Intentional subintimal carotid stenting of internal carotid dissection in a patient with acute ischaemic stroke

False Lumen Stenting to the Acute Occlusive Carotid Artery Dissection Combined With Intracranial Acute Embolic Stroke: A Case Report and Literature Review

Tandem occlusion due to acute cervical carotid artery dissection should be promptly treated with thrombectomy for reperfusion. If the cervical lesion has reached severe stenosis or complete occlusion, balloon angioplasty and, in certain cases, carotid artery stenting should be performed before thrombectomy for the intracranial lesion. Angioplasty or stent placement is performed in the true lumen, but securing the placement is challenging when the true lumen cannot be determined. In contrast, stenting in the false lumen of a carotid artery dissection is considered contraindicated. Although reports on a few similar cases have been published, no obvious complications are known, and the actual risks and outcomes remain unclear. We report the case of a 49-year-old woman with acute ischemic stroke who had tandem occlusion of the cervical internal carotid and middle cerebral arteries due to acute cervical dissection. The cervical lesion was completely occluded with no true lumen, and securing the true lumen proved extremely difficult. Therefore, we performed intracranial thrombectomy via the false lumen, followed by carotid artery stenting from the distal to the proximal true lumen via the false lumen. Six months later, follow-up examinations revealed no obvious complications. Our literature review identified only three reports of stenting in the false lumen of an acute carotid artery dissection, and no apparent complications were reported in any of these cases. Furthermore, the technique of recanalization through the false lumen is well established in chronic total occluded lesions of coronary or peripheral arteries when the true lumen cannot be secured. Therefore, access to the intracranial artery via the false lumen may be acceptable in situations of simultaneous intracranial arterial occlusion requiring rapid recanalization where securing a true lumen is challenging.

Innovative use of a stent retriever for temporary revascularization in acute internal carotid artery dissection

Internal carotid artery dissection is rare but can be a cause of stroke in young people. In a case of revascularization for stroke associated with internal carotid artery dissection, we initially used a stent retriever for thrombectomy. Since an appropriately-sized stent for permanent treatment was not available, we innovatively maintained temporary revascularization with the stent retriever for 90 minutes. Here we demonstrate the adaptability of the stent retriever for emergency care. A 49-year-old man suddenly developed severe right hemiplegia and aphasia. Magnetic resonance imaging showed occlusion of a left internal carotid artery with moderate ischemic changes in the left hemisphere cortex. Angiography showed dissection of the left internal carotid artery at the cervical level and secondary thrombus formation extending into the left middle cerebral artery. We initially attempted thrombectomy with a stent retriever and achieved successful reperfusion in the middle cerebral artery. An appropriately-sized stent was not available in the hospital at that time. During the 90-minute wait, the stent retriever was kept in place and temporary angioplasty was performed in the internal carotid artery dissection to maintain blood flow. Eventually, the stent was delivered and permanent revascularization was achieved. While there is no standard treatment for arterial dissection, endovascular strategies like stenting have been demonstrated to be beneficial. The innovative use of stent retrievers for temporary angioplasty of dissected lesions underscores their efficacy in swift deployment and maintenance of uninterrupted blood flow, particularly during emergency thrombectomy.

Prevalence and treatment of spontaneous intracranial artery dissections in patients with acute stroke due to intracranial large vessel occlusion

OBJECTIVE

To identify the prevalence and therapeutic consequences of spontaneous intracranial artery dissection (IAD) at the acute phase of ischemic stroke.

METHODS

We reviewed clinical and imaging data of consecutive patients attending our center for mechanical thrombectomy (MT) between January 2012 and November 2017. IAD was defined according to published criteria and our own angiographic criteria (no clot following MT, and normalization of the vessel caliber after stenting).

RESULTS

IAD was retrospectively diagnosed in 13/391 (3%) patients (inter-rater agreement κ=0.885, P<0.001). It was an extending of extracranial dissection in 7/13 (54%) patients. A total of 21 recanalization approaches (with or without IV tissue plasminogen activator) were analyzed in 13 patients. A medical approach was used in 7/21 (33%), MT in 7/21 (33%) (stent retriever=6, thromboaspiration=1), and permanent stenting in 7/21 (33%). A rescue recanalization was necessary after 8/14 (57%) approaches without stenting. Stenting was associated with a best rate of recanalization (P=0.001) and with a trend towards a lower rate of ischemic recurrence (P=0.057). Stenting of a circulating false lumen failed to recanalize the artery in two patients. At the last follow-up, no patient had developed a subarachnoid hemorrhage due to the dissection. The outcome at 3 months was favorable in 8/13 (62%) patients. One patient died at 3 weeks owing to a severe cerebellar infarction.

CONCLUSION

IAD is a rare diagnosis that should be systematically considered in patients with intracranial large vessel occlusion, especially in patients with extracranial artery dissection and when MT does not retrieve any clot. Stenting of IAD as first-line approach should be assessed in further studies.