Bilateral spontaneous internal carotid artery dissection managed with endovascular stenting - A case report

Abstract

Carotid artery dissection (CAD) is a frequent cause of stroke, accounting for up to 25% of all ischemic strokes in young and middle-aged patients.^1,2 It may be traumatic or spontaneous, with multi-factorial etiology. A tear in the arterial wall causes intrusion of blood within its layers, producing intra-luminal stenosis, or aneurysmal dilatation.³ Thrombo-embolism arising from this anatomic disruption has been postulated as the essential stroke mechanism in CAD.⁴ Bilateral internal carotid artery dissection (ICAD) has been rarely reported.^1,4 Antiplatelets and anticoagulation remain standard therapy for CAD.⁵ However, in patients with either expanding pseudoaneurysms, severe flow compromise, worsening symptoms despite anticoagulation or contraindication to anticoagulation, endovascular stenting is beneficial.⁶ We describe a patient with ischemic stroke from spontaneous bilateral ICAD with completely occluded left ICA. Having failed medical therapy with antiplatelets and anticoagulants due to extensive loss of carotid vascular supply, he was managed successfully with endovascular stenting with good neurological recovery.

Keywords: Carotid artery dissection; Endovascular treatment; Stroke.

Fig. 1

(A) Carotid angiogram image showing dissection of the right internal carotid artery with subtotal occlusion of the right middle cerebral artery. (B) Carotid angiogram image showing dissection of the left internal carotid artery total occlusion of the left middle cerebral artery. (C) Selective angiogram in the left internal carotid artery showing dissection of the left ICA with complete occlusion of the left middle cerebral artery.

Fig. 2

(A) Image showing three tandem stents in the left ICA. (B) Post-stenting image showing good flow in the left middle cerebral artery with collateral flow to the right middle cerebral artery through the anterior cerebral artery.