Acute bilateral internal carotid artery occlusion: A novel approach to management of a catastrophic clinical entity

Background: Acute bilateral internal carotid artery occlusion (ABICAO) represents a rare but potentially-lethal clinical entity. Guidelines for management remain to be established. However, emergent intervention is vital to prevent loss of brainstem reflexes and death.

Purpose: We describe two patients who presented with ABICAO and detail a novel management approach with carotid angioplasty and stent placement. In addition, we review the literature on ABICAO.

Results: Two patients presented within a two-week period with marked neurologic deficits. Imaging studies showed ABICAO. The first patient was initially treated with tissue plasminogen activator. No improvement occurred after two days, prompting the medical team to attempt urgent carotid artery angioplasty and stenting. However, the patient continued to deteriorate and died shortly after the intervention. The second patient underwent emergent carotid artery angioplasty and stenting within hours of presentation and recovered with only mild residual neurologic deficits.

Conclusion: Further research on ABICAO management is required to establish clinical practice guidelines. However, as evidenced by our two patients, endovascular thrombectomy should be performed as early as possible in appropriate candidates; an unfavorable outcome may occur if treatment is delayed. Based on the limited available data, emergent angioplasty and stenting should be considered a first-line intervention for patients presenting with this rare and oft-lethal event.