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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Endovascular stent-assisted thrombolysis in acute occlusive carotid artery dissection
Isabelle Mourand1, Herve Brunel, Jean-François Vendrell
1Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, 34295 Montpellier, Cedex 5, France. i-mourand@chu-montpellier.fr
Insights
Internal carotid artery dissection with tandem occlusion can cause severe strokes. Emergent endovascular stent-assisted thrombolysis using self-expandable intracranial stents offers a promising treatment option for these acute cases.
Area of Science:
- Neurology
- Interventional Neuroradiology
- Vascular Neurology
Background:
- Internal carotid artery (ICA) dissection with tandem internal carotid and middle cerebral artery (MCA) occlusion is associated with poor prognosis due to large cerebral infarction.
- Recanalization of ICA dissection via stent-assisted thrombolysis is an emerging therapeutic strategy.
Observation:
- Two patients presented with acute severe stroke symptoms (NIHSS 15 and 18) due to tandem ICA dissection and MCA occlusion.
- Perfusion-diffusion MRI revealed extensive mismatch, indicating salvageable brain tissue within 3 hours of symptom onset.
Findings:
- Successful recanalization of ICA and MCA was achieved within 6 hours using emergent endovascular stent-assisted thrombolysis with self-expandable intracranial stents.
- No periprocedural complications occurred, and follow-up imaging showed only mild infarcts in the MCA territory.
- Both patients experienced favorable outcomes at 10-12 months follow-up (NIHSS 0, mRS ≤ 1).
Implications:
- Endovascular stent-assisted thrombolysis is a viable and promising treatment for tandem occlusions secondary to ICA dissection.
- Self-expandable intracranial stents demonstrate potential utility in managing acute symptomatic ICA dissection.
Introduction:
Internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion may be responsible for large cerebral infarction that carries a general poor prognosis. Recanalization of internal carotid artery (ICA) dissection by stent-assisted thrombolysis has been recently proposed. We report two cases of acute symptomatic ICA dissection with tandem occlusion successfully treated with emergent endovascular stent-assisted thrombolysis using new self-expandable intracranial stents.
Methods:
A 37-year-old woman and a 59-year-old man were admitted in our hospital after acute severe symptoms of right-hemispheric stroke with National Institutes of Health Stroke Scale (NIHSS) scores of 15 and 18, respectively. In both cases, magnetic resonance angiography showed tandem occlusion and angiography confirmed tandem occlusion with ICA dissection. An extensive mismatch region was diagnosed by Perfusion-diffusion MRI of the brain within 3 h after symptoms onset. Treatment was initiated 4 h after symptom onset by implantation of self-expandable intracranial stents into the dissected ICA and administration of intra-arterial recombinant tissue plasminogen activator.
Results:
Recanalization of the ICA and middle cerebral artery (MCA) was accomplished within 6 h after symptoms onset. In both cases, no periprocedural complication was observed and follow-up CT scan showed only a mild brain infarct in the MCA territory. After, respectively, 12 and 10 months follow-up, patients had a favorable outcome with NIHSS 0 and mRS < or = 1.
Conclusion:
Endovascular stent-assisted thrombolysis appears to be a promising treatment in tandem occlusion due to ICA dissection. Our work underline the potential use of self-expandable intracranial stents in symptomatic acute ICA dissection.
