Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection

Abstract

Arterial dissections account for 2% of strokes in all age groups, and up to 25% in patients aged 45 years or younger. The safety of endovascular intervention in this patient population is not well characterized. We identified all patients in the Merci registry - a prospective, multi-center post-market database enrolling patients treated with the Merci Retriever thrombectomy device - with arterial dissection as the most likely stroke etiology. Stroke presentation and procedural details were obtained prospectively; data regarding procedural complications, intracerebral hemorrhage (ICH), and the use of stenting of the dissected artery were obtained retrospectively. Of 980 patients in the registry, ten were identified with arterial dissection (8/10 ICA; 2/10 vertebrobasilar). The median age was 48 years with a baseline NIH stroke scale score of 16 and median time to treatment of 4.9 h. The procedure resulted in thrombolysis in cerebral ischemia (TICI) scores of 2a or better in eight out of ten and TICI 2b or better in six out of ten patients. Stenting of the dissection was performed in four of nine (44%). The single complication (1/9; 11%) - extension of a dissected carotid artery - was treated effectively with stenting. No symptomatic ICH or stroke in a previously unaffected territory occurred. A favorable functional outcome was observed in eight out of ten patients. Despite severe strokes on presentation, high rates of recanalization (8/10) and favorable functional outcomes (8/10) were observed. These results suggest that mechanical thrombectomy in patients with acute stroke resulting from arterial dissection is feasible, safe, and may be associated with favorable functional outcomes.

Figure 1

A representative patient (case 4). An 18-year-old with spontaneous dissection of the right internal carotid artery and carotid-T occlusion. A) Left internal carotid artery injection, AP view, prior to intervention demonstrates no cross-filling of the right anterior circulation with a cutoff of the right A1 anterior cerebral artery consistent with possible carotid-T occlusion. B) Right common carotid injection, lateral view, demonstrates flame-shaped tapering/occlusion of the right ICA consistent with dissection. C) An 035 inch exchange wire was placed in the right external carotid artery and the 5F diagnostic catheter exchanged for a 6F flexor shuttle which was brought into the right carotid bulb proximal to the occlusion. The occlusion was then traversed with a coaxial system consisting of an 18L microcatheter inside an 044 inch Distal Access Catheter; this system was used as a rail allowing the 6F shuttle to be brought up distal to the occlusion. Repeat injection through the Shuttle, AP view, confirms occlusion of the carotid terminus. D) After one pass with the Merci Retriever v2.5 Firm, an injection through the guide catheter, AP view, demonstrates that the carotid terminus is recanalized, with flow re-established through the right M1 and M2 MCA branches and the right A1 ACA. E) After withdrawal of the shuttle proximal to the dissection, repeat injection, lateral view, demonstrates persistent occlusion of the right ICA. F) Repeat angiography of the left internal carotid artery demonstrates excellent cross-filling across the anterior communicating artery to supply the right anterior circulation.