Tissue plasminogen activator via cross-collateralization for tandem internal carotid and middle cerebral artery occlusion

Abstract

Tandem internal carotid and middle cerebral artery occlusion after carotid dissection predicts poor outcome after systemic thrombolysis. Current treatments include the use of endovascular carotid stenting, which carries with it a high risk of propagating further embolic events and worsening the dissection. New strategies for avoiding the aforementioned side-effects include recanalization using cross-collaterals for delivery of intra-lesional tissue plasminogen activator (tPA). We present two cases that provide further support for this novel approach. Both patients presented with a National Institute of Health Stroke Scale of 20, received intra-arterial tPA via cross-collateralization, and made full recoveries without the need for stenting.

Keywords: Tandem internal carotid artery and middle cerebral artery occlusion, Intra-arterial tissue plasminogen activator, Carotid artery dissection

Core tip: Tandem internal carotid artery and middle cerebral artery occlusions secondary to carotid artery dissections are refractory to stand alone medical management and often result in poor outcomes in patients receiving systemic tissue plasminogen activator (tPA). Cervical carotid stent assisted endovascular thrombolysis is effective, but carries the risk of worsening the dissection and propagating further thromboembolic events. Avoidance of carotid occlusions and recanalization with intra-arterial tPA using cross-collateralization, may be an effective, alternative treatment for patients with tandem internal carotid artery and middle cerebral artery occlusions.