Fluctuating patency of atherosclerotic cervical internal carotid artery treated by carotid endarterectomy successfully: a case report.

Spontaneous recanalization of an atherosclerotic internal carotid artery (ICA) occlusion has been previously reported as a rare phenomenon, but spontaneous re-occlusion shortly after recanalization under antiplatelet therapy has not been documented yet. A 63-year-old man presented with impaired consciousness and left-sided hemiparesis. Magnetic resonance imaging showed new infarction in the right middle cerebral artery territory because of right cervical internal carotid artery occlusion, which became spontaneously patent on computed tomography angiography on the sixth day of admission. So carotid endarterectomy was planned. However, the ICA was recurrently occluded on the preoperative magnetic resonance angiogram three weeks later on admission, which condition was also confirmed during the subsequent surgery. In patients with severe ICA stenosis, patency may dynamically change even under antiplatelet therapy.

Tenecteplase or Alteplase Better in Patients with Acute Ischemic Stroke Due to Large Vessel Occlusion: A Single Center Observational Study.

Background and Objectives: The study aimed to investigate the efficacy of intravenous thrombolysis with Tenecteplase before thrombectomy for acute ischemic stroke (AIS) patients compared with previous results using Alteplase. Previous trials for Tenecteplase have indicated an increased incidence of vascular reperfusion. In April 2021, we started to primarily give Tenecteplase to patients eligible to undergo thrombectomy. Materials and Methods: In this retrospective observational single-center non-randomized study, we analyzed directly admitted patients with AIS who had occlusion of the internal carotid, middle cerebral, or basilar artery and who underwent thrombectomy, as well as the recanalization rate for these patients at the first angiographic assessment (mTICI score 2b-3), and complications. Results: We included 184 patients (demographic characteristics did not differ between Tenecteplase and Alteplase groups (mean age 68.4 vs. 73.0 years; female sex 53.3% vs. 51.1%, NIHSS 14 (IQR 4-26) vs. 15 (2-31). Forty-five patients received Tenecteplase and 139 Alteplase before endovascular treatment (EVT). Pre-EVT (endovascular treatment) recanalization was more likely to occur with Tenecteplase rather than Alteplase (22.2% vs. 8.6%, p = 0.02). Successful reperfusion (mTICI 2b-3) after EVT was achieved in 155 patients (42 (93.4%) vs. 113 (81.3), p = 0.07). Hemorrhagic imbibition occurred in 15 (33.3%) Tenecteplase-treated patients compared with 39 (28.1%) Alteplase-treated patients (p = 0.5). Patients treated with Tenecteplase had higher odds of excellent functional outcome than Alteplase-treated patients (Tenecteplase 48.6% vs. Alteplase 26.1%; OR 0.37 (95% CI 0.17-0.81), p = 0.01). Conclusions: Tenecteplase (25 mg/kg) could have superior clinical efficacy over Alteplase for AIS patients with large-vessel occlusion (LVO), administered before EVT. The improvement in reperfusion rate and the better excellent functional outcome could come without an increased safety concern.

Chronic total occlusion and spontaneous recanalization of the internal carotid artery: Natural history and management strategy.

OBJECTIVES: Spontaneous recanalization of a chronic total occlusion of the extra-cranial internal carotid artery is an under-reported clinical entity. This paper reviews the different etiologies of internal carotid artery occlusion, its natural course, as well as the significance and our recommendations for the management of spontaneous internal carotid artery recanalization. METHODS: A review of literature on etiology, diagnosis, and treatment of internal carotid artery occlusion and recanalization was conducted. PubMed database was searched using the terms "internal carotid occlusion" and "recanalization". Articles were reviewed and studies involving the management of internal carotid artery occlusion and spontaneous recanalization were included. We subsequently developed a management algorithm for chronic total occlusion of the internal carotid artery and spontaneous recanalization of such lesions based on the available evidence. RESULTS: Common etiologies of chronic total occlusion of the internal carotid artery include carotid atherosclerotic disease, cardioembolic, and carotid dissection. Progression of an asymptomatic to symptomatic occlusion is estimated at 2-8% annually. Well-compensated patients can be asymptomatic. In others, clinical symptoms range from ipsilateral or global hypoperfusion to embolic stroke in some cases of spontaneous recanalization. Spontaneous recanalization occurs in 2.3-10.3% of patients but rarely results in a cerebrovascular event. CONCLUSIONS: Progression of an asymptomatic chronic total occlusion of the internal carotid artery to symptomatic is infrequent. The management algorithm of chronic total occlusion of the internal carotid artery and spontaneous recanalization of the internal carotid artery must be tailored to the patient based on symptoms, etiology of the lesion, imaging findings, surgical risk, and reliability for follow-up.

Acute symptomatic extracranial internal carotid occlusion - natural course and clinical impact.

Background: To assess the vascular and clinical course of acute symptomatic extracranial internal carotid artery (ICA) occlusion. Patients and methods: Patients with an acute ischemic event in the anterior circulation and corresponding extracranial ICA occlusion at CT angiography and/or color-coded duplex sonography underwent recurrent duplex follow-up for detection of spontaneous recanalization. Stroke recurrence and functional outcome 4.5 months after the ischemic index event assessed by modified Rankin scale served as secondary outcome parameters. Results: 133 patients (91 men, mean age 62.3 years, SD 10.8) demonstrated symptomatic occlusion of the extracranial ICA with open intracranial ICA and open middle cerebral artery and were followed-up for spontaneous recanalization. Twenty-eight recanalized spontaneously, 25 to high-grade focal stenosis within 12 days, revealing an early cumulative recanalization rate of 23 %. Detection of recanalization was independently associated with de novo dual anti-platelet therapy (adjusted odds ratio [OR], 3.24; 95 % confidence interval [CI], 1.34 to 7.80). Ischemic recurrence occurred in 16 patients, of which 10 deemed to be embolic and 5 hemodynamic. Spontaneous ICA recanalization and an exhausted cerebrovascular reserve in the hemisphere distal to the occluded ICA were both independently associated with the occurrence of a recurrent ischemic event at Cox regression. An increasing NIHSS score at admission, a decreasing middle cerebral artery flow velocity and an ischemic recurrence independently predicted poor outcome (modified Rankin scale 3 to 6) in multivariate analysis. Conclusions: Acute symptomatic extracranial ICA occlusion is an unstable condition with frequent spontaneous recanalization to severe stenosis and early embolic stroke recurrence, demanding appropriate prevention especially in those patients with only mild deficit.

[Value of fibrinogen to albumin ratio on predicting spontaneous recanalization of infarct-related artery in patients with acute ST-segment elevation myocardial infarction].

Objective: To investigate the value of fibrinogen to albumin ratio (FAR) at admission on predicting spontaneous recanalization of infarct-related artery (IRA) in patients with acute ST-segment elevation myocardial infarction (STEMI). Methods: Clinical data from 255 acute STEMI patients ((61.1±11.2) years old, 189 males) who underwent emergency coronary angiography within 12 hours in our hospital from December 2015 to April 2018 were retrospectively analyzed. The acute STEMI patients were divided into non-spontaneous recanalization group (thrombolysis in myocardial infarction (TIMI) flow grade 0-1, 203 cases) and spontaneous recanalization group (TIMI flow grade 2-3, 52 cases). Multivariate logistic regression analysis was used to evaluate related factors of IRA spontaneous recanalization. The receiver operating characteristic (ROC) curve was used to evaluate the value of FAR in predicting spontaneous coronary recanalization. Results: There was no significant difference in age,gender, hypertension, diabetes, smoking,systolic blood pressure,diastolic blood pressure,heart rate, duration of chest pain, type of infarction, infarct-related artery, door-to-balloon time, and drug used before admission between non-spontaneous recanalization group and spontaneous recanalization group (all P>0.05). The FAR and high-sensitivity C-reactive protein levels were significantly lower in the spontaneous recanalization group than in the non-spontaneous recanalization group (8.20±1.85 vs. 11.02±2.75, P<0.001; (6.87±3.36) g/L vs. (8.51±3.72) g/L, P=0.004). Multivariate logistic regression analysis showed that FAR (OR=0.492, 95%CI 0.354-0.686, P<0.001), serum uric acid (OR=0.994, 95%CI 0.989-0.999, P=0.018) and high-sensitivity C-reactive protein (OR=0.774, 95%CI 0.614-0.975, P=0.030) were independent negative correlation with spontaneous recanalization of infarct-related artery in patients with acute STEMI. The ROC curve showed that the area under the curve of FAR predicting spontaneous recanalization of infarct-related artery in patients with acute STEMI was 0.807 (95%CI 0.630-0.758, P<0.001), and the diagnostic threshold was 9.26, the sensitivity was 76.9%, the specificity was 75.9%. Conclusion: The level of admission FAR has certain predictive value for spontaneous recanalization of infarct-related arteries in patients with acute STEMI.

Correlation of ABO blood groups with spontaneous recanalization in acute myocardial infarction.

OBJECTIVES: Although previous studies have demonstrated the relationship between ABO blood groups and cardiovascular disease, the association of ABO blood type with spontaneous recanalization (SR) in patients with acute myocardial infarction (AMI) has not been previously investigated. METHODS: We performed an initial exploratory study on the association of ABO blood groups with the presence of SR in 1209 patients with AMI. They were divided into two groups according to the thrombolysis in myocardial infarction (TIMI) grades: no-SR group (TIMI 0-1, n = 442) and SR group (TIMI 2-3, n = 767). To confirm our primary findings, data from a second AMI population (n = 200) was analyzed. RESULTS: In the initial data, SR group had a significantly higher percentage of blood type O and a lower percentage of blood type A compared to the no-SR group. Multivariate logistic regression analysis showed that blood type O was positively associated with SR (odds ratio: 1.40, 95% confidence interval: 1.05-1.87, p = .02), and this finding was confirmed in our second population. CONCLUSION: The present study demonstrates that blood type O was independently and positively associated with an open culprit artery in patients with AMI, suggesting that the ABO blood type is not only associated with the susceptibility to coronary artery disease but also to spontaneous reperfusion in AMI patients.

Predictive Factors for the Spontaneous Recanalization of Large and Middle Cerebral Arteries after Acute Occlusion.

OBJECTIVE: This study aims to investigate the predictive factors for the spontaneous recanalization of occluded arteries in patients with acute ischemic stroke. METHODS: A total of 139 patients with consecutive acute ischemic stroke were enrolled from June 2010 to June 2013. The clinical and biochemical parameters were measured in each participant. Occlusion and recanalization of the carotid artery, the middle cerebral artery, and the vertebral and basilar arteries were identified by using computed tomographic angiography or digital subtraction angiography. RESULTS: Among the 139 patients, 23 showed spontaneous recanalization, whereas 116 did not. In the patients with spontaneous recanalization, the proportion of atrial fibrillation was significantly lower (0% versus 29.31%, P= .01), whereas the proportion of stage 3 hypertension was significantly higher (60.87% versus 32.76%, P= .01) than that of those without recanalization. Logistic regression analysis showed that the proportion of atrial fibrillation was negatively (odds ratio [OR]: .117, 95% confidence interval [CI]: .015-.918, P= .04) associated with spontaneous recanalization, whereas the proportion of stage 3 hypertension was positively (OR: 4.316, 95% CI: 1.533-12.154, P= .01) associated with it. CONCLUSIONS: Atrial fibrillation is associated with reduced spontaneous recanalization of the large and middle cerebral arteries in patients after acute ischemic stroke-induced occlusion, whereas stage 3 hypertension may contribute to the promotion of the recanalization.

Late spontaneous recanalization of symptomatic atheromatous internal carotid artery occlusion.

INTRODUCTION: Definitive treatment of symptomatic atheromatous internal carotid artery occlusion remains controversial, as far as in rare cases, late spontaneous recanalization has been seen. METHODS: We consecutively studied 182 patients (January 2003 to August 2012) with an ischemic stroke in the internal carotid artery territory and diagnosis of atheromatous internal carotid artery occlusion during hospitalization. FINDINGS: Seven patients presented a late spontaneous recanalization (>3 months) of the internal carotid artery. We described therapeutic attitude according to usual care in these patients. CONCLUSIONS: The authors attempt to highlight the unusual condition of recanalization after a symptomatic atheromatous chronic internal carotid artery occlusion. If these patients can be treated similar to patients with asymptomatic carotid pathology, then this needs to be clarified. However, due to the risk of ipsi- and contralateral ischemic strokes, revascularization techniques should be considered in certain cases. More studies are needed to establish the most appropriate therapeutical approach in order to avoid arbitrary treatment of these patients.

New Cortical Spot Cerebral Infarction Out of Border Zone in ICA Occlusion Suggests Recanalization: A Case Report.

Internal carotid artery occlusion rarely recanalizes spontaneously. Awareness of signs of recanalization is important, as it may necessitate changing the treatment strategy. We report a case of new cortical infarction outside the border zone, which led to the realization of internal carotid artery recanalization and revascularization. A 76-year-old woman presented with mild dysarthria. Magnetic resonance imaging showed cerebral infarction in the left-hemispheric border zone and occlusion of the internal carotid artery origin. Cerebral angiography performed showed complete occlusion of the internal carotid artery origin and intracranial collateral blood flow from the external carotid artery through the ophthalmic artery. She was diagnosed with infarction due to a hemodynamic mechanism caused by internal carotid artery occlusion and was treated with supplemental fluids and antithrombotic drugs. Four days after hospitalization, the right paralysis worsened and a new cerebral infarction was observed in the cortex, outside the border zone. This infarction appeared to be embolic rather than hemodynamic; thus, we suspected recanalization of the internal carotid artery. The patient underwent emergency cerebral angiography again, which revealed slight recanalization. Thus, emergency revascularization and carotid artery stenting were performed. New cortical infarcts outside the border zone in patients with complete internal carotid artery occlusion is an important finding, suggesting spontaneous recanalization of the occluded internal carotid artery.

Case Report: Recanalization of Branch Retinal Artery Occlusion Due to Microthrombi Following the First Dose of SARS-CoV-2 mRNA Vaccination.

Background: We report on a patient with a branch retinal artery occlusion (RAO) and its recanalization based on multimodal retinal and angiographic images after he was administered the first dose of the SARS-CoV-2 mRNA vaccine. Case summary: A 64-year-old man complained of a right, painless, inferior field defect 3 days after the first dose of BNT162b2 vaccination. Fundus examination revealed decolorization of the right upper macula, including microthrombi in the superior proximal branch of the retinal artery. Optical coherence tomography angiography revealed upper macular hypoperfusion. Fluorescein angiography revealed prolonged arteriovenous transit to the macula. After paracentesis with antiplatelet medications, the artery was recanalized as the thrombi dissolved, and the right visual field was recovered. Re-occlusion did not occur during the 3 months after the second mRNA vaccination. Conclusion: Non-embolic thrombotic RAO may develop shortly after the SARS-CoV-2 mRNA vaccine. Ophthalmologists should consider RAO as a possible post-vaccination adverse event. The temporal association between mRNA vaccination and RAO onset with evidence of microthrombi might provide additional clues to elucidate the unpredictive arterial thrombosis following SARS-CoV-2 mRNA vaccination.

Optical Coherence Tomography-OCT for Characterization of Non-Atherosclerotic Coronary Lesions in Acute Coronary Syndromes.

Cardiovascular diseases are the main cause of death worldwide, with coronary artery disease being the predominant underlying etiology. The most prevalent coronary lesions are represented by the atherosclerotic plaques, in more than 85% of cases, but there are several other non-atherosclerotic lesions such as spontaneous coronary artery dissection and/or hematoma and spontaneous recanalization of coronary thrombus, which are less common, approximately 5% of cases, but with similar clinical manifestations as well as complications. There are insufficient data regarding the pathological mechanism, true prevalence and optimal treatment of these kind of coronary lesions. Optical coherence tomography (OCT) is an intracoronary imaging technique, developed in order to overcome the diagnostic limitations of a standard coronary angiography and has an extremely high resolution, similar to that of a usual histological evaluation of a biopsy sample, thus, OCT provides a histological-like information, but in a in vivo environment. The aim of this article is to review the current knowledge regarding non-atherosclerotic coronary lesions, with an emphasis on the importance of OCT for optimal identification, characterization of pathogenic mechanisms and optimal treatment selection.

Return of the Left Internal Mammary Artery.

Competitive flow from a non-critical native vessel leading to longitudinal narrowing/atresia of the left internal mammary artery (LIMA) is described as "the string phenomenon." We describe spontaneous recanalization of an atretic LIMA following coronary artery bypass grafting for multivessel coronary artery disease.

Optical Coherence Tomography for In Vivo Identification, Characterization and Optimal Treatment of Spontaneous Recanalization of Coronary Thrombus.

BACKGROUND/AIM: Spontaneous recanalization of coronary thrombus (SRCT) is a rare in vivo appearance, with a nonspecific angiographic aspect. The aim of this study was to investigate the importance of optical coherence tomography (OCT) use for SRCT identification, characterization of pathogenic mechanisms and optimal treatment. PATIENTS AND METHODS: We retrospectively analyzed all patients with angiographic suspicion of SRCT who underwent coronary angiography for suspected coronary artery disease and afterward investigated by OCT imaging. RESULTS: We identified 28 cases with angiographic suspicion of SCRT (0.41% of CA) and confirmed it in 4 patients (0.05% of CA). OCT provided insight about the underlying SRCT mechanism: possible complicated atherosclerotic plaques in two cases and, respectively, spontaneous coronary artery dissection in other two cases. OCT provided accurate lesion assessment and offered optimal PCI materials selection. CONCLUSION: Besides providing the diagnosis, OCT also improved characterization of SRCT pathogenic mechanisms, in the four confirmed SRCT cases, supporting the role of coronary wall in situ complications, namely dissection of an atherosclerotic plaque or spontaneous dissection of a normal coronary wall.

Acute Recanalization of a Partially Thrombosed Large Intracranial Aneurysm.

BACKGROUND: Thrombosed large intracranial aneurysms (TLIAs) are not continuously contemplated as stable lesions. Spontaneous recanalization of completely occluded large intracranial aneurysms has been described previously. CASE DESCRIPTION: We report a middle-aged patient presenting with agitation, acute headache, visual field defects, and left hemiparesis. A large thrombosed posterior communicating (PCom) artery aneurysm was identified with an infarct at the same arterial territory on neuroimaging studies. Digital subtraction angiography (DSA) performed 1 week later demonstrated complete recanalization of the TLIA. It was treated endovascularly with coils. The patient returned several days later with augmenting headaches due to quadrigeminal system subarachnoid hemorrhage. Repeat DSA showed filling of the coiled aneurysm from the internal carotid artery injection. The PCom artery was catheterized and deconstructed. The patient was discharged to home with no additional neurologic deficits. CONCLUSIONS: TLIAs are insidious vascular lesions. They can cause nerve or vessel damage by a mass effect or through ischemic stroke by emitting emboli into distal vasculature. We advise close periodic radiologic follow-up for TLIAs.

Delayed spontaneous recanalization of chronic total occlusion of left anterior descending artery after attempted but failed revascularization during percutaneous coronary intervention.

Chronic total occlusion (CTO) of coronary artery remains the Achilles heel of the interventional cardiologist and is present in a significant proportion of referrals for coronary artery bypass graft surgery (CABG); however, with the development and standardization of modern CTO recanalization techniques, it has been able to achieve excellent success while coping with lesions of increasing complexity. Nevertheless, failure to recanalize despite the development of new techniques still remains one of the challenges in the field of interventional cardiology. Spontaneous recanalization has been described in nonocclusive coronary artery dissections in detail; none has addressed the possibility of spontaneous recanalization after failed percutaneous coronary intervention (PCI). We report a case of spontaneous but delayed recanalization of CTO of left anterior descending artery 3 years after attempted but failed revascularization during PCI.

Prognosis of patients with late spontaneous recanalization of the atherosclerotic occlusion of internal carotid arteries: A pilot case series.

Late spontaneous recanalization (SR) of an occluded internal carotid artery (ICA) has been rarely reported and the prognosis of affected patients remains elusive. In the present study, the incidence of late SR of atherosclerotic occlusion of the ICA and associated outcomes were assessed in a single center. A total of 36 patients with ICA occlusion, who underwent carotid artery stenting or vertebral artery stenting in arteries other than the occluded ICA, were prospectively included and followed up for ≥18 months. SR was diagnosed by color Doppler ultrasound imaging. The incidence of late SR, the functional outcome and the incidence of adverse cardiovascular events in these patients were evaluated. During the follow-up, three patients had late SR of the occluded ICA (8.3%). All patients had vascular events prior to the confirmation of late SR of the ICA. Subsequent to SR, the patients were clinically stable with preserved functional ability, based on the Modified Rankin Scale. Of these patients, one suffered from re-occlusion of the recanalized ICA without presenting with any novel significant symptoms. In conclusion, patients with late SR of the ICA appear to have preserved functional ability and favorable clinical outcomes. Large-scale cohorts are required to determine the clinical characteristics that contribute to the incidence of late SR of the ICA.

Spontaneous recanalization of an occluded middle cerebral artery in a patient with moyamoya.

Moyamoya disease is a rare cerebrovascular disorder that is characterized by progressive stenosis of the distal portion of the internal carotid artery and its main branches. Here the authors present the first case of spontaneous recanalization of an occluded middle cerebral artery in a woman with moyamoya who had not undergone surgical or endovascular treatment. Although the exact mechanisms remain unclear, spontaneous recanalization in moyamoya could be considered a possible phenomenon. Thus, the neurosurgeons should always pay attention to the pathological variety of dynamic changes in the cerebrovascular structure in moyamoya.

Spontaneous recanalization of the basilar artery with conservative management months after symptom onset.

Basilar artery occlusion may be associated with a poor prognosis in the absence of recanalization. Choices in aggressive treatment for this potentially fatal condition vary from intra-arterial or intravenous thrombolysis, endovascular removal, or a combination of the two, with adjunct anti-coagulation therapy. These therapies have proven to be effective in recanalization, whereas conservative management with anti-coagulants alone has had more limited success in the literature. We report a case of basilar artery occlusion managed conservatively with unfractionated heparin, resulting in complete recanalization 3.5 months after symptom onset. Conservative management of basilar artery occlusion with unfractionated heparin was associated with complete recanalization long after symptom onset.