara - 390 015, Gujarat
Source of Support: None, Conflict of Interest: None
Complete bilateral intracranial internal carotid artery occlusion is a rare disease with grave prognosis. It may cause recurrent stroke and extensive disability. We discuss a case of 62-year-old man who presented with sudden onset right sided hemiplegia, and GCS 7/15. CT scan revealed acute ischemic infarct in left MCA territory with mass effect and compression over the left lateral and third ventricle. Cerebral angiography showed bilateral intracranial internal carotid artery and middle cerebral artery occlusion. We present the case in view of wide range of presentation which depends on collateral formation and lack of specific guidelines for management.
Keywords: Aphasia, bilateral intracranial internal carotid artery occlusion, hemiplegia, stuporous
|How to cite this article:|
Doshi M, Muley A, Kumar S, Kanojiya S. A case of bilateral internal carotid artery complete occlusion. J Integr Health Sci 2019;7:65-8
|How to cite this URL:|
Doshi M, Muley A, Kumar S, Kanojiya S. A case of bilateral internal carotid artery complete occlusion. J Integr Health Sci [serial online] 2019 [cited 2020 Jun 2];7:65-8. Available from: http://www.jihs.in/text.asp?2019/7/2/65/274528
| Introduction|| |
Stroke is among the frequent and important neurological diseases in adults. Stroke is the most common cause of mortality second to coronary artery disease (CAD) in the world. The incidence of stroke in India ranges from 112/100,000 to 145/100,000/year. Atherosclerosis is one of the most significant causative factors for arterial stenosis/occlusion., The main risk factors for atherogenesis are hypertension, hyperlipidemia, diabetes, and smoking.,
Mead et al. found out that 99.6% of occlusions involve only one side of the internal carotid artery. Bilateral internal carotid artery occlusion (BICAO) is an extremely rare disease that only accounts for 0.4% of transient ischemic patients with completed stroke., A study of 21 BICAO patients reported an overall mortality of 52% when followed up for 1–11 years (average: 6 years), and a greater risk of the recurrent stroke. There is a limited literature available on the best medical management and long-term outcome for these cases. So far, only a few studies on BICAO with severe clinical symptoms have been reported,,,,,, whereas long-term survival cases with mild clinical symptoms remain nonexistent. Here, we present a case of BICAO and review the literature to gain insight into this rare but important entity.
| Case Report|| |
A 62-year-old male, right-handed chronic tobacco smoker and chronic alcoholic were brought to the emergency department of our hospital with complaints of altered sensorium, right-sided hemiplegia, and speech disturbance for 1 day. In the morning of that very day, while performing his daily chores, he suddenly developed both the upper limb and lower limb weakness on the right side which progressed to hemiplegia within 15–20 min. This was associated with sudden-onset aphasia. Following this, the patient developed loss of consciousness and was brought to the emergency department. By the time 8 h had passed since the onset of weakness. The patient had no history of headache, vomiting, seizure, dysphagia, or trauma before this episode. There was no any history of transient ischemic attack (TIA), valvular heart disease, CAD, hypertension, diabetes, or dyslipidemia. Family history did not suggest a history of stroke at young age. On examination, he had normal body temperature, pulse rate of 60/min with normal force, volume, tension, and no radio-radial or radio-femoral delay. His blood pressure was 170/100 mmHg in the right brachial artery in the supine position. His cardiovascular, respiratory, and abdominal examination had no apparent abnormality. His nervous system examination revealed that the patient was stuporous, his Glasgow Coma Scale was 7/15 with no verbal response, eye-opening to painful stimulus showed decerebrate rigidity upon pain stimulation. Power in both the upper limb and lower limb on the right side was Medical Research Council Grade 0. This was associated with increased muscle tone, exaggerated deep tendon reflexes, and decreased superficial reflexes on the right side. Babinski's sign was also positive on the right side. There was sphincter involvement in the form of loss of bowel and bladder control. The sensory examination could not be performed, as the patient was stuporous. There were no nystagmus, ataxia, or tremors. The gait, posture, finger–nose test, dysdiadochokinesia, overshooting, heel-to-shin, and heel tapping could not be performed. Cranial nerves could not be examined. On eye examination, pupils were round, regular, and reacting to light with changes of papilledema but no change of hypertensive retinopathy on fundus examination. The investigations of our patient were as in [Table 1] [Figure 1] [Figure 2].
|Figure 1: Image of the magnetic resonance imaging showing nonhemorrhagic infracts in frontal, parietal, and temporal lobes|
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|Figure 2: Image of the magnetic resonance angiography showing bilateral internal carotid artery complete occlusion|
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The airway was secured through endotracheal intubation, and Ryle's tube and Foley's catheter were inserted in the emergency department itself.
The patient refused for any thrombolysis, mechanical thrombectomy, or any surgical procedure. Hence, he was managed conservatively with dual antiplatelets, statins and osmotic diuretics, and physiotherapy.
The patient was gradually weaned off the ventilator and no longer required ventilator support. There was a significant improvement in the consciousness of the patient, as he was conscious and oriented to time place and person, but global aphasia and spastic hemiparesis on the right side persisted. The patient was discharged after 14 days of hospitalization on request of the family with Ryle's tube and Foley's catheter in situ and was continued on the same medication.
| Discussion|| |
BICAO is a rare disease with an unfavorable prognosis. A study reported that out of 2228 patients with completed stroke or TIA only 0.4% patients had BICAO. Another study by Persoon et al. showed in patients with BICAO stroke rates are between 0% and 13% per year. According to Wade et al., 53% of patients developed another stroke with an ischemic event rate of 15%/patient/year in 74 patients with atherosclerotic occlusion of both internal carotid arteries.
The clinical presentation of carotid artery stenosis/occlusion may vary from as mild as totally asymptomatic to as severe as fatal ischemic stroke. This variation in the presentation is determined by the collateral circulation, which is by the vertebrobasilar system with cross-filing of the middle cerebral artery (MCA), an external carotid/ophthalmic anastomosis, or a combination of the two. According to Henderson et al., if the hemisphere distal to severe internal stenosis is supplied by collaterals, the risk of stroke and TIA is much lesser than if there are no collaterals.
It has been reported that bilateral occlusion of internal carotid arteries results in 2.5-fold increased flow through the basilar artery, suggesting the basilar artery to be the main supplying artery.
Our patient had an ischemic infarct at the left MCA and was diagnosed on MR angiography as BICAO. The patient was on conservative treatment. There was no much improvement with respect to the hemiplegia or aphasia; however, the higher cortical functions were improved.
The selection of surgical approach for BICAO remains controversial; some of the choices are as follows: vascular bypass, external carotid artery revascularization, including carotid endarterectomy and carotid artery stenting. Friedman et al. concluded that only 10% of BICAO patients undergoing external carotid artery revascularization experience a transient ischemic stroke during the follow-up period. Furthermore, they found that extracranial–intracranial bypass or medical therapy alone is not an effective way to provide enough blood supply to improve the patient symptoms.
Of the 21 patients with BICAO followed up for an average of 6 years, 13 patients underwent vascular surgical intervention in a study by AbuRahma and Copeland. The study in the surgical group, 38% were expired, and 15% had multiple ischemic strokes, whereas 75% of patients in the medical group were expired and one developed an ischemic stroke. Persoon et al. observed that 57 patients with BICAO treated with nonsurgical methods achieved a better prognosis than the surgical methods. A randomized trial by Yoshida et al. stated that BICAO patients acquired a good clinical result after undergoing a bypass.
However, a meta-analysis conducted by Mylonas et al. revealed no significant difference in therapeutic effect between medical therapy and revascularization. Furthermore, long-term observation is necessary to obtain a better understanding of its therapeutic effect of a surgical or conservative approach. Hence, the proper treatment of BICAO remains controversial. We discussed this case to highlight the fact that although rare, BICAO usually presents with stroke and affects the quality of life of both the patients and the family members. Hence, it is high time proper guidelines should be in place to decide whether these patients should undergo surgery or conservative management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patientsunderstand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]