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Case Reports
. 2020;14(10):420-427.
doi: 10.5797/jnet.cr.2019-0126. Epub 2020 Aug 10.

A Case of Internal Carotid Artery Dissection with Ischemic Onset, Followed by Subarachnoid Hemorrhage during Diagnostic Angiography

Takuma Maeda  1 , Tetsu Satow  1 , Eika Hamano  1 , Naoki Hashimura  1 , Junpei Koge  2 , Kanta Tanaka  3 , Takeshi Yoshimoto  4 , Manabu Inoue  2   3 , Masatoshi Koga  2 , Masaki Nishimura  1 , Jun C Takahashi  1
Affiliations
Case Reports

A Case of Internal Carotid Artery Dissection with Ischemic Onset, Followed by Subarachnoid Hemorrhage during Diagnostic Angiography

Takuma Maeda et al. J Neuroendovasc Ther. 2020.

Abstract

Objective: Internal carotid artery (ICA) dissection is known to cause binary types of stroke, cerebral infarction, and subarachnoid hemorrhage (SAH). However, it is rare that these two pathologies take place in a clinical scenario. We report a case of ICA dissection with ischemic onset, which was followed by SAH on the same day during diagnostic angiography.

Case presentation: A 60-year-old woman with chronic hypertension rapidly developed right hemiplegia. She had been suffering from slight headache and abnormal sensation in the right limbs 1 week before the ictus. MRI demonstrated small acute infarctions in the left middle cerebral artery (MCA) territory. The left ICA was not visualized on MRA. Diffusion-perfusion mismatch was indicated by the automated image postprocessing system. Endovascular recanalization was planned to prevent the progression of cerebral infarction. After advancing a 5MAX ACE, initial left ICA angiography was performed, resulting in extravasation of contrast medium from the C2 segment of the left ICA. 3D rotational angiography revealed left ICA dissection of the C2 segment. To secure hemostasis, the patient underwent internal trapping at the C1 and C2 segments of the left ICA. Collateral flow to the left MCA via an anterior communicating artery was observed. On day 28, the patient was transferred to a rehabilitation hospital with right hemiplegia and motor aphasia.

Conclusion: In cases of tandem lesions with preceding neurological symptoms, ICA dissection should be considered as one of the causes. Careful injection of contrast medium may be necessary if ICA dissection is strongly suspected.

Keywords: cerebral infarction; endovascular treatment; internal carotid artery dissection; parent artery occlusion; subarachnoid hemorrhage.

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Conflict of interest statement

Dr. Satow reports grants from CANON Medical Systems Corporation, outside of the submitted work. Dr. Inoue reports lecturer’s fees from Daiichi Sankyo, Bayer, Bristol- Myers Squibb, and Medtronic outside of the submitted work. The other authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1. MRI on admission. (A and B) DWI showed small acute infarctions in the left MCA territory. (C and D) The left ICA was not visualized on MRA, and the distal M1 segment of the left MCA was obstructed. (E and F) Carotid ultrasonography image of the left ICA showed stenosis with high echoic plaques. The peak systolic velocity was 2.3 m/sec. There was no evidence of dissection in the cervical carotid artery. DWI: diffusion-weighted image; ICA: internal carotid artery; MCA: middle cerebral artery
Fig. 2
Fig. 2. The automated image postprocessing system (RAPID) on admission. (A) DWIs overlaid with the stroke core identified using the apparent diffusion coefficient threshold. The estimated stroke core was 13 mL. (B) Tmax maps with green overlay for regions with abnormal flow (Tmax >6 sec). The estimated volume of delayed flow was 170 mL. The diffusion–perfusion mismatch ratio was 13.1 . DWI: diffusion-weighted image
Fig. 3
Fig. 3. Pre- and intraoperative angiography. (A) Preoperative left carotid angiography showed severe stenosis of the ICA at the level of its bifurcation. (B and C) Initial left ICA angiography after advancing the 5MAX ACE showed active bleeding into the subarachnoid space from the C2 segment of the left ICA. (D) Cone beam CT during the procedure revealed leakage of contrast medium and diffuse SAH. (E and F) 3D angiography revealed irregular dilatation at the C1 and C2 segments of the left ICA, suggesting dissection. ICA: internal carotid artery; SAH: subarachnoid hemorrhage
Fig. 4
Fig. 4. Postoperative angiography. (A–D) Left ICA angiography demonstrated obliteration of the C2 segment of the left ICA. (E and F) Collateral flow to the left MCA via an AComA was observed. The A2 segment of the left ACA and inferior trunk of the left MCA were obstructed due to thrombus migration. AComA: anterior communicating artery; ICA: internal carotid artery; MCA: middle cerebral artery
Fig. 5
Fig. 5. Follow-up MRI and angiography. (A and B) Postoperative day 1 DWI showed extensive hemispheric cerebral infarction of the left MCA and ACA territory. (C) Postoperative day 14 left carotid angiography revealed obliteration of the ICA. (D) Collateral flow to the left MCA via the AComA was still observed. The A2 segment of the left ACA and inferior trunk of the left MCA were obstructed as on postoperative DSA . ACA: anterior cerebral artery; AComA: anterior communicating artery; DWI: diffusion-weighted image; ICA: internal carotid artery; MCA: middle cerebral artery
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References

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