Internal carotid artery dissection with associated perfusion deficit treated by stent placement
Presentation
Right eye vision disturbances and left sided fluctuating sensorimotor hemiparesis since 2 hours.
Patient Data
CT & Perfusion
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 hemodynamic relevance.
Angio & stent Rt ICA placement
Angiogram shows right ICA dissection followed up by ICA stent placement.
Control angiogram after stent placement shows alleged influx lesion.
CTP post carotid stent
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.
MRI postinterventional
Postinterventional MRI two days after symptom onset and stent placement shows no territorial infarction, tissue edema or intracranial hemorrhage.
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 ischemia. The anticoagulation we used during the intervention was Eptifibatide (Integrilin) by perfusor and acetylsalicylate 500mg bolus i.v. Upon waking up from general anesthesia the patient was symptom free, the postinterventional perfusion showed normalized perfusion.
There are risks associated with stenting of a carotid artery dissection like embolization 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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