Spontaneous improvement of idiopathic intracranial carotid artery dissection: a case report

We report a rare case of spontaneous intracranial carotid artery dissection presenting with multiple infarctions. A 65-year-old man became aware of transient visual disturbance in the right eye and headache. Magnetic resonance imaging (MRI) at a local neurosurgical clinic depicted fresh multiple infarctions of the right cerebral hemisphere along with severe right carotid artery stenosis and delayed cerebral blood flow on the right side. The patient was transferred to our hospital. Three-dimensional computed tomography (3D-CT) showed an intimal flap in the righ petrous internal carotid artery and we diagnosed spontaneous intracranial carotid artery dissection of the petrous portion. We started conservative therapy including anti-coagulant and antiplatelet drug and blood pressure control. Two weeks after admission, angiography, 3D-CT, MR angiography demonstrated that the dissection had improved and the patient was discharged without neurological deficit. In this case, 3D-CT was effective for the diagnosis of intracranial carotid artery dissection. We report this rare case along with a literature review of the clinical profile and related neuroimaging findings.     

Endovascular repair of a spontaneous carotid artery dissection with carotid stent and coils

Dissection of the internal carotid artery is an under-recognized cause of transient ischemic attack and cerebral vascular accident. Spontaneous dissections, in which no precipitating cause can be identified, occur infrequently. Endovascular intervention is an evolving treatment option in patients in whom anticoagulation therapy alone is not adequate, who are not suitable candidates for major surgery, or who have extremely distal dissections that are difficult to access. We report a case of successful endovascular stenting and coil application in a patient with spontaneous dissection of the distal cervical internal carotid artery with extension to its petrous portion and an accompanying pseudoaneurysm at the level of the skull base.     

Isolated spontaneous dissection of the superior mesenteric artery treated by percutaneous stent placement: case report

Acute ischemia due to spontaneous dissections of the superior mesenteric artery are uncommon events, with sporadic reports. Therapeutic options include clinical management, direct artery repair, bowel resection, and more recently, endovascular stenting. We present a case of abdominal pain due to superior mesenteric artery spontaneous isolated dissection treated with stent placement and with a favorable 31-month follow-up period.     

Stenting for intracranial internal carotid artery stenosis with the use of a coronary stent: a case report

A 61-year-old man was admitted to our hospital for mild left hemiparesis and speech disturbance. An initial angiogram revealed occlusion of the right internal carotid artery (ICA) but with sufficient collateral flow by compensated the contralateral carotid artery. Severe stenosis (70%) in the intracavernous (C4-5) portion was identified in the left ICA. Cerebral blood flow was remarkably decreased in both hemispheres. The patient's hemiparesis fluctuated according to the systemic blood pressure in such a manner that induced hypertension therapy was mandatory. On the 19th hospital day, we performed stenting of the left ICA stenosis using a coronary stent. A flexible coronary stent, NIR PRIMO stent 3.0 mm/16 mm (SCIMED, Boston Scientific) was deployed after the predilatation (2.5 mm/10 atm). The initial 70% stenosis was reduced to 6% after the postdilatation (3.75 mm/8 atm). The neurological status was stable after the procedure and we stopped the induced hypertension therapy the next day. We consider that intracranial artery stenting will be a common therapeutic modality in the near future.     

A case of spontaneous cervical carotid artery dissection managed by using primary stent placement

The authors report the case of a 35-year-old male who underwent stenting for spontaneous cervical carotid dissection. He presented with sudden onset of hemicrania and left facial palsy followed by left hemiparesis and dysarthria. On admission, carotid angiography revealed postsinus tapering occlusion of the right internal carotid artery. Initially, he was managed with conservative treatment, but his neurological status deteriorated. Findings of brain CT, MRI and IMP-SPECT suggested hypoperfusion of the right cerebrum. A Palmaz stent, 39 mm in length, was successfully placed over the site of the dissection to restore normal patency through the dissected carotid artery. Following stent implantation, his neurological signs improved gradually but completely. Since the procedure, with oral administration of antiplatelet medication, he has suffered no cerebral ischemic events. Follow-up carotid angiography one year after stent implantation showed good patency of the stented segment. The present case emphasizes the usefulness of stenting for spontaneous cervical carotid dissection.     

Traumatic internal carotid artery dissection associated with playing soccer: a case report

Soccer, one of the most popular sports worldwide among young men, can result in a wide range of orthopedic injuries. Although vascular injuries such as dissection occur rarely, they can cause significant mortality if left undiagnosed. We report herein a 31-year-old male who suffered a large middle cerebral artery infarction due to traumatic internal carotid artery dissection after a ball struck his head and neck. He recovered with mild neurologic deficit after decompressive surgery.     

A case of iatrogenic carotid artery dissection treated with radial artery graft

A case of iatrogenic intracranial artery dissection is reported. A 52-year-old female developed severe headache and nausea. Brain CT showed diffuse subarachnoid hemorrhage. On admission, carotid angiography revealed an aneurysm in the right middle cerebral artery and the intact right internal carotid artery. The aneurysm was clipped successfully. Carotid angiography on day 7 revealed dissection in the right internal carotid artery. Repeated angiograms at 10 and 31 days showed progression of the carotid artery dissection. Findings of ECD-SPECT on day 31 (Balloon occlusion test) suggested low perfusion of the right internal carotid artery territory. The patient underwent surgical reconstruction of the right internal carotid artery using a radial artery. She presented with right abducens nerve palsy three days after the radial artery graft. The patency of the radial artery graft was proved by the post-operative angiography. Internal carotid artery dissection may occur spontaneously or as a result of trauma. An iatrogenic dissection is an uncommon complication of cerebral angiography. There are no evidence-based guidelines for the treatment although anticoagulation therapy is most commonly used. The present case emphasizes the usefulness of radial artery graft for traumatic carotid artery dissection.     

Endovascular stent placement of cervical internal carotid artery dissection related to a seat-belt injury: a case report.

OBJECT: The incidence of carotid artery dissection related to blunt injury is very low, but the mortality rate is high. Rapid diagnosis and proper treatments are discussed. CLINICAL PRESENTATION: A 48-year-old woman presented diplopia and pulsating tinnitus of the left ear. An angiography showed a carotid cavernous fistula (CCF) and dissection of the extra-cranial internal carotid artery (ICA). To treat the dissection, a self-expanding endovascular stent was used. She has been followed for 6 years without any event and the ICA is patent. CONCLUSION: Prompt diagnosis without delay and intimate follow-up is the key for the treatment of a carotid injury. Those patients who exhibit cervical bruits and/or seat-belt signs should be examined aggressively. Angioplasty with stents is amenable for patients with traumatic carotid dissections requiring vascular reconstruction in the acute stage.     

应用自膨式支架置入治疗颈动脉狭窄

目的　探索颈动脉狭窄的治疗方法。　方法　应用 14枚自膨式支架血管内置入治疗 9例有症状颈动脉狭窄患者的 10处病变 ,狭窄程度 70 % -95 %。　结果　治疗后短暂性脑缺血发作 (TIA)消失 ,残余狭窄均 <5 0 %。无症状脑梗塞 1例。无死亡。　结论　应用自膨式支架血管内置入是治疗颈动脉狭窄是一种安全有效的方法     

Common carotid artery dissection propagated from acute aortic dissection: a case successfully treated by PTA

We reported a rare case, which was successfully treated by PTA, of right common carotid artery dissection propagated from acute aortic dissection (AAD) type A. A 45-year-old male with a past history of hypertension and an artificial graft replacement of the abdominal aorta due to AAD type B, 7 years ago, was brought into our hospital by ambulance 30 minutes after an attack of fainting and left hemiparesis. On admission, the patient complained not of chest pain or left hemiparesis, but nausea. At that time his consciousness level was JCS 1. During examinations, he had the same attack twice and his consciousness level deteriorated to JCS 2. Brain MRI showed no abnormality, but cervical MRA did not visualize the right carotid artery and thoracic CT depicted acute aortic dissection including branches of the aorta. Emergent angiography disclosed that the dissecting 99% stenosis of the right common carotid artery had developed from AAD type A with poor collateral blood flow. PTA was carried out 8 times and reduced the residual stenosis to about 50% with shortened circulation time. The patient's consciousness disturbance improved. After the replacement of the whole aortic arch in an artificial graft, the residual stenosis disappeared. The patient recovered without neurological deficit but right frontal silent embolic infarction caused by the artificial graft replacement was detected. AAD is a catastrophic illness and sometimes accompanied by devastating ischemic cerebral disease (ICD) because of propagation of dissecting to extracranial vessels. This is the first report that shows the efficacy of PTA for treatment of ICD associated with AAD.     

CT demonstration of spontaneous internal carotid artery dissection. Case report

A case of internal carotid artery dissection is presented. It was diagnosed by computerized tomography (CT) and confirmed by angiography. The typical clinical presentation and radiographic evaluation are briefly reviewed. High-resolution CT scanning with intravenous contrast enhancement is a valuable diagnostic aid in the diagnosis of this entity.     

Endovascular management of spontaneous carotid artery dissection

OBJECTIVE: Despite medical therapy, a subset of patients with spontaneous carotid artery dissection (SCD) experience recurrent or progressive symptoms. In this study, we assessed the safety and efficacy of endovascular stent angioplasty in the treatment of SCD. METHODS: Seven consecutive patients with SCD underwent endovascular stent angioplasty of a total of 12 vessels. Indications included the presence of a large or enlarging pseudoaneurysm, a contraindication to anticoagulation, failure of anticoagulation, and compromised cerebral blood flow. RESULTS: Five patients had fibromuscular dysplasia. All patients tolerated the procedure well, with no adverse clinical events. All patients showed symptomatic improvement on clinical follow-up except for one patient, who had hemorrhagic conversion of a pre-existing large ischemic stroke 13 days after intervention; he made an eventual recovery to baseline. All stents have remained patent on radiologic follow-up. CONCLUSIONS: This study provides additional evidence that endovascular stent angioplasty is a safe and effective treatment for SCD in patients for whom medical treatment is not adequate.     

Bilateral spontaneous dissection of the internal carotid arteries--a case report.

A 41-year-old African American man presented with an acute stroke secondary to bilateral spontaneous internal carotid artery dissections following exercise. Spontaneous bilateral carotid artery dissection is an unusual and uncommon occurrence that can be successfully diagnosed by color-flow duplex ultrasonography and magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) imaging. A review of the literature and the authors' experience supports initial medical management of these patients. Surgery should be considered for those patients who exhibit progressive neurologic symptoms during medical management or when significant carotid artery complications, aneurysms, or flow-limiting stenoses persist.     

Middle cerebral artery dissection treated with intravenous tissue plasminogen activator injection: a case report

We present a case of middle cerebral artery (MCA) dissection that was treated with intravenous administration of recombinant tissue plasminogen activator (rt-PA). A 72-year-old woman suddenly developed dysarthria and left motor weakness without headache. On arrival at the hospital, her NIH stroke scale (NIHSS) score was 13. Magnetic resonance imaging (MRI) revealed severe stenosis of the right proximal MCA segment; this appeared to be the cause of atherothrombosis. After the MRI study, her NIHSS score improved to 5, but the evidence of MCA stenosis indicated the need for thrombolytic treatment. We injected rt-PA 102 min after the symptom onset; however, her NIHSS score fluctuated thereafter; at worst, it was 13 at 78 min after the initiation of rt-PA treatment. Eventually, her neurological status improved and after 12 hours, her NIHSS score improved to 1 but the MRI showed cerebral infarction restricted in the right putamen. Since persistent irregularity of the right MCA was shown by follow-up magnetic resonance angiography (MRA), digital subtraction angiography was performed on the 14th day after admission. Double lumen of the right MCA was detected, which was a definite proof of artery dissection. Here, we discuss the difficulties encountered in the diagnosis and treatment for MCA dissection.     

Endovascular management of a ruptured cavernous carotid artery aneurysm associated with a carotid cavernous fistula with an intracranial self-expanding microstent and hydrogel-coated coil embolization: case report and review of the literature

BACKGROUND: Ruptured CCAs are traditionally treated with endovascular management. Advances in microstent and coil technology have allowed improved intracranial navigation, increased coil packing density, and coil volume expansion to facilitate complete coil embolization of aneurysms/fistulae. We report a case of a ruptured CCA with an associated CCF treated with an intracranial, self-expanding microstent in combination with coil embolization using hydrogel-coated platinum coils. CASE DESCRIPTION: A 50-year-old woman presented with a 7-day history of severe headache and 2 days of progressive left-sided ptosis, ophthalmoplegia, and facial dysesthesias. A cerebral angiogram demonstrated a left ruptured wide-necked CCA with an associated CCF. An intracranial, self-expanding microstent (Neuroform(3), Boston Scientific, Natick, MA) was placed across the aneurysmal neck. The aneurysm was subsequently embolized with hydrogel-coated platinum coils (HydroCoil). A 3-month follow-up angiogram showed complete resolution of arteriovenous shunting with near-complete occlusion of the CCA. The patient's ocular pain and facial dysesthesias resolved completely, with near-complete resolution of ophthalmoplegia. CONCLUSIONS: This case demonstrates near-complete occlusion of a ruptured CCA and obliteration of an associated CCF using endovascular combinational therapy of an intracranial, self-expanding microstent with hydrogel-coated platinum coils. Use of this newer-generation stent-coil combination may allow more complete and durable lesion occlusion because of increased coil packing density and coil volume expansion without the need for parent artery sacrifice or balloon-remodeling techniques, thus avoiding the potential complications of such therapies.