Internal carotid artery dissection with associated perfusion deficit treated by stent placement

Case contributed by Yves Leonard Voss

Presentation

Right eye vision disturbances and left sided fluctuating sensorimotor hemiparesis since 2 hours.

Patient Data

Age: 40
Gender: Male
CT

CT and Perfusion showing right ICA dissection

CT shows no infarction, no hyperdense vessel sign.

CT angiogram shows dissection of the right internal carotid artery.

CT perfusion shows marked deficit for right ACA / MCA / PCA territory suggesting haemodynamic relevance.

DSA (angiography)

Angiogram and stent right ICA placement

Angiogram shows right ICA dissection followed up by ICA stent placement.

Control angiogram after stent placement shows alleged influx lesion.

CT perfusion after ICA stenting shows normalized perfusion in MTT, TTP with a tendency to luxury perfusion of the right ICA territory in CBF and CBV.

Postinterventional MRI two days after symptom onset and stent placement shows no territorial infarction, tissue oedema or intracranial haemorrhage.

There are small cortical areas of restricted diffusion in the right MCA territory (bright spots in the b1000 diffusion weighted image). These are very probably localizations of microembolism due to the ICA dissection or due to the interventional procedure. These lesions were clinically asymptomatic.

Case Discussion

A young, healthy, heavily affected patient showed a dissection of his right internal carotid artery in typical location. In this situation with markedly decreased CT perfusion and fluctuating symptoms we performed an angiogram and followed up with ICA stenting to minimize the risk of ischaemia. The anticoagulation we used during the intervention was Eptifibatide (Integrilin) by perfusor and acetylsalicylate 500mg bolus i.v. Upon waking up from general anaesthesia the patient was symptom free, the postinterventional perfusion showed normalized perfusion.

There are risks associated with stenting of a carotid artery dissection like embolisation of throm­botic material during catheterization and deployment of the stent, reperfusion hemorrhage, worsening or extension of the dissection in the weakened vessel wall. Late postprocedural risks after stenting are re-stenosis or occlusion of the stent. Therefore, this procedure should be used deliberately in select patients and should be performed by experienced interventionalists along with proper pharmacological treatment. 

Case courtesy of Prof. R. Chapot (Alfried Krupp Krankenhaus Essen, Germany).

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Case information

rID: 55801
Published: 12th Oct 2017
Last edited: 27th Jan 2018
Inclusion in quiz mode: Excluded

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