Endovascular Treatment of Spontaneous Intracranial Internal Carotid Dissection in a Young Patient Affected by Systemic Lupus Erythematosus: A Case Report

Abstract

Systemic lupus erythematosus (SLE) increases the risk of cerebrovascular events due to vascular changes, resulting in the weakening of the vessel walls. Moreover, patients with SLE have more incidence of arterial lesions such as dissections. Internal carotid dissection (ICA) is an infrequent cause of ischemic stroke, representing 2% of all ischemic events. We present a case of ischemic stroke, caused by a spontaneous dissection of intracranial ICA, treated with endovascular stent implantation, in a 22-year-old woman affected by SLE, newly diagnosed. ICA dissection with consequent ischemic stroke is an unusual first presentation of SLE disease. Our case highlights how, despite an infrequent occurrence, ICA dissection should be considered for young adults presenting with ischemic stroke, especially in those affected by SLE. This paper also shows the good technical result in the use of stenting in case of intracranial ICA dissection.

Keywords: Systemic lupus erythematosus (SLE); dissection; internal carotid artery (ICA).

Figure 1. Axial NCCT scan depicts hyperdensity of right ICA distal bifurcation due to occlusion (arrow).

Figure 2. (A) Axial MRA TOF-3D scan shows intimal flap of ICA probably related to dissection (arrow). (B) MRI DWI (b = 1000 s/mm²) shows hyper-intensity of frontal lobe, lenticular nucleus, head of caudate, insula, and deep frontal white matter. (C) Axial MRA TOF-3D shows right ICA occlusion with some flow in M2–M3 segments. (D) pCASL sequence shows wide hypo-perfusion of right hemisphere compared with DWI compatible with ischemic penumbra.

Figure 3. Angiographic series in L–L view show slow flow into middle cerebral artery beyond tight stenosis of ICA due to dissection (red arrow).

Figure 4. Angiographic series in oblique view after stent implantation show a better visualization of middle cerebral artery, despite a stenosis at the origin (red arrow).

Figure 5. (A) Axial CTA scan performed after 12 hours shows stent patency. (B) Axial FLAIR scan performed after nine days since admission shows the same lesions at the admission MRI plus a new post-central ischemic area (white arrows). (C) MRA TOF-3D Axial scan shows blood flow through the stent into middle cerebral artery segments despite the presence of prominent artifacts. (D) pCASL sequence performed after nine days since admission shows a better perfusion of right hemisphere than the same sequence performed at admission.