Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents

Abstract

Background and purpose: Although most cervical dissections are managed medically, emergent endovascular treatment may become necessary in the presence of intracranial large-vessel occlusions, flow-limiting and long-segment dissections with impending occlusion, and/or hypoperfusion-related ischemia at risk of infarction. We investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting.

Materials and methods: We retrospectively studied long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥3 stents) and presenting with acute (<12 hours) ischemic stroke symptoms (NIHSS score, ≥4). We analyzed patient demographics, vascular risk factors, clinical presentations, imaging/angiographic findings, technical procedures/complications, and clinical outcomes.

Results: Fifteen patients (mean age, 51.5 years) with acute ischemic stroke (mean NIHSS score, 15) underwent endovascular stent reconstruction for vessel and/or ischemic tissue salvage. All carotid dissections presented with >70% flow limiting stenosis and involved the distal cervical ICA with a minimum length of 3.5 cm. Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b-3 reperfusion. Two procedural complications were limited to thromboembolic infarcts from in-stent thrombus and asymptomatic hemorrhagic infarct transformation (7% morbidity, 0% mortality). Angiographic and ultrasound follow-up confirmed normal carotid caliber and stent patency, with 2 cases of <20% in-stent stenosis. Early clinical improvement resulted in a mean discharge NIHSS score of 6, and 9/15 (60%) patients achieved a 90-day mRS of ≤2.

Conclusions: Emergent stent reconstruction of long-segment and flow-limiting carotid dissections in acute ischemic stroke intervention is safe and effective, with favorable clinical outcomes, allowing successful thrombectomy, vessel salvage, restoration of cerebral perfusion, and/or prevention of recurrent thromboembolic stroke.

Fig 1.

Illustrative case (patient 13). A, NCCT axial image demonstrates no large regional infarction or intracranial hemorrhage, but a hyperdense left MCA sign suggestive of a large vessel occlusion. Coronal (B) and axial (C) CTA head/neck images demonstrate a long-segment left ICA dissection involving the proximal cervical-to-horizontal petrous segment with an associated distal M1 segment left MCA occlusion. D, CT brain perfusion study with preserved relative cerebral blood volume, markedly elevated relative mean transit time (E), and mildly decreased relative cerebral blood flow (F), consistent with severe hemodynamic impairment and hypoperfusion-related ischemia in the left cerebral hemisphere.

Fig 2.

Illustrative case (patient 13). A and B, Lateral DSA images demonstrate a tapered and severely narrowed left ICA dissection with flow limitation that extends across the cervical segment into the skull base. C, Anteroposterior DSA image of an aspiration thrombectomy catheter navigated across the left ICA cervical dissection and placed just proximal to the M1 segment thromboembolus. D, Lateral DSA image demonstrates successful thrombolysis/thrombectomy, resulting in complete recanalization and eventual TICI 3 reperfusion of the left MCA distribution. E–H, Serial anteroposterior DSA images demonstrate stent reconstruction of the long-segment left ICA dissection after MCA thrombectomy, distal to the petrocavernous junction into the proximal cervical left ICA, resulting in near-normal vessel caliber, with no residual stenosis or flow limitation. Note spontaneous thrombosis of the carotid pseudoaneurysm (arrow) and no residual subintimal contrast in the midcervical segment after stent-induced apposition of the intimal flap.