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Primary stenting of the extracranial internal carotid artery in a patient with multiple cervical dissections:
D Coric1, J A Wilson, J D Regan
1Department of Neurosurgery, Wake Forest University Baptist Medical Center, Winson-Salem, North Carolina 27157-1029, USA.
Insights
Spontaneous extracranial carotid and vertebral artery dissection can cause stroke. Neurovascular stenting offers a minimally invasive treatment option for patients who remain symptomatic despite anticoagulation.
Area of Science:
- Neuroendovascular surgery
- Cerebrovascular disease
- Interventional neurology
Background:
- Spontaneous dissection of extracranial internal carotid artery (ICA) and vertebral artery (VA) is a recognized cause of stroke in young adults.
- Standard treatments like antiplatelets or anticoagulation are effective for many, but a subset of patients experience poor outcomes.
- Traditional surgical interventions for these dissections are technically challenging and often yield suboptimal results.
Observation:
- A 36-year-old male presented with transient neurological deficits suggestive of stroke.
- Cerebral angiography revealed severe stenosis in bilateral ICAs and left VA, along with right VA occlusion.
- Despite therapeutic anticoagulation with heparin, the patient experienced worsening symptoms.
Findings:
- The patient underwent successful primary stenting of the left ICA using overlapping coronary stents.
- Post-procedure, the patient remained asymptomatic with no neurological complications.
- Follow-up angiography at 9 months demonstrated sustained patency of the stented left ICA and recanalization of the right ICA and VA.
Implications:
- Neurovascular stenting presents a minimally invasive and potentially effective therapeutic strategy.
- This approach may help prevent cerebral ischemia in patients with spontaneous extracranial dissection.
- Stenting could be a viable option for patients with persistent symptoms despite anticoagulation therapy.
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.