Abstract 4369480: Carotid Occlusion and Thrombolysis: A New Paradigm Shift in Stroke Management

Introduction: Carotid artery occlusion due to plaque rupture carries a high risk of stroke, yet current guidelines do not recommend intervention for occluded or trickle-flow carotid arteries. Thrombolysis occasionally achieves recanalization, revealing underlying critical stenosis that may warrant surgical treatment. We present two cases of stroke with carotid occlusion where post-thrombolysis imaging uncovered severe stenosis, guiding successful endarterectomy. These cases highlight the need for systematic rescanning after thrombolysis to optimize management. Methods: Case 1: A 70-year-old male with hypertension, diabetes, and hyperlipidemia presented with sudden left hemiparesis. CT angiography (CTA) showed occlusion of the right internal carotid artery (ICA) and the M1 segment of the right middle cerebral artery (MCA). Thrombolysis led to complete recanalization, exposing >90% stenosis at the right ICA origin. However, incidental repeat CTA within 24 hours of the thrombolysis confirmed bilateral ICA stenoses (right >90%, left 50–59%). The patient then underwent right carotid endarterectomy (CEA) and recovered without complications. Case 2: A 68-year-old female with hypertension and asthma presented with sudden left hemiparesis. An initial CT scan revealed an occlusion of the right ICA at its origin, likely due to atherosclerotic plaque, and a clot of approximately 3.5mm at the M1/M2 junction of the right MCA. Post-thrombolysis, the patient’s symptoms were resolved, while rescanning on the second day showed 90% right ICA stenosis. The patient underwent CEA and recovered fully. For secondary prevention, both patients received dual antiplatelets, aspirin and clopidogrel. Results: Thrombolysis recanalized occluded ICAs in both cases, unmasking critical stenosis (≥90%) that would have otherwise been missed. Post-CEA, neither patient experienced recurrent stroke at follow-up. Conclusion: Current guidelines lack recommendations for post-thrombolysis carotid imaging, yet our cases demonstrate its utility in identifying surgically treatable lesions. Recanalization after thrombolysis may unmask high-grade carotid stenosis, a treatable stroke risk factor. We advocate for mandatory post-thrombolysis carotid imaging, even in symptomatically resolved patients, to guide timely CEA. This paradigm shift could reduce long-term morbidity by addressing the underlying stenosis, which current protocols overlook.