Surgical treatment for spontaneous carotid dissection with impending stroke. Case report

Carotid Artery Aneurysms: Serbian Multicentric Study

This multicentric Serbian study presents the treatment of 91 extracranial carotid artery aneurysms in 76 patients (13 had bilateral lesions). There were 61 (80.3%) male and 15 (19.7%) female patients, with an average age of 61.4 years. The aneurysms were caused by atherosclerosis in 73 cases (80.2%), trauma in six (6.6%), previous carotid surgery in six (6.6%), tuberculosis in one (1.1%), and fibromuscular dysplasia in five (5.5%). The majority (61 cases or 67%) of the aneurysms involved the internal carotid artery, 29 (31.9%) the common carotid artery bifurcation, and one (1.1%) the external carotid artery. Forty-five (49.4%) aneurysms were fusiform, while 46 (50.6%) were saccular. Twenty-nine (31.9%) cases were totally asymptomatic at the time of diagnosis. The remainder presented with compression in 14 (15.4%) cases, stroke in 11 (12.1%) cases, transient ischemic attack in 33 (36.3%) cases, and rupture in four (4.4%) cases. In cases where the aneurysm involved the internal carotid artery, four surgical procedures were performed: aneurysmectomy with end-to-end anastomosis in 30 (33.0%) cases, aneurysmectomy with vein graft interposition in 20 (22.0%) cases, aneurysmectomy with anastomosis between external and internal carotid artery in eight (8.8%) cases, and aneurysmectomy followed by arterial ligature in three cases. One case of external carotid artery aneurysm also was treated by aneurysmectomy and ligature. Aneurysm replacement with Dacron graft was performed in 29 (31.9%) cases where common carotid artery bifurcation was involved. Two (2.2%) patients died after the operation due to a stroke. They had ruptured internal carotid artery aneurysm treated by aneurysmectomy and ligature. Including these, a total of five (5.5%) postoperative strokes occurred. In two (2.2%) cases, transient cranial nerve injuries were found. Excluding the five patients who were lost to follow-up, 69 other surviving patients were followed from 2 months to 12 years (mean 5 years and 3 months). In this period, there were no new neurological events and all reconstructed arteries were patent. Three patients died more than 5 years after the operation, due to myocardial infarction. Aneurysms of the extracranial carotid arteries are rare vascular lesions that produce a high incidence of unfavorable neurological sequelae. Because of their varied etiology, location, and extension, different vascular procedures have to be used during repair of extracranial carotid artery aneurysms. In all of these procedures, an aneurysmectomy with arterial reconstruction is necessary.

Treatment of symptomatic cervical carotid dissections with endovascular stents

OBJECTIVE

Symptomatic dissections of the cervical carotid artery (CCA) can be spontaneous or secondary to trauma and may be associated with pseudoaneurysms. Surgical treatment is often difficult or unavailable. We report the successful use of endovascular stents in the treatment of symptomatic dissection of the CCA.

METHODS

Five consecutive patients with symptomatic CCA dissection were seen at our institution. There were four female patients and one male patient, ranging in age from 19 to 56 years. One dissection was spontaneous. The others were secondary to a gunshot wound (one patient), blunt neck trauma (two patients), and endovascular treatment of atherosclerotic carotid bifurcation disease (one patient). Balloon-expandable and self-expanding stents were placed via a transfemoral approach.

RESULTS

Success in restoring the carotid lumen with two to five stents in each patient was angiographically demonstrated. There were no procedure-related complications. All patients experienced significant clinical improvement within the first 24 hours and complete long-term recovery.

CONCLUSION

Symptomatic dissections of the CCA can be successfully treated by using endovascular stents.

Primary stenting of the extracranial internal carotid artery in a patient with multiple cervical dissections: technical case report

OBJECTIVE AND IMPORTANCE

Spontaneous dissection of the extracranial internal carotid artery (ICA) and vertebral artery (VA) is a well-documented cause of stroke in young, previously healthy patients. The majority of patients with spontaneous dissection are successfully treated with antiplatelet or anticoagulation therapy, but a significant proportion of patients progress to suffer devastating morbidity and mortality. Surgical intervention has primarily consisted of proximal ligation, extracranial-intracranial bypass, or endarterectomy. Generally, these procedures are technically demanding and yield disappointing clinical results.

CLINICAL PRESENTATION/INTERVENTION

A 36-year-old man without a significant medical history initially presented with a several-day history of episodic right upper extremity weakness and numbness and visual obscurations. Cerebral angiography revealed bilateral ICA long segment narrowing (95%), distal left VA high-grade (95%) stenosis compatible with dissections, and right VA proximal occlusion. While therapeutically anticoagulated on heparin, the patient continued to experience crescendo episodes of right upper extremity paresis and paresthesias as well as aphasia. The patient underwent primary stenting of the left ICA, using a series of six overlapping stents (three Gianturco-Roubin coronary stents and three Palmaz-Schatz coronary stents). The patient remained symptom-free without neurological complications, and subsequent angiography performed at the 9-month follow-up examination confirmed continued patency of the stented left ICA as well as recanalization of the right ICA and VA.

CONCLUSION

Neurovascular stents offer a minimally invasive and potentially efficacious treatment for the prevention of cerebral ischemia in patients with spontaneous extracranial dissection who remain symptomatic despite therapeutic anticoagulation.

Treatment of dissecting pseudoaneurysm of the cervical internal carotid artery using a wall stent and detachable coils: case report

OBJECTIVE AND IMPORTANCE

This case illustrates the use of an endovascular stent and coiling combination to treat a giant wide-necked pseudoaneurysm of the cervical internal carotid artery.

CLINICAL PRESENTATION

A 20-year-old male patient presented with a bilateral dissection of the cervical internal carotid artery and a right giant wide-necked pseudoaneurysm of the cervical segment of the internal carotid artery after a high-speed motor vehicle collision.

INTERVENTION

After failing conservative therapy, the patient was treated by endovascular placement of a Palmaz wall stent at the level of the pseudoaneurysm and filling of the pseudoaneurysm with multiple Guglielmi detachable coils. Obliteration of the pseudoaneurysm was achieved, and patency of the right internal carotid artery was maintained.

CONCLUSION

The patient's neurological symptoms resolved completely after treatment, and he sustained no neurological complications during the 20-month follow-up period. This case illustrates the successful treatment of a wide-based giant pseudoaneurysm by using a combination of an endovascular stent and coil embolization.

Painful Horner's syndrome due to spontaneous carotid artery dissection

Spontaneous dissection of the internal carotid artery as a cause of Horner's syndrome has only been recognized in recent years. The authors describe three patients with this condition. Associated symptoms included ipsilateral orbital and frontal headache (3 patients), neck and facial pain (2), amaurosis fugax (1), and dysgeusia (1). The symptoms resolved in all patients within three months, yet oculosympathetic paralysis has persisted. Diagnosis of carotid dissection required cerebral arteriography, and the angiographic features are presented. Patients were treated with platelet antiaggregants, and they have remained neurologically stable during follow-up (mean, 12 months; range, 10-14 months).