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Progressive symptomatic carotid dissection treated with multiple stents
Alessandra Biondi1, Jeffrey M Katz, Janardhan Vallabh
1Department of Radiology, New York Presbyterian Hospital, Weill Medical College, Cornell University, New York, NY 10021, USA.
Insights
Multiple stents successfully treated a spontaneous internal carotid artery dissection extending to the brain, offering a new option for complex cases unresponsive to standard therapies.
Area of Science:
- Vascular Neurology
- Interventional Neuroradiology
- Cardiovascular Surgery
Background:
- Internal carotid artery (ICA) dissection is a significant cause of stroke in young adults.
- While anticoagulation and antiplatelet therapy are standard, they can fail or be contraindicated.
- Endovascular stent-assisted angioplasty is an option for extracranial ICA reconstruction in select cases.
Observation:
- A 48-year-old patient presented with symptomatic spontaneous carotid dissection extending from the cervical to the supraclinoid ICA segments.
- Despite anticoagulant therapy, the dissection progressed, leading to transient ischemic attacks (TIAs).
- The patient underwent endovascular treatment with 5 tandem stents deployed from the terminal ICA to the cervical segment.
Findings:
- Post-procedure angiography showed successful luminal diameter reconstitution of the ICA.
- The patient experienced clinical improvement with resolution of TIAs.
- At 8-month follow-up, the vessel remained patent with mild myointimal hyperplasia and a normal neurological exam.
Implications:
- This case demonstrates the efficacy of multi-stent endovascular treatment for extensive, spontaneous ICA dissection.
- The successful outcome, including the distal supraclinoid segment, expands treatment options for complex carotid dissections.
- This approach offers a viable alternative when medical management fails or is not feasible.
Background And Purpose:
Internal carotid artery (ICA) dissection remains a major cause of stroke in the young. Although systemic anticoagulation and antiplatelet therapy allow healing of the dissection in most patients, medical treatment can fail or be contraindicated. In selected cases of carotid dissections, the use of endovascular stent-assisted angioplasty has been reported to permit reconstruction of the extracranial ICA.
Methods:
We report a case of symptomatic spontaneous carotid dissection which progressively extended from the cervical to the supraclinoid segments of the ICA in a 48-year-old patient under anticoagulant therapy. Because of failed medical therapy and further transient ischemic attacks (TIAs), the patient was treated by 5 tandem stents deployed in an overlapping fashion from the terminal ICA to the cervical segment.
Results:
Postprocedure angiography demonstrated reconstitution of the luminal diameter of the ICA. The patient progressively improved and no further TIAs were observed. At 8-month follow-up, the vessel remained patent with a slight intra-extracranial reduction in size suggesting myointimal hyperplasia. Neurological exam was normal.
Conclusions:
The successful angiographic and clinical results observed in our case of intra-extracranial stenting of a long dissection contributes to the literature of carotid dissection treated with multiple stents. The excellent mid-term follow-up in our patient confirms the efficacy of this treatment and good tolerance to multiple stents. To our knowledge this is the first case of spontaneous dissection treated with stenting including the distal supraclinoid segment, through an extensive proximally dissected artery.
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