Endovascular stent therapy for extracranial and intracranial carotid artery dissection: single-center experience

Medical and interventional outcome of dissection of the cervical arteries: Systematic review and meta-analysis

OBJECTIVE

The management of cervical artery dissections (CADs) is poorly standardized given the scarce number of prospective studies comparing medical and interventional approach to CAD. The aim of the present study is to perform a systematic review and meta-analysis of studies on the treatments of CAD.

METHODS

Systematic review and meta-analysis (pre-registered on PROSPERO [CRD42022297512] are performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA] guidelines searching in three different databases [PubMed, Embase and Cochrane Database]) of studies on medical or interventional approach to CAD. Only prospective studies were selected to reduce the risk of bias for the primary meta-analysis. Secondarily, retrospective studies were also included. The aim was to assess the rate of stroke and of stroke/death/bleeding (major or intracranial) by Der Simonian-Laird weights of random effects model.

RESULTS

After screening 456 articles, 6 prospective and 22 retrospective studies were identified. Two randomized controlled trials and five retrospective studies comparing antiplatelet (APT) vs oral anticoagulant therapy (OAC) for CAD were identified, as well as four prospective and 17 retrospective single-arm studies evaluating stenting for CAD. In the meta-analysis of randomized controlled trials comparing APT vs OAC, 444 patients were considered, and a borderline significant association was identified in terms of stroke/death in the APT vs OAC groups (odds ratio [OR], 5.6; 95% confidence interval [CI], 0.94-33.38; P = .06; I2 = 0%). No differences were found for the stroke/death/bleeding outcome (OR, 1.25; 95% CI, 0.19-8.18; P = .81; I2 = 0%) between the two treatments. In the meta-analysis including also retrospective studies, overall risk of bias was considered "serious," and 4104 patients were included with no differences in APT vs OAC for stroke (OR, 1.06; 95% CI, 0.53-2.11; P = .29; I2 = 18%); no other comparisons were possible. The pooled meta-analysis of prospective studies on stenting for CAD included four series, for a total of 68 patients, in whom stenting was adopted primarily after failed medical therapy or after traumatic dissection. The pooled rate of stroke/death was 7% (95% CI, 3%-17%; I2 = 0%). The analysis of moderators identified a significant inverse association between the percentage of traumatic dissection and a reduction in postoperative stroke (Y = -1.60-2.02X; P = .03). The pooled rate of the composite endpoint of stroke/death/ or major bleeding was 8% (95% CI, 3%-18%; I2 = 0%). Secondarily, the meta-analysis also included 17 retrospective studies with overall 457 patients and showed a 2.1% pooled rate of stroke/death (95% CI, 1.0%-3.3%; I2 = 0%) and 3.2% stroke/death/bleeding (95% CI, 1.8%-4.7%; I2 = 0%).

CONCLUSIONS

Few prospective studies on CAD treatment are present in literature. APT and OAC seem to have similar efficacy in reducing the recurrence of stroke after CAD. No definitive conclusion can be drawn for stenting, due to the low number of studies available. More prospective studies are necessary to evaluate its potential additional value over medical therapy alone in the early phase after CAD.

Association between cervicocerebral artery dissection and tortuosity - a review on quantitative and qualitative assessment

Cervicocerebral artery dissection stands out as a significant contributor to ischemic stroke in young adults. Several studies have shown that arterial tortuosity is associated with dissection. We searched Pubmed and Embase to identify studies on the association between arterial tortuosity and cervicocerebral artery dissection, and to perform a review on the epidemiology of cervicocerebral artery tortuosity and dissection, pathophysiology, measurement of vessels tortuosity, strength of association between tortuosity and dissection, clinical manifestation and management strategies. The prevalence of tortuosity in dissected cervical arteries was reported to be around 22%-65% while it is only around 8%-22% in non-dissected arteries. In tortuous cervical arteries elastin and tunica media degradation, increased wall stiffness, changes in hemodynamics as well as arterial wall inflammation might be associated with dissection. Arterial tortuosity index and vertebrobasilar artery deviation is used to measure the level of vessel tortuosity. Studies have shown an independent association between these two measurements and cervicocerebral artery dissection. Different anatomical variants of tortuosity such as loops, coils and kinks may have a different level of association with cervicocerebral artery dissection. Symptomatic patients with extracranial cervical artery dissection are often treated with anticoagulant or antiplatelet agents, while patients with intracranial arterial dissection were often treated with antiplatelets only due to concerns of developing subarachnoid hemorrhage. Patients with recurrent ischemia, compromised cerebral blood flow or contraindications for antithrombotic agents are usually treated with open surgery or endovascular technique. Those with subarachnoid hemorrhage and intracranial artery dissection are often managed with surgical intervention due to high risk of re-hemorrhage.

Successful carotid stenting of a carotid arterial dissection after straightening the tortuosity using an inflated balloon guiding catheter and the delivery wire of an anchored stent retriever

The authors present a patient with carotid dissection in a tortuous arterial segment who successfully underwent carotid artery stenting (CAS) by straightening the tortuosity using an inflated balloon guiding catheter (BGC) and a stent retriever (SR). A 56-year-old man was transferred to our institute with right hemiparesis and a National Institutes of Health Stroke Scale score of 9. Magnetic resonance imaging showed left internal carotid artery (ICA) occlusion and ischemic change in the parietal lobe. Emergent angiography revealed tapered extracranial ICA occlusion sugg carotid artery dissection (CAD). CAS was attempted for CAD due to a mismatch of the motor area on clinical imaging. However, several attempts to navigate the stent delivery system over a guidewire failed. Therefore, we deployed a Trevo NXT ProVue SR (3 × 32 mm) in the middle cerebral artery, inflated a BGC, and then pulled on both to straighten the tortuous carotid artery, which resulted in successful navigation of the stent delivery system. The patient's symptoms improved after the recanalization. This case demonstrates the utility of a technique for navigation of a stent delivery system through a tortuous carotid artery in which the tortuosity is straightened by pulling on an inflated BGC and the delivery wire of the SR.

Cervical Artery Dissections-A Demographical Analysis of Risk Factors, Clinical Characteristics Treatment Procedures, and Outcomes-A Single Centre Study of 54 Consecutive Cases

Cervical artery dissections (CAD) are a common cause of ischemic cerebrovascular events among the younger and middle-aged population. Altogether, CAD counts for up to 15% of all causes of stroke in patients aged 50 or younger. Among the known etiological causes, especially addressing the younger population with mechanical traumas and whiplash injuries are regarded as the main culprits. However, cases of spontaneous dissection are also widespread, with risk factors such as hypertension, migraine, and lifestyle factors increasing the risk of occurrence. Clinically, the symptoms associated with a cerebrovascular event caused by CADs are highly variable and can be classified as either compressive symptoms (such as Horner's syndrome and cervical pain) or stroke syndromes attributable to cerebral ischemia. Therefore, establishing an early diagnosis might be particularly challenging as it requires particular attention and quick clinical reasoning when interviewing the patient. With these certain particularities, our main focus was to conduct a prospective study involving up to 54 patients who were diagnosed with CAD in our clinical facility between January 2015 and December 2022, with the focus of assessing certain individual parameters attributable to each patient and their influence and prognosis value for their short and long term evolution. An important emphasis was placed on parameters such as topographical localization, clinical presentation, severity of the questioned cerebrovascular event, outcomes, and causative factors. Statistical validity tools were applied when possible.

A case of intracerebral hemorrhage due to cerebral hyperperfusion after stenting for acute cervical carotid artery dissection

Urgent carotid artery stenting (CAS) is effective for treatment-resistant cervical internal carotid artery dissection (CICAD). We experienced a 37-year-old woman who presented with sudden onset of cervical pain, blurred vision in the right eye, and numbness in the left upper and lower extremities. Due to neurological deterioration resulting from hemodynamic impairment, urgent CAS was performed under general anesthesia. Brain perfusion single-photon emission computed tomography performed immediately after CAS showed increased blood flow in the right hemisphere despite no evidence of hemorrhage or ischemic lesion on brain computed tomography (CT). Systolic blood pressure was therefore strictly controlled below 110 mm Hg perioperatively. However, the day after CAS, a follow-up CT showed intracerebral hemorrhage in the right temporal lobe. Urgent CAS in patients with progressive deterioration of hemodynamic impairment caused by CICAD may induce intracerebral hemorrhage due to cerebral hyperperfusion. Care should be taken to recognize and manage this phenomenon during the perioperative period.

Malignant ischemic stroke revealing a spontaneous carotid dissection in a young patient: Rare case report

Ischemic stroke remains today a major health problem that requires adequate management and etiological research. The prevalence in young people has increased. This article is a case report of a 37-year-old female diabetic patient who had an acute ischemic stroke due to spontaneous dissection of the right internal carotid artery. The article discusses the epidemiology, pathophysiology, diagnosis, and treatment of cervical artery dissection, which is a common cause of stroke in young patients. The use of antiplatelet and anticoagulant therapy, as well as endovascular and surgical interventions, is also discussed. Spontaneous carotid bulb dissection is an emergency in ischemic stroke in young people. The prognosis depends on the severity of the initial injury and the extent of collateral circulation, with successful recovery in 75% of cases.

Results of Angioplasty With Double-Layer Mesh Stent and Protection Systems of the Extra- and Intracranial Dissection of Cephalic Arteries

PURPOSE

Although a majority of cervical artery dissections can be managed conservatively, patients presenting with cerebral embolization or significant stenosis require a more aggressive approach. However, complications associated with endovascular repair are quite frequent and optimal interventional technique still remains to be established.

MATERIALS AND METHODS

The aim of this post hoc survey was to analyze results of endovascular treatments for symptomatic dissections of the internal carotid and vertebral arteries, which were performed under protection and with the use of double-layer mesh stents. During endovascular procedure catheters, stents and protection systems were tailored according to the angioarchitecture of dissection, particularly to its location, length and coexisting stenotic or aneurysmatic lesions. We evaluated retrospectively midterm and late results of endovascular treatment of 25 patients presenting with symptomatic dissection of cervical arteries, including 11 patients with dissections of intracranial segments of the internal carotid artery. Follow-ups were scheduled 1, 3 and 6 after the procedure, and then every 6 months. Control computed tomography (CT) or digital subtraction angiography (DSA) arteriographies were performed 1-6 months and 12 months after endovascular repair.

RESULTS

There were no periprocedural major adverse events. All patients completed the 12-month follow-up. There were neither fatalities nor new neurologic adverse events at the 30-day follow-up, and no such adverse events during long-term follow-up. At 12-month follow-up, in all patients, angiographies revealed patent stents, full coverage of lesions by stents and complete thrombotic closure of the pseudoaneurysms.

CONCLUSIONS

A tailored endovascular management of symptomatic dissection of cervical arteries is safe and efficient, also in a long run.

Surgical and radiological interventions for treating symptomatic extracranial cervical artery dissection

BACKGROUND

Cervical artery dissection (CeAD) is a pathological bleed or tear, or both, in the wall of the carotid or vertebral arteries as they course through the neck, and is a leading cause of stroke in young people.

OBJECTIVES

To assess the effectiveness of surgical and radiological interventions versus best medical treatment alone for treating symptomatic cervical artery dissection.

SEARCH METHODS

We performed comprehensive searches of the Cochrane Stroke Group Trials Register (last searched March 2020), the Cochrane Central Register of Controlled Trials (CENTRAL), 2020, Issue 4, in the Cochrane Library (searched March 2020), MEDLINE (1946 to March 2020) and Embase (1974 to March 2020). We searched relevant ongoing trials and research registers (searched March 2020), checked references in all relevant papers for additional eligible studies, and contacted authors and researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of either surgical or endovascular intervention for the management of symptomatic CeAD were eligible for inclusion. Only studies with anticoagulants or antiplatelet treatment as the control group were included. Two review authors planned to independently extract data.

DATA COLLECTION AND ANALYSIS

Primary outcomes were ipsilateral stroke and disability. Secondary outcomes were death, any stroke, or transient ischaemic attack, residual stenosis (> 50%), recurrence of cervical dissection, expanding pseudoaneurysm, or major bleeding. We analysed the studies according to the first choice of treatment. We planned to assess for risk of bias and apply GRADE criteria for any included studies.

MAIN RESULTS

We did not find any completed RCTs or CCTs undertaken in this area of research.

AUTHORS' CONCLUSIONS

No RCTs or CCTs compared either surgery or endovascular therapy with control. Thus, there is no available evidence to support their use for the treatment of extracranial cervical artery dissection in addition to antithrombotic therapy in people who continue to have neurological symptoms when treated with antithrombotic therapy alone.

Utility of Pipeline embolization device for emergency recanalization of a dissecting carotid tonsillar loop: illustrative cases

BACKGROUND

Cervical arterial tortuosity is not uncommon in patients with spontaneous carotid artery dissections (CADs), but the tortuosity often precludes endovascular stent reconstruction. The authors report 2 cases of emergency recanalization of a carotid tonsillar loop dissection using a Pipeline embolization device (PED).

OBSERVATIONS

Two patients presented with symptomatic CAD involving tonsillar looping of the cervical internal carotid artery (ICA). Although the tonsillar loop prevented navigation of the carotid and peripheral stent delivery system, a PED was easily navigated and successfully deployed, resulting in successful recanalization of a looped ICA.

LESSONS

Emergency recanalization of a cervical CAD using a PED is a feasible alternative for treating a cervical CAD associated with tonsillar loops.

Flow-diverter reconstruction of an intracranial internal carotid artery dissection during thrombectomy for acute ischaemic stroke

Intracranial carotid artery dissections are challenging, as there are no specific guidelines for their treatment, and most research suggests solutions for treating those involving extracranial vessels. We describe a patient with an acute ischaemic stroke within the territory of the right internal carotid artery, who was found to have intracranial carotid artery dissection during the thrombectomy procedure. The dissected lumen was successfully reconstructed via deployment of a Derivo flow-diverter stent. A balloon-assisted 'jacking' manoeuvre, in which a balloon is partially inflated at the beginning of the dissection to serve as leverage, was used to overcome the challenge of navigating the microcatheter tip through the stenosis proximal to the dissection. This case demonstrates the feasibly and safety of stenting with a flow diverter in a patient with internal carotid artery dissection; however, further studies are needed to confirm this finding.

Endovascular management of carotid and vertebral artery dissections with new generation double-mesh stent and protection systems - single-center early and midterm results

INTRODUCTION

Symptomatic dissections (SD) of cervical arteries are still a therapeutic problem. Although endovascular management (EM) is currently a preferred method of treatment of SD, complications associated with this method of treatment in published reports are quite frequent (3-16%).

AIM

In this retrospective study we analyzed the results of EM with novel, double-mesh stent and protection systems (PS) for SD of the internal carotid (IC) or vertebral arteries (VA) that coexisted with hemodynamically significant stenosis or aneurysmatic dilatation of the dissected artery.

MATERIAL AND METHODS

We evaluated the results of EM in 19 patients (men 15, median age: 55, range: 25-83), presenting with SD of the IC or VA with coexisting stenosis and/or aneurysmatic dilatation of the artery in segments C1-C5 of IC or V0-V4 of VA. Twelve patients had a stroke, 6 TIA, and 3 patients a headache and/or a neck pain with Horner syndrome. Stents and PS were tailored according to the location, length of dissection and coexisting stenotic or aneurysmatic lesions.

RESULTS

There were no new strokes, in-hospital deaths or other serious morbidities during the procedure and postprocedural hospital stay. There were no fatalities during 6-40 months of follow-up. In control angiographies performed after interventions all patients demonstrated a patent target artery, complete coverage of the dissection and aneurysm by stents and no new lesions in the area of the previous dissection.

CONCLUSIONS

The results of this study indicate that EM of SD of IC and VA with the new stents and PS is safe and effective with good early and midterm results.

Spontaneous Bilateral Cervical Internal Carotid Artery Dissection Treated with Simultaneous Bilateral Carotid Artery Stenting: A Case Report

Spontaneous cervical internal carotid artery dissection (CICAD) is occasionally treated with conservative management, mainly using antithrombotics. However, we have to consider emergency interventions for bilateral CICAD occurring simultaneously and accompanied by progressive cerebral ischemia. A 46-year-old woman was brought to our hospital with a complaint of left-handed clumsiness, blurred vision in the left eye, and right hemiplegia. Acute cerebral infarction in bilateral cerebral hemispheres was evident on brain magnetic resonance imaging. Bilateral internal carotid arteries were barely visible on time-of-flight magnetic resonance angiography. Subsequent cerebral angiography demonstrated that cervical internal carotid arteries on both sides were tapered off immediately after the bifurcations, indicating CICAD. Despite management with intravenous antithrombotic agents and hydration, neurological status gradually deteriorated. After insertion of a transvenous temporary pacemaker, we performed simultaneous bilateral carotid artery stenting (sbCAS) 3 days after admission. The patient first suffered slight right-sided hemiplegia and hoarseness, but symptoms resolved after rehabilitation, and modified Rankin Scale was 0 as of 2 years after the procedure. Bilateral CICAD causes severe insufficiency of cerebral blood flow, and symptoms often persist even after administration of antithrombotic agents. In such refractory cases, early intervention should be considered, and sbCAS can be safely performed. During the procedure, a transvenous temporary pacemaker maintains hemodynamic stability and might be a favorable option.

[Stroke prevention]

Prevention is essential to stroke management because of the high risk of recurrence. Stroke incidence is increased by known risk factors, which can be prevented. Cardiovascular prevention after stroke or TIA also includes aetiology-specific treatment, when it is known. Endovascular treatment is not indicated as a first-line treatment for atheromatous cervical or intracranial stenosis. Endovascular or surgical treatment is not indicated as first-line treatment for cervical arterial dissection because of its minor risk of stroke recurrence.

A novel technique to visualize true lumen in endovascular treatment of the occlusive carotid dissection and the usefulness of external-internal carotid collateral channel

Background Dissection of the internal carotid artery (ICA) can cause occlusion or severe stenosis and is known to be one of the major causes of ischemic stroke in the young. Endovascular treatment is one of the useful options for carotid dissections, but passing the guidewire through the occlusion (lesion-cross) and confirmation of the true lumen are sometimes difficult. Case presentation A 40-year-old right-handed man complaining of dysarthria and gait disturbance consulted our hospital. Magnetic resonance imaging and angiography revealed right ICA dissection. Because of worsening symptoms with conservative treatment, we performed endovascular treatment. Prior to the lesion-cross, a microcatheter was navigated to the third segment of the internal maxillary artery and a balloon-guiding catheter was navigated to the proximal ICA. Under balloon occlusion of the ICA, superselective angiography via the ipsilateral maxillary artery and slow evacuation from the balloon-guiding catheter were performed. Thereafter, the course of the true lumen was clearly visualized, and we were able to navigate another microcatheter without difficulty. Subsequently, angioplasty and stent placement were successfully accomplished. Conclusion We presented a case of ICA dissection and demonstrated a novel technique for a safe lesion-cross for occlusive ICA dissection.

Stent Reconstruction of Carotid Tonsillar Loop Dissection Using Telescoping Peripheral Stents

Background

Endovascular treatment options for internal carotid artery (ICA) dissection with tandem intracranial occlusion are evolving. We report 2 cases of stent reconstruction of carotid loop dissections.

Methods

Two patients with symptomatic ICA dissections of true 360° tonsillar loops and tandem intracranial occlusions were treated with manual aspiration thrombectomy (MAT) and telescoping Zilver self-expanding peripheral stents. Patient demographics, clinical presentations, endovascular techniques, and clinical outcomes were reviewed.

Results

In both cases, MAT achieved modified Treatment in Cerebral Ischemia scale 2B reperfusion, and complete endovascular reconstruction of the dissected extracranial loop was performed. Both patients had improved pre- to postintervention National Institutes of Health Stroke Scale scores (16 to 0 and 14 to 0), and both had modified Rankin scale scores of 1 at 3-month follow-up.

Conclusions

Stent reconstruction of complex cerebrovascular anatomy is increasingly feasible with advancements in stent technology and catheter support system design. This technique may be of use to neuroendovascular surgeons who encounter variant ICA anatomy.

Extracranial Cervical Artery Dissections

Cervical artery dissections (CeAD) include both internal carotid and vertebral artery dissections. They are rare but important causes of stroke, especially in younger patients. CeAD should be considered in patients with strokelike symptoms, a new-onset headache and/or neck pain, and/or other risk factors. Early imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is key to making the diagnosis. Treatment may vary depending on the extent of the dissection, timing of the dissection, and other comorbidities. The overall prognosis is good, but does depend on the initial severity of symptoms.

Headache, TIA and subarachnoid haemorrhage: dissecting an unusual cause for stroke-like symptoms

We present a case of supraclinoid internal carotid artery dissection. Eleven months prior, the patient developed isolated periorbital pain and was diagnosed with giant-cell arteritis with iritis. The patient experienced recurrent spells concerning for transient ischaemic attacks and was transferred to our institution for endovascular intervention after head CT revealed an embolic infarct with a 'dense middle cerebral artery sign.' Digital subtraction angiography was negative for occlusion, instead demonstrating luminal stenosis and poststenotic dilatation. He subsequently experienced acute neurological decline secondary to massive subarachnoid haemorrhage. Non-invasive vascular imaging revealed an intimal flap and a pseudoaneurysm at the site of luminal stenosis, confirming our suspicion for intracranial carotid artery dissection. Given the moribund clinical state, the family opted to withdraw care, and he quickly expired.

Endovascular Management vs Intravenous Thrombolysis for Acute Stroke Secondary to Carotid Artery Dissection: Local Experience and Systematic Review

BACKGROUND

Little is known regarding the endovascular management of acute ischemic stroke (AIS) related to carotid artery dissection (CAD).

OBJECTIVE

To report our interventional experience in AIS from CAD and to compare it with conservative treatment of CAD with intravenous thrombolysis (IVT) via systematic review.

METHODS

Retrospective analysis of consecutive high-grade steno-occlusive CAD with National Institutes of Health Stroke Scale (NIHSS) >5 and ≤12 hours of last seen normal from 2 tertiary centers. A systematic review for studies on IVT in the setting of CAD via PubMed was performed for comparison.

RESULTS

Of 1112 patients treated with endovascular interventions within the study period, 21 met the inclusion criteria. Mean age was 52.0 ± 10.9 years, 76% were male, NIHSS was 17.4 ± 5.8, 52% received IVT before intervention, and 90% had tandem occlusions. Mean time from last-known-normal to puncture was 4.8 ± 2.1 hours and procedure length 1.8 ± 1.0 hours. Stents were used in 52% of cases, and reperfusion (modified Treatment in Cerebral Ischemia 2b-3) achieved in 95%. No parenchymal hemorrhages were observed and 71% achieved good outcome (90-day modified Rankin Scale 0-2). The literature review identified 8 studies concerning thrombolysis in the CAD setting fitting inclusion criteria (n = 133). Our endovascular experience compared with the pooled IVT reports indicated that, despite presenting with higher NIHSS (17 vs 14; P = .04) and experiencing a longer time to definitive therapy (287 vs 162 minutes; P < .01), patients treated intra-arterially had similar rates of symptomatic cerebral/European Cooperative Acute Stroke Study-parenchymal hematoma 2 hemorrhage (0% vs 6%; P = .43) and good outcomes (71% vs 52%; P = .05).

CONCLUSION

Our study provides evidence that the endovascular management of AIS in the setting of CAD is a feasible, safe, and promising strategy.

Endovascular treatment of acute internal carotid artery dissections: technical considerations, clinical and angiographic outcome

INTRODUCTION

In acute internal carotid artery dissection (a-ICAD) with concomitant intracranial large vessel occlusion or haemodynamic impairment, the effectiveness of medical treatment is limited and endovascular therapy (EVT) can be considered. Feasibility, safety and outcome of EVT in a-ICAD are not well described yet.

METHODS

From an institutional database, we retrospectively selected consecutive patients treated for a-ICAD between January 2007 and July 2015. We assessed recanalization results defining <50 % residual stenosis and mTICI ≥2b as successful. Procedural adverse events and symptomatic haemorrhages were reported as well as clinical outcome at 90 days defining a mRS ≤2 as favourable. Follow-up angiographies were reviewed and retreatments reported.

RESULTS

In the defined period, 73 patients (mean age 48 years (31-73), mean NIHSS 11 (0-27)) received EVT for a-ICAD. The majority (60 %) had tandem occlusions. Cervical artery reconstruction was successful in 100 % and intracranial thrombectomy in 85 %. Thrombus formation (18 %) and thromboembolism (20 %) were the most frequent adverse events but clinically relevant only in 8 %. Symptomatic haemorrhage occurred in 5 %. Clinical outcome was favourable in 64 %, with a lower chance after tandem occlusion (55 vs. 79 %, p = 0.047). Death rate was 10 %. None of the patients developed recurrent ischaemic symptoms, but control angiography revealed abnormal findings of the reconstructed ICA in 38 % leading to retreatment in 17 %.

CONCLUSION

EVT of a-ICAD is feasible with a predominantly favourable clinical outcome. Improvement of devices and techniques is warranted to reduce the risk of thrombus formation and thromboembolism during treatment and insufficient vessel wall healing thereafter.

Endovascular reconstruction of internal carotid artery dissection in patients with acute ischemic stroke using the Wingspan stent

OBJECTIVE

The purpose of this study is to demonstrate our experience in endovascular reconstruction of carotid dissections using the Wingspan Stent System™ (Boston Scientific, Natick, MA, USA), a device we use because of its high radial force and its navigation in extreme curves.

METHODS

We treated 11 consecutive patients with acute ischemic stroke due to carotid dissection with the Wingspan stent, in the cervical carotid artery.

RESULTS

Functional evaluation revealed that 10 of the 11 patients were independent at 3 months post surgery and that the 11 stents used were found to be patent at the 6-month follow-up digital subtraction angiography (DSA).

CONCLUSIONS

The Wingspan stent is an alternative to classic carotid stents and flow diverters for the treatment of cervical internal carotid artery (ICA) dissection associated with ectasias or large loops. The device remains patent over the long term and it is not associated with arterial wall complications.

Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach

Background

Carotid dissection (CD) may, in certain cases, lead to significant stenosis, occlusion, or pseudoaneurysm formation, causing embolic stroke or hemodynamic failure, despite medical therapy.

Objective

To evaluate the results of endovascular treatment and clinical outcomes of patients with CD.

Methods

A four-hospital retrospective study of endovascular treatment of extracranial CD in which medical treatment had failed or patients presented with a National Institute of Health Stroke Scale (NIHSS) score ≥8.

Results

Thirty-eight patients (mean age 46.6±13.5 years, 78.9% male, 84.2% spontaneous CD, 44.7% left CD and 26.3% bilateral CD) were analyzed. In 24 patients (63.2%) treatment was undertaken in the acute-phase CD (APCD). IV recombinant tissue plasminogen activator was administered in 7 (29.2%) APCD cases. The patients with APCD exhibited a high rate of successful revascularization (Thrombolysis In Cerebral Infarction ≥2b; 19 patients (79.2%)), a low risk of symptomatic intracranial hemorrhage (n=2 (8.3%)), and good global functional outcomes (modified Rankin Scale (mRS) ≤2; n=17 (70.8%)). Good recanalization correlated (p=0.001) with good clinical evolution (mRS ≤2) in the patients with APCD. Of the 14 patients with non-acute phase CD (NAPCD), seven were treated for pseudoaneurysm with multiple stents (six patients) or covered prostheses, with stenosis being treated in the remaining seven patients.

Conclusions

Endovascular treatment of selected cases of patients with CD associated with thromboembolic events and hemodynamic failure after unsuccessful medical therapy is a safe and effective method of restoring vessel lumen integrity, with good short-term clinical evolution.

Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection

Objective

The safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT.

Design

Demographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0–2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ² tests and multivariate logistic regression.

Results

There were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0–2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34).

Conclusions

IAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study.

Delayed Collapse of a Pipeline Embolization Device

BACKGROUND

The Pipeline Embolization Device (PED) is a treatment modality for wide-neck complex intracranial aneurysms. There have been recent reports for the use of PEDs in dissecting pseudoaneurysms of the cervical carotid arteries. The use of this flow diversion technology has emerged as a promising alternative; however, there are various risks and complications that one should be aware of.

OBJECTIVE

To report a rare postoperative complication, identified during follow-up, in a patient initially treated for an internal carotid artery dissection with multiple overlapping PEDs.

METHODS

A 53-year-old male with unremarkable history presented with acute Horner's syndrome, and imaging findings revealing internal carotid artery dissection and pseudoaneurysm with significant flow-limiting stenosis. He underwent treatment with a PED.

RESULTS

At 3 months post-operation, a cerebral angiogram demonstrated that one of his pipeline stents in the posterior cavernous segment had collapsed at its central portion. Flow was preserved around the outside of the collapsed device. We performed 4 rounds of balloon angioplasty with modest, but not complete, re-expansion of the stent. The patient has been doing well in the postoperative period with no complications.

CONCLUSION

The PED's role in the management of aneurysms and other intra- and extra-cranial vascular pathologies continues to expand, and new complications are bound to be discovered, similar to our case. As the use of these devices becomes routine and widespread, the frequency of these complications will increase. The management of unforeseen complications of PEDs, such as a collapsed stent, will need to be determined on an individual basis.

Management of Bilateral Carotid Occlusive Disease

BACKGROUND

Symptomatic bilateral internal carotid occlusive disease is a rare but potentially devastating entity. Medical therapy alone is associated with high rates of mortality and recurrent stroke. The optimal management of this disease remains poorly understood.

METHODS

A retrospective review of a prospectively maintained database was conducted for patients who presented with an acute stroke in the setting of bilateral carotid occlusive disease between May and October 2013.

RESULTS

We identified 3 patients. The admission National Institutes of Health Stroke Scale score ranged from 4 to 7. All patients had small- to moderate-sized infarcts in the anterior circulation on presentation. Angiography confirmed bilateral internal carotid occlusions with collateral filling via the posterior communicating artery and retrograde filling via external carotid artery supply to the ophthalmic artery. All patients were initially managed with permissive hypertension and anticoagulation followed by carotid angioplasty and stenting. At 1-year follow-up, all patients demonstrated a modified Rankin scale score of 0-1.

CONCLUSIONS

Carotid stenting may be a safe and effective therapy for patients presenting with symptomatic bilateral carotid occlusions.

A Case of Complete Recovery of Fluctuating Monocular Blindness Following Endovascular Treatment in Internal Carotid Artery Dissection

BACKGROUND

Monocular blindness may appear as the first symptom of internal carotid artery dissection (ICAD). However, there have been no reports that monocular visual loss repeatedly occurs and disappears in response to postural change in ICAD.

METHODS

A 33-year-old woman presented with transient monocular blindness (TMB) following acute-onset headache. TMB repeatedly occurred in response to postural change. Two days later, she experienced transient dysarthria and right hemiparesis in upright position. Pupil size and light reflex were normal, but a relative afferent pupillary defect was positive in the left eye. Diffusion-weighted imaging showed no acute lesion, but perfusion-weighted imaging showed perfusion delay in the left ICA territory. Digital subtraction angiography demonstrated a false lumen and an intraluminal filling defect in proximal segment of the left ICA.

RESULTS

Carotid stenting was performed urgently. After carotid stenting, left relative afferent pupillary defect disappeared and TMB was not provoked anymore by upright posture. At discharge, left visual acuity was completely normalized.

CONCLUSIONS

Because fluctuating visual symptoms in the ICAD may be associated with hemodynamically unstable status, assessment of the perfusion status should be done quickly. Carotid stenting may be helpful to improve the fluctuating visual symptoms and hemodynamically unstable status in selected patient with the ICAD.

Pipeline Embolization Device for treatment of high cervical and skull base carotid artery dissections: clinical case series

BACKGROUND

Most cervical dissections are treated with anticoagulation or antiplatelet agents with very good results; however, some patients may benefit from endovascular intervention. High cervical and skull base dissections are often more challenging to treat because of the distal location and tortuous anatomy. The Pipeline Embolization Device (PED) may be a reasonable treatment option for this indication.

OBJECTIVES

To report a case series of patients treated with the PED for high cervical and skull base dissections, focusing on their presentation, indications for treatment, dissection revascularization success, and pseudoaneurysm obliteration evaluated by imaging, and to review available pertinent literature.

METHODS

We retrospectively reviewed all cases of high cervical and skull base dissections treated with a PED at our institution. Patient clinical characteristics, presentation, procedural and follow-up imaging, and clinical course were analyzed to evaluate for procedure complications, dissection revascularization success, pseudoaneurysm obliteration, and clinical outcome.

RESULTS

This is a retrospective case series including 11 patients with 13 carotid dissections treated in our center. There were nine traumatic and four spontaneous dissections. The most common presentation was cerebrovascular accident/transient ischemic attack (CVA/TIA; 5 patients) and headache/face pain (4 patients). Eleven dissections were associated with pseudoaneurysms. Three patients failed medical management with anticoagulation, although flow-limiting stenosis was the main indication for endovascular intervention. Up to three PEDs per vessel were deployed. Angioplasty was used in 10 cases. Complete revascularization (<10% residual stenosis) was achieved in 91% of vessels and 50% of pseudoaneurysms were completely or near completely obliterated immediately after PED(s) deployment. Proximal iatrogenic dissection was the only intraoperative complication. Follow-up imaging was available for nine treated vessels and demonstrated patent PEDs without significant in-stent stenosis up to 9 months after intervention. 75% of pseudoaneurysms were completely obliterated at follow-up. One PED partially collapsed but had no neurological consequences. There were no new CVA/TIAs.

CONCLUSIONS

Our initial experience with treatment of high cervical and skull base dissections with the PED appears to show that this technique may be a safe and viable treatment option. However, long-term results are needed to fully evaluate the efficacy of such treatment.

Extracranial Internal Carotid Artery Dissection Treated with Self-expandable Stents: A Single-Centre Experience

PURPOSE

Treatment of choice for the internal carotid artery dissection (ICAD) is anticoagulation for three to 6 months. Endovascular procedures may be a promising alternative for patients (pts) with haemodynamic impairment, recurrent ischaemic symptoms or symptomatic pseudoaneurysms. Thus, the purpose of this study was to evaluate the efficacy and safety of carotid artery stenting in treatment of selected pts with extracranial ICAD.

METHODS

This study involved 18 symptomatic pts with the mean age of 44.6 ± 10.4 years with ICAD treated with the use of self-expandable stents. Six months after primary procedures, pts were readmitted to hospital and physical examination followed by cerebral angiography was performed. In the late follow-up period, clinical evaluations completed by duplex Doppler ultrasonography were carried out every 6 months and at the end of the follow-up period.

RESULTS

Nobody died and no life-threatening adverse events were observed during either the in-hospital stay or post-discharge follow-up period (median 21 months). Stent deployment immediately restored flow in the true lumen of ICA in all cases. However, residual blood flow through the false lumen was observed in one pt. Complete resolution of clinical symptoms was observed in 14 pts (78%), partial improvement in 2 (11%) and persistence of neurological deficit in 2 (11%).

CONCLUSIONS

Implantation of self-expandable stents in treatment of selected extracranial ICAD cases is safe. This method may enable us to restore immediately and usually permanently proper arterial blood flow in the ICA and in consequence lead to significant clinical improvement in the late follow-up period.

Open retrograde endovascular stenting for left common carotid artery dissection secondary to surgical repair of acute aortic dissection: a case report and review of the literature

A 30-year-old male presented with an acute aortic artery dissection (Stanford type A) and underwent total arch replacement using a stented elephant trunk technique. One month later, the patient developed dissections in the innominate and left common carotid artery (CCA). The innominate artery dissection caused occlusion in the right internal carotid artery (ICA) and a major stroke. Dissection of the left CCA progressed and extended to the bifurcation site. Antegrade access for a left carotid intervention was deemed as difficult because of the previously implanted stent and the additional risks of embolic events and dissection enlargement. Hybrid procedures combining left carotid bifurcation exposure and retrograde endovascular stenting were successfully completed. This report is a rare case of retrograde endovascular reconstruction for the left CCA dissection following surgical repair of an aortic artery dissection. Here, we also review previous cases of iatrogenic carotid dissections following surgical intervention.

A systematic review of endovascular management of internal carotid artery dissections

BACKGROUND

We conducted a review of the safety and outcomes of endovascular intervention in patients with internal carotid artery dissection (ICAD).

SUMMARY

A literature review was performed. PubMed and Medline databases were searched from inception to September 2012 with the key words 'carotid artery' (title), 'dissection' (title) and 'endovascular' (title/abstract). All studies were included which reported outcomes of endovascular intervention in ICAD and provided information about technical and clinical results. After screening, we included 23 articles. In total, 201 patients (128 male and 73 female) were included in the eligible studies. The mean age was 46.7 years (range 13-83 years). Of the 201 patients, the causes of the carotid dissections were traumatic in 69 (34.3%), spontaneous in 115 (57.2%) and iatrogenic in 17 (8.5%). The technical success rate was 99.1%. The overall rate of major cardiovascular events in the perioperative period was 4%. No procedure-related deaths occurred. Imaging follow-up data (mean follow-up time 16.5 months) demonstrated that only 3.3% of patients had intimal hyperplasia or in-stent restenosis or occlusion of a treated vessel. Clinical follow-up data (mean follow-up period 20.9 months) showed that only 2.1% of patients had a recurrent transient ischemic attack in the territory of the treated vessel.

KEY MESSAGES

Endovascular intervention with stenting or stent-graft-supported angioplasty in selected patients with ICAD is promising. However, further evaluation is warranted to provide more evidence to support the feasibility of endovascular procedures in treating ICAD.

Stratifying carotid diseases for endovascular treatments

Endovascular angioplasty and stenting (CAS) has evolved as an alternative for treating occlusive carotid diseases in recent years. Carotid diseases are characterized by manifold etiologies and miscellaneous clinical manifestations. Although CAS is efficacious in treating patients with occlusive carotid diseases as a whole, the long-term risk-benefit ratio may vary in individual patients. Interventional strategies, such as angioplasty and stenting, should be individualized based on the etiology and clinical profiles to maximize the benefits and minimize the hazards of treatment. Based on recent publications, this review proposes a stratified treatment strategy for occlusive carotid diseases.

Quantitative analysis of high-resolution, contrast-enhanced, cone-beam CT for the detection of intracranial in-stent hyperplasia

BACKGROUND

Intracranial in-stent hyperplasia is a stroke-associated complication that requires routine surveillance.

OBJECTIVE

To compare the results of in vivo experiments to determine the accuracy and precision of in-stent hyperplasia measurements obtained with modified C-arm contrast-enhanced, cone-beam CT (CE-CBCT) imaging with those obtained by 'gold standard' histomorphometry. Additionally, to carry out clinical analyses comparing this CE-CBCT protocol with digital subtraction angiography (DSA).

METHODS

A non-binned CE-CBCT protocol (VasoCT) was used that acquires x-ray images with a small field-of-view and applies a full-scale reconstruction algorithm providing high-resolution three-dimensional (3D) imaging with 100 µm isotropic voxels. In an vivo porcine model, VasoCT cross-sectional area measurements were compared with gold standard vessel histology. VasoCT and DSA were used to calculate in-stent stenosis in 23 imaging studies.

RESULTS

Porcine VasoCT cross-sectional stent, lumen, and in-stent hyperplasia areas strongly correlated with histological measurements (r(2)=0.97, 0.93, 0.90; slope=1.14, 1.07, and 0.76, respectively; p<0.0001). Clinical VasoCT percentage stenosis correlated well with DSA percentage stenosis (r(2)=0.84; slope=0.76), and the two techniques were free of consistent bias (Bland-Altman, bias=3.29%; 95% CI -14.75% to 21.33%). An illustrative clinical case demonstrated the advantages of VasoCT, including 3D capability and non-invasive IV contrast administration, for detection of in-stent hyperplasia.

CONCLUSIONS

C-arm VasoCT is a high-resolution 3D capable imaging technique that has been validated in an animal model for measurement of in-stent tissue growth. Successful clinical implementation of the protocol was performed in a small case series.

Stent recanalization of carotid tonsillar loop dissection using the Enterprise vascular reconstruction device

Although advances in endovascular techniques have permitted reconstruction of intimal dissections and related pseudoaneurysms of the extracranial cervical internal carotid artery, highly tortuous tonsillar loop anatomic variants still pose an obstacle to conventional extracranial self-expanding carotid stents. During a 12 year period, nine of 48 cases with cervical carotid dissections were associated with a tonsillar loop. Five patients required endovascular treatment, which was performed using a microcatheter-based technique with the low-profile Enterprise vascular reconstruction device (Codman Neurovascular, Raynham, MA, USA). Technical, radiographic, and clinical outcomes were analyzed for each patient. Dissection etiology was spontaneous in three patients, iatrogenic in one, and traumatic in one. Four near-occlusive tonsillar loop dissections were successfully recanalized during the acute phase. Dissection-related stenosis improved from 90±22% to 31±13%, with tandem stents needed in three instances to seal the inflow zone. There were no procedure-related transient ischemic attacks (TIA), minor/major strokes, or deaths. Angiographic follow-up for a mean of 28.0±21.6 months showed all stents were patent, with average stenosis of 25.2±12.2%. Focal ovalization and kinking of the closed-cell design was noted at the sharpest curve in one patient. Clinical outcome (follow-up of 28.1±21.5 months) demonstrated overall improvement with no clinical worsening, new TIA, or stroke. Tonsillar loop-associated carotid dissections can be successfully and durably recanalized using the low-profile Enterprise stent with an excellent long-term patency rate and low procedural risk. The possibility of stent kinking and low radial force should be considered when planning reconstruction with this device.

Endovascular treatment of intracranial artery dissection: clinical and angiographic follow-up

Background. Intracranial artery dissections are rare and many controversies exist about treatment options. The aim of this study was to evaluate the efficacy and safety of the endovascular approach in patients with an intracranial dissection presenting with different symptoms. Methods. We prospectively evaluated the clinical features and treatment outcomes of 30 patients who had angiographically confirmed nontraumatic intracranial dissections over 4 years. Patients were followed up for 17 months, and their final outcomes were assessed by the modified Rankin Score (mRS) and angiography. Results. Sixteen (53.3%) patients had a dissection of the anterior circulation, whereas 14 (46.7%) had a posterior circulation dissection. Overall, 83.3% of the patients suffered a subarachnoid hemorrhage (SAH). Grade IV Hunt and Hess score was seen in 32% of the SAH presenting cases. Parent artery occlusion (PAO) with coil embolization was used in 70% of the cases. The prevalence of overall procedural complications was 23.3%, and all were completely resolved at the end of follow-up. No evidence of in-stent occlusion/stenosis or rebleeding was observed in our cases during follow-up. Angiography results improved more frequently in the PAO with coil embolization group (100%) than in the stent-only-treated group (88.9%) (P = 0.310) and the unruptured dissection group (5/5, 100%) in comparison with the group that presented with SAH (95.8%) (P = 0.833). Conclusion. Favorable outcomes were achieved following an endovascular approach for symptomatic ruptured or unruptured dissecting aneurysms. However, the long-term efficacy and durability of these procedures remain to be determined in a larger series.

Treatment of middle cerebral artery occlusion and internal carotid artery dissection with combined mechanical thrombectomy and stenting of the internal carotid artery. A case report

We describe a case of combined mechanical thrombectomy of the right middle cerebral artery and stent angioplasty of the right internal carotid artery in a severe stroke caused by arterio-arterial embolism due to a traumatic dissection of the internal carotid artery. The patient was admitted with an NIHSS score of 19 and was discharged from hospital with a score of 2. Three months later neurological examination disclosed no pathological findings. The case demonstrates the crucial role of interventional procedures in the treatment of severe stroke where intravenous thrombolysis has little prospect of success.

Surgical repair of a common carotid artery pseudoaneurysm after minor blunt trauma

Pseudoaneurysms of the common carotid arteries are rare and have been associated with both penetrating and blunt trauma. Intervention is warranted in most cases to avert the sequelae of rupture or embolization. Treatments are tailored to the specific patient on a case by case basis. This report describes an unusual case of common carotid artery pseudoaneurysm after minor blunt trauma and reviews the diagnostic and treatment modalities available.

Perioperative Complications After Carotid Artery Stenting

BACKGROUND:

Technological advances have resulted in diminishing perioperative complications reported during carotid artery stenting (CAS) trials. Because trial experience lags behind technological advances, an understanding of the incidence of perioperative complications after CAS remains in flux.

OBJECTIVE:

In this single-arm, observational study, a contemporary experience of CAS at a high-volume academic training center for neuroendovascular surgeons was reviewed to assess perioperative morbidity.

METHODS:

A prospectively maintained database of all neuroendovascular procedures was queried for all CAS procedures performed for stenotic atherosclerotic disease between 2009 and 2011. Each case was assessed for major perioperative (30 day) adverse events, including new acute ischemic stroke, postoperative symptomatic intracranial hemorrhage, myocardial infarction (MI), and mortality.

RESULTS:

A total of 474 patients were identified. Perioperative adverse events were noted in 13 patients (2.7%). These included 4 ischemic strokes, 4 intracranial hemorrhages, 3 MIs, and 5 deaths. Most perioperative events occurred in symptomatic patients (10 of 239 symptomatic patients with events, 4.2% event incidence), whereas these events occurred rarely in asymptomatic patients (3 of 235 asymptomatic patients with events, 1.3% event incidence).

CONCLUSION:

In this retrospective analysis of consecutive patients treated with CAS, the perioperative incidence of stroke (0.9%), MI (0.6%), and death (1.1%) was favorable.