Combined therapeutic approach of intra-arterial thrombolysis and carotid endarterectomy in selected patients with acute thrombotic carotid occlusion

Purpose: The feasibility and clinical outcome of intra-arterial thrombolysi s followed by carotid endarterectomy (CEA) for acute thrombotic occlusion o f the internal carotid artery (ICA) were evaluated. Methods: Intra-arterial thrombolysis and CEA were performed in four patient s with acute thrombotic ICA occlusion. Computed tomography scans, cerebral angiograms, and the severity of carotid plaques were examined, and the pati ents' clinical outcome was evaluated. Results: All 4 patients had severe hemiparesis; 3 patients were alert, and 1 patient was lethargic at the time of hospital admission. New lesions were not shown by means of the initial computed tomography scan. ICA occlusion was indicated in all four patients by means of cerebral angiograms; in thre e patients, middle cerebral artery occlusion was noted. Collateral circulat ion was manifested in all patients. Partial recanalization of the occluded ICA was obtained in all patients. Two patients with severe residual ICA ste nosis underwent an emergency CEA soon after thrombolysis; the other two pat ients were treated by means of CEA in the subacute or chromic stage. Plaque rupture and intraplaque hemorrhage were seen in all four patients. All fou r patients recovered completely, and restenosis of the ICA was not shown by means of follow-up angiograms. Conclusion: Intra-arterial thrombolysis followed by CEA may be an effective therapeutic approach for treating acute thrombotic ICA occlusion. The opti mal timing of CEA remains controversial.