Letter to the Editor
Spontaneous recanalisation of a chronic internal carotid artery occlusion
Recanalización espontánea de una oclusión crónica de arteria carótida interna
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(B) Brain and orbital MRI scan: gadolinium-enhanced T1-weighted axial sequence revealing asymmetrical contrast uptake in the orbital apex and the lateral wall of the right cavernous sinus.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Carreón, S. Muñiz, D. Di Capua, J. Porta-Etessam" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Carreón" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Muñiz" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Di Capua" ] 3 => array:2 [ "nombre" => "J." 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Tejada Meza, J. Artal Roy, R. Martínez García, J. Marta Moreno" "autores" => array:4 [ 0 => array:4 [ "nombre" => "H." "apellidos" => "Tejada Meza" "email" => array:1 [ 0 => "htmeza@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Artal Roy" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Martínez García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Marta Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recanalización espontánea de una oclusión crónica de arteria carótida interna" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1547 "Ancho" => 2833 "Tamanyo" => 339697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Angiography of the SATs showing the occlusion of the right ICA. (B) Angiography of the SATs showing recanalization of the right ICA.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Internal carotid artery (ICA) occlusion is an important cause of stroke: stroke most frequently occurs at the time of occlusion or during the following year, due to low perfusion and cerebral ischaemia or artery-to-artery embolism. In symptomatic stenosis with more than 70% of arterial lumen, selected symptomatic patients with stenosis of more than 50%, or asymptomatic patients with a more than 70% stenosis, endarterectomy or carotid stent placement has been shown to be beneficial for secondary prevention of ischaemic strokes. However, there is no recommended surgical or interventional procedure for carotid occlusion and current recommendations focus on monitoring the contralateral ICA, controlling cardiovascular risk factors, avoiding distal hypoperfusion, and awaiting the development of natural compensatory mechanisms. The possibility of spontaneous recanalisation of the occluded artery is frequently overlooked.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a patient with ICA occlusion which was confirmed by arteriography and followed up with ultrasound. At 18 months, spontaneous recanalisation was observed, with a critical stenosis of that artery, which poses the following questions: How frequent is spontaneous recanalisation of an occluded ICA? When does it happen? How should we react? For how long should we follow up patients with occluded ICAs?</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical case</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a male smoker, aged 52, with type 2 diabetes mellitus and no history of arterial hypertension. He was admitted due to left hemiparesis with faciobrachial predominance and sudden-onset ipsilateral hypoaesthesia, with no language impairment, visual field deficit, or any other associated neurological symptoms. A brain MRI showed an infarct in the right middle cerebral artery (MCA) territory. An echo-Doppler study of the supra-aortic trunks (SAT) revealed an occlusion of the right proximal ICA, a stenosis of less than 50% of the left ICA, and multiple, well-defined atherosclerotic plaques in both carotid sinuses and in the right common carotid artery. These findings were confirmed by angiography of the SATs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), which revealed no radiological findings typical of fibromuscular dysplasia, vasculitis, or arterial dissection. The patient's clinical symptoms stabilised and he was discharged after 8 days of hospitalisation, receiving 300<span class="elsevierStyleHsp" style=""></span>mg of acetylsalicylic acid and 80<span class="elsevierStyleHsp" style=""></span>mg atorvastatin daily.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A follow-up echo-Doppler study of the SATs performed 6 months later showed the same results as those obtained during hospitalisation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Eighteen months after his discharge, the patient visited our department due to a one-week history of dizziness without vertigo and no other associated clinical symptoms. Physical examination revealed no new findings besides the sequelae of the previous cerebral ischaemic event. Vascular risk factors were adequately controlled, although LDL cholesterol levels had decreased only to 90<span class="elsevierStyleHsp" style=""></span>mg/dL. An echo-Doppler study of the SATs revealed a filiform flow in the right ICA (which was occluded in the previous studies). This was confirmed by a new angiography of the SATs, which revealed a critical stenosis secondary to an atherosclerotic plaque at this level (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The right hemisphere was adequately supplied by the left ICA. Lastly, considering the compensatory flow through the collateral arteries of the circle of Willis, the absence of significant interhemispheric asymmetries in the evaluation of haemodynamic reserve, the lack of microembolism detected by the transcranial Doppler ultrasound, and the fact that the patient had remained asymptomatic for the 18 months he was receiving the prescribed treatment, it was decided, in consensus with the interventional neuroradiology and vascular surgery departments, to continue the conservative treatment and periodic follow-up with ultrasound studies.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Spontaneous recanalisation of an occluded ICA was believed to be an infrequent phenomenon; however, the number of published cases and some case series<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1-4</span></a> make us believe that this phenomenon is probably more frequent than thought. It most frequently occurs shortly after the occlusion<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a>; however, published rates of late recanalisation range from 2.3% to 11%.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,6,7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The mechanism by which an occluded ICA is recanalised is subject to debate. Acute occlusions may be recanalised by endogenous lysis, decreased endothelial oedema located at the level of the occlusion, or intraplaque haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> Several hypotheses have been proposed for the recanalisation of chronic occlusions, including the activation of endothelial thrombolytic mechanisms; the histological characteristics of the plaque are also believed to influence the probability of recanalisation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Carotid occlusions have long been described as a stable condition not requiring surgery, unlike severe, symptomatic carotid stenosis (from 70% to 99% of arterial lumen), which may be considered to involve high embolic risk and, therefore, benefit from endarterectomy or angioplasty. After spontaneous recanalisation, an occluded ICA develops severe stenosis; the therapeutic approach to be taken with these patients may change as a result of this, especially in those who have experienced an improvement in the sequelae caused by the previous stroke, and with the brain parenchyma supplied by the occluded ICA being partially preserved.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Intra-arterial angiography is the standard test of reference to observe an occlusion or differentiate it from an ICA with severe stenosis<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a>; however, this is an invasive procedure and may be associated with a certain risk of complication. The availability of the echo-Doppler study of the SATs, and its good sensitivity and specificity to detect ICA pseudo-occlusions (94% and 100%, respectively),<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">9,10</span></a> support the use of this technique for proper follow-up of these patients. In doubtful cases, an echo-Doppler study of the SATs together with a CT angiography or contrast-enhanced MRI angiography may avert the need to perform an angiography.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> The duration and frequency with which follow-up echo-Doppler studies of the SATs should be performed in patients with carotid occlusions are not clear.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This case is an example of the possibility of late spontaneous recanalisation of an occluded ICA. This event may be more frequent than expected. Therefore, we deem it interesting to consider following up patients with an occluded ICA through echo-Doppler studies of the SATs with the aim of promptly detecting candidates to invasive treatment due to recanalisation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Tejada Meza H, Artal Roy J, Martínez García R, Marta Moreno J. Recanalización espontánea de una oclusión crónica de arteria carótida interna. Neurología. 2018;33:66–68.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1547 "Ancho" => 2833 "Tamanyo" => 339697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Angiography of the SATs showing the occlusion of the right ICA. (B) Angiography of the SATs showing recanalization of the right ICA.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Internal carotid artery occlusion: its natural history including recanalization and subsequent neurological events" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Morris-Stiff" 1 => "M. Teli" 2 => "P.Y. Khan" 3 => "S.O. Ogunbiyi" 4 => "C.S. Champ" 5 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 22 | 6 | 28 |
| 2024 September | 46 | 6 | 52 |
| 2024 August | 32 | 2 | 34 |
| 2024 July | 26 | 3 | 29 |
| 2024 June | 29 | 6 | 35 |
| 2024 May | 22 | 7 | 29 |
| 2024 April | 24 | 1 | 25 |
| 2024 March | 43 | 9 | 52 |
| 2024 February | 20 | 5 | 25 |
| 2024 January | 37 | 7 | 44 |
| 2023 December | 45 | 6 | 51 |
| 2023 November | 29 | 9 | 38 |
| 2023 October | 52 | 8 | 60 |
| 2023 September | 19 | 3 | 22 |
| 2023 August | 22 | 10 | 32 |
| 2023 July | 29 | 8 | 37 |
| 2023 June | 28 | 9 | 37 |
| 2023 May | 47 | 4 | 51 |
| 2023 April | 26 | 4 | 30 |
| 2023 March | 30 | 13 | 43 |
| 2023 February | 24 | 5 | 29 |
| 2023 January | 17 | 7 | 24 |
| 2022 December | 26 | 4 | 30 |
| 2022 November | 32 | 8 | 40 |
| 2022 October | 24 | 8 | 32 |
| 2022 September | 21 | 9 | 30 |
| 2022 August | 27 | 11 | 38 |
| 2022 July | 25 | 6 | 31 |
| 2022 June | 29 | 20 | 49 |
| 2022 May | 23 | 6 | 29 |
| 2022 April | 43 | 11 | 54 |
| 2022 March | 29 | 12 | 41 |
| 2022 February | 21 | 7 | 28 |
| 2022 January | 45 | 16 | 61 |
| 2021 December | 36 | 13 | 49 |
| 2021 November | 32 | 18 | 50 |
| 2021 October | 33 | 13 | 46 |
| 2021 September | 35 | 16 | 51 |
| 2021 August | 49 | 12 | 61 |
| 2021 July | 29 | 12 | 41 |
| 2021 June | 22 | 11 | 33 |
| 2021 May | 28 | 9 | 37 |
| 2021 April | 41 | 12 | 53 |
| 2021 March | 30 | 9 | 39 |
| 2021 February | 33 | 6 | 39 |
| 2021 January | 17 | 17 | 34 |
| 2020 December | 22 | 13 | 35 |
| 2020 November | 26 | 7 | 33 |
| 2020 October | 27 | 7 | 34 |
| 2020 September | 25 | 8 | 33 |
| 2020 August | 25 | 6 | 31 |
| 2020 July | 27 | 7 | 34 |
| 2020 June | 27 | 8 | 35 |
| 2020 May | 21 | 13 | 34 |
| 2020 April | 15 | 5 | 20 |
| 2020 March | 23 | 2 | 25 |
| 2020 February | 31 | 10 | 41 |
| 2020 January | 25 | 3 | 28 |
| 2019 December | 48 | 11 | 59 |
| 2019 November | 25 | 15 | 40 |
| 2019 October | 26 | 1 | 27 |
| 2019 September | 26 | 8 | 34 |
| 2019 August | 30 | 7 | 37 |
| 2019 July | 36 | 10 | 46 |
| 2019 June | 91 | 16 | 107 |
| 2019 May | 202 | 22 | 224 |
| 2019 April | 69 | 10 | 79 |
| 2019 March | 26 | 13 | 39 |
| 2019 February | 26 | 4 | 30 |
| 2019 January | 23 | 2 | 25 |
| 2018 December | 15 | 3 | 18 |
| 2018 November | 31 | 0 | 31 |
| 2018 October | 28 | 13 | 41 |
| 2018 September | 26 | 1 | 27 |
| 2018 August | 5 | 1 | 6 |
| 2018 July | 4 | 3 | 7 |
| 2018 June | 7 | 1 | 8 |
| 2018 May | 14 | 1 | 15 |
| 2018 April | 18 | 0 | 18 |
| 2018 March | 2 | 1 | 3 |
| 2018 February | 1 | 2 | 3 |
| 2018 January | 2 | 0 | 2 |
| 2017 December | 1 | 5 | 6 |
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