Thrombolytic Therapy for Acute Bilateral Carotid Artery Occlusion

Context: Acute bilateral internal carotid artery occlusion is a rare condition which is frequently associated with prolonged coma or brain death. There is no consesus on which is the optimal therapy for this condition, although there are reports of clinical improvement after mechanical thrombectomy. We present a case report of a patient treated with intravenous thrombolytic therapy. Case Report: A 82 year-old woman with previous history of hypertension and coronary artery disease presented with seizures, followed by coma. There was no description of focal neurological deficit. On examination, patient was comatous, with decebrate posturing after painful stimulus, bilateral myosis, showed absent oculocephalic reflex and absent corneal reflex on the left eye. CT scan showed diffuse hypodensities on the frontal and parietal lobes and on the superior temporal lobes. CT angiography showed occlusion of the right internal carotid artery and of the left common carotid artery. The patient was treated with 72mg of IV alteplase within 4 hours after symptom onset. There was no improvement after 24 hours. A new CT scan showed infarction of all anterior circulation territory. Diagnosis of brain death was made after 48 hours. Conclusions: Acute bilateral carotid artery occlusion is usually associated with poor outcome despite treatment. Endovenous thrombolytic therapy did not lead to clinical improvement on the presented patient. There is limited data on the efficacy of IV thrombolysis and other recanalization therapies for acute bilateral carotid artery occlusion.