eMedicine Specialties > Radiology > Vascular/Interventional

Carotid Artery, Stenosis: Follow-up

Author: Lennard A Nadalo, MD, Clinical Professor, Department of Radiology, University of Texas Southwestern Medical School; Consulting Staff, Envision Imaging of Allen and Radiological Consultants Association
Coauthor(s): Michelle C Walters, DO, Consulting Staff, Radiological Consultants Association
Contributor Information and Disclosures

Updated: Jul 23, 2009

Intervention


Intervention in patients with acute CVA is usually based on an attempt to relieve the intracranial thrombosis or an embolization by using thrombolytic agents. The success of such treatment depends on early intervention (during the first 4 h) after the onset of the ischemic event.

With the demonstration of a thrombosis by using perfusion CT or perfusion-diffusion MRI techniques, catheter-directed thrombolytic therapy may be administered by using recombinant tissue-type plasminogen activator (rTPA) or another thrombolytic agent. The success of this therapy remains controversial and is the subject of ongoing research.

Another important area of primary intervention is the treatment of ICA stenosis by using an endovascular stent across the stenotic vessel segment. This treatment results in improved vascular flow rates across the stenotic segment. Suboptimal anatomic results have been reported with the use of the self-expanding Wallstent in this application. Restenosis and recurrent cerebral embolization have been reported following endovascular treatment of carotid stenosis. The increased application of carotid stent placement can be expected to preserve the role of catheter-based cervical-cerebral carotid catheter angiography.

Recent study

 The use of intravenous tissue plasminogen activator (t-PA) for stroke 3-4.5 hours after symptoms has been recommended by the American Heart Association, although time to treatment remains of extreme importance and should not be delayed. The European Cooperative Acute Stroke Study 3 (ECASS 3) showed benefit from t-PA in patients treated 3-4.5 hours after onset of symptoms of stroke.31,32,33,34

Medicolegal Pitfalls

  • Use of interventional therapies in the treatment of acute CVA and carotid stenosis represents complex clinical decision making, which is subject to alternative interpretations of what constitutes a good standard of care.
    • Patients with acute cerebral infarct may have significant morbidity if a large infarction is not corrected on an emergency basis, whereas thrombolytic therapy (intra-arterial or intravenous) may result in fatal intracerebral hemorrhage.
    • The benefits of interventional treatment of patients with carotid stenosis must compare favorably with those of conventional surgery of the carotid artery to avoid medical/legal challenges.
    • Interventional therapies, including angioplasty and angioplasty with stent placement, may result in a hyperperfusion syndrome.
    • Hemorrhage can occur within the zone of hyperperfusion.
    • Preoperative CT scans and MRIs of the brain must be used to exclude focal hemorrhage.
    • Hyperperfusion syndrome has also been described after angioplasty of an MCA stenosis.

See also the Medscape topic Medical Malpractice and Legal Issues.


 


More on Carotid Artery, Stenosis

Overview: Carotid Artery, Stenosis
Imaging: Carotid Artery, Stenosis
Follow-up: Carotid Artery, Stenosis
Multimedia: Carotid Artery, Stenosis
References
Further Reading
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References

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  37. Pexman JH, Barber PA, Hill MD, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol. Sep 2001;22(8):1534-42. [Medline].

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Keywords

carotid artery stenosis, carotid plaque, ulcerated carotid plaque, carotid artery stenosis, carotid arterial stenosis, stroke, brain attack, CVA, cerebrovascular accident, carotid stenosis, carotid bruit, extra cranial carotid occlusive disease

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Contributor Information and Disclosures

Author

Lennard A Nadalo, MD, Clinical Professor, Department of Radiology, University of Texas Southwestern Medical School; Consulting Staff, Envision Imaging of Allen and Radiological Consultants Association
Lennard A Nadalo, MD is a member of the following medical societies: American College of Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Radiological Society of North America, and Texas Radiological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michelle C Walters, DO, Consulting Staff, Radiological Consultants Association
Disclosure: Nothing to disclose.

Medical Editor

Robert A Koenigsberg, DO, MSc, FAOCR, Professor, Director of Neuroradiology, Program Director, Diagnostic Radiology and Neuroradiology Training Programs, Department of Radiology, Hahnemann University Hospital, Drexel University College of Medicine
Robert A Koenigsberg, DO, MSc, FAOCR is a member of the following medical societies: American Osteopathic Association, American Society of Neuroradiology, Radiological Society of North America, and Society of NeuroInterventional Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Douglas M Coldwell, MD, PhD, Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine
Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American College of Radiology, American Heart Association, American Physical Society, American Roentgen Ray Society, Society of Cardiovascular and Interventional Radiology, Southwest Oncology Group, and Special Operations Medical Association
Disclosure: Sirtex, Inc. Consulting fee Speaking and teaching

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR, William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System
Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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