Stent-coil treatment of a distal internal carotid artery dissecting pseudoaneurysm on a redundant loop by use of a flexible, dedicated nitinol intracranial stent

Abstract

Treatment of dissecting pseudoaneurysms of the distal cervical internal carotid artery with preservation of the parent artery by using stents or coils has become routine. Tortuosity remains a significant obstacle to successful endovascular treatment in some cases. We report the use of a stent-coil technique to treat a nonhealing dissecting pseudoaneurysm and associated stenosis with anatomic preservation of a redundant loop involving the stented arterial segment. This was accomplished by using a Neuroform dedicated intracranial stent.

Fig 1.

A 34-year-old woman presenting with neck pain and right arm numbness after jogging. A lateral view from an acute left common carotid angiogram (A) demonstrates flame-shaped occlusion of the proximal left internal carotid artery consistent with acute dissection. An anteroposterior intracranial view from an acute right internal carotid angiogram (B) shows good cross-filling through the anterior communicating artery.

Fig 2.

After transfer to consider extracranial-intracranial bypass, a repeat left common carotid angiogram 1 week after initial presentation (A) shows recanalization of the left internal carotid artery with slow flow into the intracranial circulation and dissection of the distal cervical internal carotid artery. A follow-up left common carotid angiogram (B) obtained to confirm a pseudoaneurysm suspected because of CT angiography findings shows a dissecting pseudoaneurysm of the distal cervical internal carotid artery situated on a redundant loop of vessel with an associated significant stenosis.

Fig 3.

Endovascular treatment was performed approximately 8 months after the patient’s initial diagnosis. She was treated with anticoagulant therapy for the entire period. A selective microcatheter injection of the left internal carotid artery (A) demonstrates the pseudoaneurysm and associated stenosis. An unsubtracted left internal carotid angiogram after stent placement but before coil placement (B) shows anatomic correction of the stenosis with the Velocity stent and neck bridging of the pseudoaneurysm with preservation of the redundant loop by using the Neuroform stent. A microcatheter is seen within the aneurysm. An unsubtracted left internal carotid angiogram after coiling (C) shows near-complete obliteration of the pseudoaneurysm sac with endovascular coils. The last coil placed into the aneurysm remains attached in the image.

Fig 4.

Single-frame images from left common carotid rotational angiography before (A) and after (B) endovascular treatment demonstrate correction of the arterial stenosis, near-complete obliteration of the dissecting pseudoaneurysm by coils, and anatomic preservation of the distal cervical redundant loop of the internal carotid artery.