Journal of the Neurological Sciences 238 (2005) 101 104 www.elsevier.

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Bilateral common carotid artery occlusion A case report and literature review
Shiao-Lin Lai a, Yi-Chun Chen b, Hsu-Huei Weng c, Sien-Tsong Chen b, Shih-Pin Hsu d, Tsong-Hai Lee b,*
b a Department of Neurology, Chiayi, Chang Gung Memorial Hospital, Taiwan Department of Neurology, Linkou, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan c Department of Diagnostic Radiology, Chiayi, Chang Gung Memorial Hospital, Chiayi, Taiwan d Department of Neurology, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan

Received 25 February 2005; received in revised form 6 May 2005; accepted 29 June 2005 Available online 18 August 2005

Abstract Although unilateral common carotid artery (CCA) occlusion and bilateral internal carotid artery (ICA) occlusion have been reported in the past, bilateral CCA occlusion is rare. The management and mechanism of unilateral CCA occlusion and bilateral ICA occlusion are debatable, but those of bilateral CCA occlusion are largely unknown. Herein, we present a case of bilateral CCA occlusion that had an acceptable outcome with medical treatment. The literature regarding unilateral CCA occlusion, bilateral ICA occlusion and bilateral CCA occlusion is also discussed. Experience implies that the collateral circulation gives rise to the clinical presentation, and may affect the outcome of various managements. Our review and case study may provide new information for future studies of carotid artery occlusion. D 2005 Elsevier B.V. All rights reserved.
Keywords: Common carotid artery; Internal carotid artery; Artery occlusion

1. Introduction The incidence of common carotid artery (CCA) occlusion in stroke patients is estimated to vary from 1% to 5% [1]. It is reported that about 2% of symptomatic carotid artery disease is found to have CCA occlusion [2]. In clinical practice, CCA occlusion is rare and represents less than 1% of all stroke syndromes. Chang et al. [3] reviewed 5400 carotid duplex ultrasonograms, and found that 2.5% had internal carotid artery (ICA) occlusion, 0.24% had unilateral CCA occlusion, and none had bilateral CCA occlusion. In our 812 consecutive angiograms over a 6-year period, only one case of bilateral CCA occlusion was found. We herein report this case of bilateral CCA occlusion, and

review of literature [4 7]. Unilateral CCA occlusion and bilateral ICA occlusion are also reviewed.

2. Case report A 63 year-old male had suffered from dizziness and drop attacks since January 2002. The dizziness occurred with unsteadiness while he was walking, and the drop attacks occurred when he got up to walk. He complained of blurred vision during the attack of severe dizziness, but there was no diplopia or blackout. He denied experiencing headache, focal weakness, tinnitus, or hearing impairment. He also denied having hypertension, diabetes mellitus, or a previous cerebrovascular accident. He smoked 1.5 packs of cigarette per day for 30 years. Due to the dizziness and drop attacks, he came to our hospital for help on March 2002. The neurological examination revealed normal results. The blood examinations revealed no anemia, and no renal and

* Corresponding author. Tel.: +886 3 3281200x8340; fax: +886 3 3288849. E-mail address: thlee@adm.cgmh.org.tw (T.-H. Lee). 0022-510X/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.jns.2005.06.012

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S.-L. Lai et al. / Journal of the Neurological Sciences 238 (2005) 101 104

Fig. 1. (A) Diffusion-weighted image shows hyperintense rim and central hypointense core at the left parietal occipital lobe, indicating a new-onset infarct. (B) The digital subtraction angiogram of the aortic arch shows no opacification of the bilateral common carotid arteries (CCA) from the origins (Left CCA: LCCA, Right CCA: RCCA). (C) The AP view of the digital subtraction angiogram of the left vertebral artery (LVA) shows that there is an anastomosis (ANA) between the vertebral and external carotid artery (ECA), and that the internal carotid artery (ICA) is filled retrogressively from the external carotid artery. (D) The digital subtraction angiogram of the right subclavian artery shows that the thyrocervical trunk (TC) opacified the external carotid artery (ECA) through the occipital artery (OA). The internal carotid artery (ICA) is opacified retrogressively from the external carotid artery.

hepatic dysfunction. Resting EKG showed normal sinus rhythm, and cardiac echo revealed a normal function (ejection fraction 64%). Due to three episodes of dizziness and drop attacks happened in six months, under the suspicion of ischemic attack in the posterior circulation, magnetic resonance image (MRI) study was performed on July 2002, and left parietal occipital area infarction was noted, indicating a new-onset cortical infarct (Fig. 1A). The carotid duplex showed a thrombus formation in the bilateral CCAs with no detectable Doppler flow. Cerebral angiography showed total occlusion at the bilateral CCAs, but the bilateral internal and external carotid arteries were patent due to collateral flow from a vertebral occipital arterial anastomosis (Fig. 1B, C, D). Oral anticoagulant was used to keep international normalized ratio (INR) of prothrombin time around 2 3, and adequate hydration was advised. The patient showed an improvement in the dizziness and there was no drop attack during a two-year period of regular medication at our outpatient clinic.

were 105 cases of unilateral CCA occlusion and 209 cases of bilateral ICA occlusion in the literature [1 3,8 20]. Seven cases of bilateral CCA occlusion were found, including six cases [4 7] reported in the literature and our one case. Among these seven bilateral CCA occlusion cases, five, including ours, were presumed due to atherosclerosis, and the other two were due to complications after irradiation [5,7].

4. Results The clinical profiles of the seven cases with bilateral CCA occlusion were summarized in Table 1 [4 7]. The mean age was 59 T 12 years (35 to 75). Five of the seven patients were men. The three most common vascular risk factors were hypertension (5 cases, 71%), smoking (5 cases, 71%), and dyslipidemia (4 cases, 57%), and none had diabetes. The most common clinical presentation was stroke (5 cases, 71%) with three occurred in the anterior circulation and the other two in the posterior circulation. One of the three surgically treated cases was free of symptoms for five years [4,6,7]. None of the four medically treated cases had a new stroke, but all experienced orthostatic dizziness, including ours, in more than two years of follow-up [5]. The clinical profiles of the bilateral CCA occlusion, unilateral CCA occlusion, and bilateral ICA occlusion patients were summarized in Table 2. In the unilateral

3. Methods We reviewed the 1960 2004 English literature regarding unilateral CCA occlusion, bilateral CCA occlusion, and bilateral ICA occlusion in the Medline service. Key words in the search included common carotid artery occlusion, internal carotid artery occlusion and bilateral. There

S.-L. Lai et al. / Journal of the Neurological Sciences 238 (2005) 101 104 Table 1 Clinical profiles in patients with bilateral common carotid artery occlusion (CCAO) Age/sex 14 25 35 45 56 67 7Our 35/M 76/F 61/F 75/M 40/M 67/M 64/M HT + + + NA + + DM NA Smoking history + + + + + Dyslipidemia + + + + CCAO site Origin NA NA NA Origin Origin Origin Patency of ICA and ECA Bilateral ICAs and ECAs Bilateral ICAs and ECAs Lt ICA and ECA Bilateral ICAs and ECAs N N Bilateral ICAs and ECAs Other cerebral vessel disease (R 50%) NA NA NA NA Lt brachiocephalic trunk, Lt VA Left subclavian N Neurological presentation TIA (AC) Amourosis furax TIA (AC) TIA (PC) stroke (PC) Stroke (AC) Stroke (AC) TIA (PC) stroke (AC) TIA (PC) stroke (PC)

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TX S M M M S S M

+: Yes, : no, N: none, NA: not available, L: Left, B: bilateral, TIA: transient ischemic attack, AC: anterior circulation, PC: posterior circulation, TX: treatment, M: medical treatment, S: Surgery.

CCA occlusion, [1 3,8 14] the outcome of surgical treatment seemed acceptable without mortality, but a few patients suffered from transient ischemic attack (TIA) [9,11] or stroke [11] during a follow-up of more than a year. In the medical treatment group, two patients suffered from recurrent stroke, one with TIA and stroke, and the other had mortality due to stroke [3]. In the bilateral ICA occlusion, [15 20] eight in the medical group suffered from late stroke (17.4%), and the mortality was 9.6% (10 / 104). However, in the surgical group, the rate of late stroke was 10% (2 / 20) and the mortality was 30% (6 / 20).

5. Discussion Our review showed that stroke was the most common clinical presentation in both bilateral CCA occlusion (71%) and bilateral ICA occlusion (66%), but not in unilateral CCA occlusion (32%). However, TIA in the anterior circulation (43%) is more common than stroke (32%) in unilateral CCA occlusion, which is similar to some previous studies [1,2,12 14]. In addition, asymptomatic cases were
Table 2 Comparisons among bilateral CCA occlusion (BCCAO), unilateral CCA occlusion (CCAO) and bilateral ICA occlusion (BICAO) BCCAO Case number (%) 7 Clinical presentation described 7 (100) Asymptomatic* 0 Symptomatic* 7 (100) Stroke 5 (71) TIA (AC) 2 (29) TIA (PC) 3 (43) Visual disturbance 1 (14) Treatment described 7 (100) Medical treatment 4 (57) Surgical treatment 3 (43) No information on treatment 0 CCAO 105 100 6 94 34 45 18 17 78 25 53 27 (95) (5) (90) (32) (43) (17) (16) (74) (24) (50) (26) BICAO 209 113 3 110 76 60 23 29 124 104 19 85 (54) (1) (53) (66) (53) (20) (26) (59) (50) (9) (41)

CCA: common carotid artery, ICA: internal carotid artery, TIA: transient ischemic attack, AC: anterior circulation, PC: posterior circulation, Visual disturbance includes amaurosis fugax, blurred vision or visual loss. *: The asymptomatic and symptomatic refers to the status at the time when the occlusion was discovered.

more common in unilateral CCA occlusion (6%) than in bilateral ICA occlusion (2.6%), while this was not seen in bilateral CCA occlusion (0%). The collateral circulation in bilateral CCA occlusion is mainly the vertebrobasilar (VB) system or the anastomosis [16 19]. The collateral circulation in bilateral ICA occlusion comes from the VB system with cross filling of the middle cerebral artery through the circle of Willis, an external carotid/ophthalmic anastomosis, or a combination of the two [18]. However, the collateral circulation in unilateral CCA occlusion can come from the contralateral carotid system, the thyrocervical or costocervical trunk of the subclavian artery, the VB system, or the ipsilateral external or internal carotid artery [1,3,11,13 15]. The reason why stroke occurred more frequently in bilateral CCA occlusion (71%) and bilateral ICA occlusion (66%) than in unilateral CCA occlusion (32%) may be that unilateral CCA occlusion has a more versatile collateral circulation than bilateral CCA occlusion and bilateral ICA occlusion. The reason for TIA in the posterior circulation occurring more frequently in bilateral CCA occlusion (43%) than in unilateral CCA occlusion (18%) and bilateral ICA occlusion (20%) may be that the VB system is the only collateral supplier and that a hemodynamic instability in the carotid system may cause the phenomenon of stealing from the VB system. Our patient presented several episodes of TIA and stroke in the posterior circulation that may have been due to the shunting of blood from the posterior to the anterior circulation, resulting in insufficient posterior circulation. (Fig. 1C, D). We found that most unilateral CCA occlusion patients (68%) received medical treatment, while most bilateral ICA occlusion patients (84%) preferred surgery. The difference is poorly explained and deserves further investigation. In the management of unilateral CCA occlusion, some literature supports the notion that surgical treatment is suitable for CCA occlusion with a patent ICA or with adequate collateral flow [11,12,15]. However, most studies suggest that a larger series and a longer period of follow-up are necessary to answer the clinical questions regarding the patient with unilateral CCA occlusion [1,2,10,13,14].

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S.-L. Lai et al. / Journal of the Neurological Sciences 238 (2005) 101 104 [8] William M, Blackshear JR, Phillips DJ, Bodily KC, Strandness Jr DE. Ultrasonic demonstration of external and internal carotid patency with common carotid occlusion: a preliminary report. Stroke 1980; 11:249 52. [9] Martin III RS, Edwards WH, Mulherin Jr JL, Edwards Jr WH. Surgical treatment of common carotid artery occlusion. Am J Surg 1993; 165:302 6. [10] Prodore PC, Rob CG, Deweese JA. Chronic common carotid occlusion. Stroke 1981;12:98 100. [11] Collice, DAngelo V, Arena O. Surgical treatment of common carotid artery occlusion. Neurosurgery 1983;12:515 24. [12] Keller HM, Valavanis A, Imhof HG, Turina M. Patency of external and internal carotid artery in the presence of an occluded common carotid artery: noninvasive evaluation with combined Cerebrovascular Doppler examination and sequential computer tomography. Stroke 1984;15:149 57. [13] Belkin M, Mackey WC, Pessin MS, Caplan LR, ODonnell TF. Common carotid artery occlusion with patent internal and external carotid arteries: diagnosis and surgical management. J Vasc Surg 1993;17:1019 27. [14] Maier W, Fradis M, Malatskey S, Krebs A. Diagnostic and therapeutic management of bilateral carotid artery occlusion caused by nearsuicidal hanging. Ann Otol Rhinol Laryngol 1999;108:189 92. [15] Berguer R, McCaffrey JF, Bauer RB. Bilateral internal carotid artery occlusion. Its surgical management. Arch Surg 1980;115:840 3. [16] AbuRahma AF, Copeland SE. Bilateral internal carotid artery occlusion; natural history and surgical alternatives. Cardiovasc Surg 1998;6:579 83. [17] Wade JP, Wong W, Barnett HJ, Vandervoort P. Bilateral occlusion of the internal carotid arteries. Presenting symptoms in 74 patients and a prospective study of 34 medically treated patients. Brain 1987;110: 667 82. [18] Fields WS, Lemak NA. Joint study of extracranial arterial occlusion. J Am Med Assoc 1976;235:2734 8. [19] Nicholls SC, Kohler TR, Bergelin RO, Primozich JF, Lawrence RL, Strandness DE. Carotid artery occlusion: natural history. J Vasc Surg 1986;4:479 85. [20] Faught WE, Van Bemmelen PS, Mattos MA, Hodgson KJ, Barkmeier LD, Ramsey DE, et al. Presentation and natural history of internal carotid artery occlusion. J Vasc Surg 1993;18:512 24.

In our review, [15,16,17,18,19,20] the mortality of bilateral ICA occlusion patients in the medical group was 9.6%, while in the surgical group, the mortality was 30%. The rate of recurrent stroke in the medical group was 17.4% vs. 10% in the surgical group. The above results show that the mortality was lower, while the recurrent stroke rate was higher in the medical group than that in the surgical group. This implies that medical treatment may be safer, but has a higher recurrent stroke rate in bilateral ICA occlusion. In bilateral CCA occlusion, the experience from our patient and previous reports [5] suggests that medical treatment may be an acceptable management. However, it is unknown whether medical or surgical management is optimal for patients with bilateral CCA occlusion.

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