Intentional subintimal carotid stenting of internal carotid dissection in a patient with acute ischaemic stroke

Abstract

Carotid artery dissection is a common cause of juvenile stroke. Endovascular treatment of acute stroke due to carotid dissection can be challenging, and endoluminal crossing of the dissection is sometimes impossible. We describe a case of intentional subintimal recanalisation of a cervical carotid dissection followed by intracranial thrombectomy and stenting. We report the case of a young woman with severe acute ischaemic stroke due to carotid artery dissection and intracranial embolism. After failure of endoluminal crossing of the dissected segment, intentional subintimal crossing with re-entry distally to the dissection was achieved and a stent was deployed. Then, middle cerebral artery thrombectomy was performed achieving good recanalisation. Acute thrombus formed in the bulged segment of the carotid stent and was managed with additional stent placement. The patient had a good clinical recovery. In selected cases, after failure of conventional techniques, subintimal recanalisation of carotid dissections may be performed.

Keywords: Stroke; carotid dissection; stenting; subintimal.

Figure 1.

Right common carotid artery angiography showing dissection of the internal carotid artery (ICA) (a). Slow selective injection of the ICA confirms the presence of non-occlusive dissection of the extracranial ICA with embolic occlusion of the syphon (b). Contralateral ICA injection shows trans-communicating filling of the right anterior cerebral artery and pial collateral circulation for right middle cerebral artery territory (c).

Figure 2.

Selective injection from a microcatheter in the intrapetrous segment of the internal carotid artery (ICA) after re-entry in the true lumen. The injection shows filling of the true lumen distal to the dissected segment, the intimal flap with a fluid–fluid level at the re-entry point and retrograde filling of the false lumen (a). After deployment, the carotid Wallstent appeared overdilated in the proximal segment, maybe because of the low resistance of the carotid wall in subintimal tract (b). Selective injection confirming carotid syphon occlusion (c). After thrombectomy, the ICA and middle cerebral artery were recanalised with a small residual distal occlusion (TICI 2b) (d). A large non-occlusive clot inside the stent was observed (e). The final result after deployment of another coaxial carotid stent with distal protection (f).