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AJNR - American Journal of Neuroradiology

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Endovascular Management of Extracranial Carotid Artery Dissection Achieved Using Stent Angioplasty

Adel M. Malek^,a, Randall T. Higashida^a, Constantine C. Phatouros^a, Todd E. Lempert^a, Philip M. Meyers^a, Wade S. Smith^a, Christopher F. Dowd^a and Van V. Halbach^a

^a From the Departments of Radiology (A.M.M., R.T.H., C.C.P. T.E.L., P.M.M., C.F.D., V.V. H.), Division of Interventional Neurovascular Radiology, Neurosurgery (R.T.H., C.F.D., V.V.H.), and Neurology (W.S.S.), University of California, San Francisco, 94143, USA.

View larger version (54K): [in a new window]   FIG 1. Simplified schematic illustration of the pathophysiologic process of carotid artery dissection proceeding from the acute stage to either spontaneous healing (1), formation of false lumen (2), residual stenosis of varying degree or complete occlusion (3), and formation of a pseudoaneurysm (4). A stent is used in cases that have not responded to medical therapy either to relieve a hemodynamically significant stenosis, to occlude a false lumen, or to serve as a scaffold to enable coil embolization of a wide-necked pseudoaneurysm

View larger version (159K): [in a new window]   FIG 2. A 45-year-old woman (patient 1) noted to have developed left hemiparesis after diagnostic angiography at an outside hospital. Head CT scan shows evidence of a previous focal infarct as well as diffuse edema in the right posterior frontal lobe (A). Digital subtraction angiography of the right common carotid artery reveals tapering of the right internal carotid artery, to a complete occlusion, with appearance consistent of dissection (B). Injection of the right external carotid artery (C) shows retrograde collateral flow through the right ophthalmic artery, with filling of the cavernous segment of the right ICA. Injection of the left internal carotid artery shows no significant flow across the anterior communicating artery (D)

View larger version (213K): [in a new window]   fig. 2 (continued). Treatment approach consisted of initial recanalization of the dissected right internal carotid artery achieved by entering the true lumen by using a Rapid Transit microcatheter and Instinct-10 microguidewire (arrowheads) (E), and advancing up to the cavernous portion of the right internal carotid artery (arrow) (F). Superselective injection shows a patent right middle and anterior cerebral artery (G). An 8-mm x 2-cm Wallstent was then deployed at the dissection site over a Stabilizer exchange microguidewire at the C2 level (H). The reconstitution of the lumen of the right internal carotid artery is shown by injection of the right common carotid artery (I), with resumption of intracranial perfusion (J)

View larger version (99K): [in a new window]   FIG 3. A 51-year-old man (patient 5) with a 10-day history of left-sided TIAs now presents with sudden onset of aphasia and right hemiparesis. Axial T1-weighted contrast-enhanced MR imaging shows a left frontal infarct (A). Digital subtraction angiography of the left common carotid artery showed progression of a left internal carotid dissection from a partial stenosis, 2 days prior, to a complete occlusion despite systemic anticoagulation (B). Digital subtraction angiography of the right common carotid artery revealed a dissection of the right internal carotid artery with an associated long-segment stenosis and an expansile pseudoaneurysm at the distal end (C). A Rapid Transit microcatheter was used to navigate the patent lumen of the right internal carotid artery and to deploy three Wallstents (6 mm x 45 mm, 7 mm x 20 mm, and 8 mm x 20 mm) in a tandem overlapping fashion with postdeployment balloon angioplasty (D). The procedure resulted in reconstitution of the normal lumen of the right internal carotid artery (E)

View larger version (132K): [in a new window]   FIG 4. An 83-year-old man (patient 4) with a history of aortic dissection, which was surgically repaired 10 years previously, presents with left hemispheric TIAs and episodes of aphasia. Digital subtraction angiography of the left common carotid artery outlines a chronic extensive dissection, with antegrade flow through the true lumen and retrograde flow in the false lumen down to the aorta, by virtue of the Venturi effect at the aortic arch (A, early injection; B, late injection). Two stents were placed in tandem overlapping fashion, followed by postdeployment angioplasty, resulting in a near-complete elimination of the retrograde flow in the now-reduced false lumen (C, D)

View larger version (237K): [in a new window]   FIG 5. A 51-year-old man (patient 3) developed sudden loss of vision in the left eye, a left Horner's syndrome, and orthostatic lightheadedness. Digital subtraction angiography with injection of the right common carotid artery shows intimal dissection of the right internal carotid artery in the high cervical region, with delineation of the true and false lumen (A, B). Injection of the left common carotid artery, which had evidence of dissection but was shown to be patent on an angiogram obtained 4 days earlier, now reveals complete left internal carotid artery occlusion (arrowhead) despite systemic anticoagulation (C). A Rapid Transit microcatheter was used to catheterize the true lumen, followed by deployment of a Wallstent (6 mm x 20 mm) in the proximal portion of the dissected segment (D). Persistent filling of the false lumen, however, required the tandem placement of two additional GFX stents (4 mm x 12 mm) in the petrous segment of the right internal carotid artery (E), with reconstitution of the normal luminal diameter (F)