Contralateral cerebral infarction after stent placement in carotid artery: an unexpected complication

Abstract

Stenting is a useful alternative treatment modality in carotid artery stenosis patients who are too high-risk to undergo carotid endarterectomy (CEA). We report a case of contralateral cerebral infarction after stenting for extracranial carotid stenosis. A 78-year-old woman was admitted to the hospital with left-sided weakness. Based on magnetic resonance imaging (MRI) of the brain and conventional angiography, she was diagnosed with an acute watershed infarct of the right hemisphere secondary to severe carotid stenosis. Stenting was performed for treatment of the right carotid artery stenosis after a one-week cerebral angiogram was completed. Thirty minutes after stent placement, the patient exhibited a generalized seizure. Four hours later, brain MRI revealed left hemispheric cerebral infarction. Complex aorta-like arch elongation, tortuosity, calcification, and acute angulation at the origin of the supra-aortic arteries may increase the risk of procedural complications. In our case, we suggest that difficult carotid artery catheterization, with aggressive maneuvering during stenting, likely injured the tortuous, atherosclerotic aortic arch, and led to infarction of the contralateral cerebral hemisphere by thromboemboli formed on the wall of the atherosclerotic aorta.

Keywords: Carotid stenosis; Complication; Stenting.

Fig. 1

A : Diffusion-weighted magnetic resonance image showing acute watershed infarction in the right hemisphere. B, C : Right brachiocephalic arteriogram (B) and non-subtracted image of catheterization in the left common carotid artery (C) showing the right brachiocephalic trunk (long arrow) arising below the top of the aortic arch (dotted line) with sharp angulation, bilateral tortuous common carotid arteries (by look of simmons catheters), and multiple calcifications (short arrow) along the wall of the aortic arch.

Fig. 2

A : Right common carotid arteriogram showing severe stenosis of the internal carotid artery. B, C : Left extracranial (B) and intracranial (C) carotid arteriograms showing no significant stenosis in the extracranial or intracranial portions of the vessel.

Fig. 3

A : Right common carotid arteriogram after stenting shows no residual stenosis. B, C : Diffusion-weighted magnetic resonance image (B) and magnetic resonance angiogram (C) show new acute infarction in the frontal branch territory and occlusion of the frontal branch (arrow) of the left middle cerebral artery.