Primary stent implantation for bilateral spontaneous cervical ICA dissections with hypoperfusion after 72 h from onset: a case report

Abstract

Background: Spontaneous cervical internal carotid artery dissection (cICAD) is a common cause of stroke in young adults. Endovascular therapy is an indispensable treatment for cICAD in some cases, but it faces great challenges.

Case presentation: A bilateral spontaneous cICADs with hypoperfusion-related AIS after 72 h from the onset was presented herein. The patient responded well to primary Solitaire stent detachment at the critical flow-limiting site.

Conclusions: Primary stent implantation at the critical flow-limiting site rather than covering the entire dissection may be a therapeutic option in spontaneous cICAD complicated with cerebral hypoperfusion. The Solitaire stent may be a good choice at the acute and subacute stages of cICAD.

Keywords: Acute ischemic stroke; Endovascular treatment; Internal carotid artery; Spontaneous dissection; Stenting.

Fig. 1

The first procedure. a-b On Sep 2, 2020, emergent head NCCT revealed new infarctions in the right internal watershed area. (a. red arrows), head CTP showed an ischemic penumbra of 100.3 mL in the bilateral ICAs (green area). c-h Emergent EVT on Sep 3, 2020: Preprocedural angiogram showed long stenosis with a double lumen sign, distal to the right carotid bulb (c. red arrows indicated a flow-limiting segment), string-like stenosis distal to the left carotid bulb (d. red arrows indicated a flow-limiting segment) with an opening into left PCom A (e. red arrow); The microcatheter was in the true lumen, which was confirmed by post-lesion angiography (f. red arrow); A 6 × 30 mm Solitaire FR stent was temporarily deployed in the key flow-limiting segment through a microcatheter (g. red arrows indicated the distal and proximal markers of the stent); After the stent release, angiogram showed that the stenosis of the lesion was reduced, the double-lumen sign disappeared, the anterior blood flow was significantly improved, and a small amount of compensation was made to the left anterior circulation through ACom A (h). i-j On Sep 4, 2020, repeated head NCCT revealed more pronounced infarctions than the pre-procedure status (red arrows), head CTP showed that the perfusion of the blood supply area of the right ICA was recovered, and the penumbra of the blood supply area of left ICA was enlarged to 114.2 mL, compared with that before the procedure (green area)

Fig. 2

The second procedure. a-b On Sep 9, 2020, emergent head NCCT showed no new lesion in the left hemisphere, and head CTP revealed a new core infarct of 18.2 mL in the left frontal lobe with an ischemic penumbral area of 100.4 mL in the left ICA supply area. c-i On Sep 9, 2020, an emergent EVT was performed. Preprocedural angiogram showed that the right ICA remained patent with residual moderate-to-severe stenosis and dissecting aneurysm and compensation to the left ACA and MCA via the ACom A (c), the left ICA was occluded distal to the bulb and manifested a flame sign with a refluxed flow to the C4 segment via the ophthalmic artery in the distal end (d); the position of the microcatheter tip (e. white arrow), the position of the CAT6 tip (e. black arrow), the position of the 8F guide catheter tip (e. red arrow); Applying with SCP technique, the left ICA was revascularized with a residual dissecting aneurysm (f. white arrow) and a red arrow indicated the key flow-limiting stenosis (f); red arrows indicated the distal and proximal markers of the 6 × 30 mm Solitaire FR stent (g); the P-A and oblique angiogram after stent detachment showed that the stenosis was relieved and the dissecting aneurysm disappeared (h-i). j-k On Sep 14, 2020, repeated head NCCT showed that the new core infarct appeared in the left frontal lobe, and head CTP suggested that the perfusion of bilateral ICAs blood supply areas returned to normal

Fig. 3

Follow-up images. a-b Follow-up CTA at three months showed that bilateral ICAs were repaired well (Nov 26, 2020); c-d Follow-up CTA at 15 months showed that bilateral ICAs remained patent and no dissection relapsed (Dec 13, 2021)