In contrast to data clearly supporting thrombectomy for distal carotid terminus occlusion, complete occlusion of the cervical ICA typically makes mechanical thrombectomy more dangerous. Existing studies suggest chronic total occlusions should receive medical management alone, while there is emerging data to support consideration for selective intervention for acute complete cervical carotid occlusions. It is often difficult to assess the chronicity of a complete occlusion without access to previous imaging.
Pseudo-occlusion is a phenomenon where a CT angiogram has the appearance of a complete occlusion of the cervical ICA due to distally impeded flow. In this case, the cervical ICA is open, and the occlusion involves the distal intracranial carotid artery. Mistaking a pseudo-occlusion for a true occlusion could lead doctors to avoid thrombectomy, leading to poor patient outcomes.
Our patient is a 99-year-old female with dyslipidemia, atrial fibrillation on Rivaroxaban, who came in with acute onset of left hemiparesis, neglect, and dysarthria. Initial NIH 15. CT head showed no acute intracranial findings. CT angiogram demonstrated right cervical ICA occlusion. The patient underwent conventional cerebral angiogram that revealed a patent cervical ICA with right ICA terminus and middle cerebral artery occlusions. Patient underwent medical thrombectomy and TICI III recanalization was achieved. Following thrombectomy, her left hemiparesis, dysarthria, and neglect improved. She was discharged home and functioning independently.