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“Malignant” Carotid Artery Dissection

Published online by Cambridge University Press:  02 December 2014

J. Max Findlay ,
Robert Ashforth  and
Naeem Dean
J. Max Findlay
Affiliation:
Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
Robert Ashforth
Affiliation:
Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
Naeem Dean
Affiliation:
Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
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Abstract

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Purpose:

Carotid artery dissection resulting in occlusion or severe narrowing and massive intracranial embolism can result in life-threatening hemispheric ischemia. Aggressive endovascular and microsurgical measures may be necessary to salvage life and minimize stroke morbidity in this extreme situation.

Patients and Methods:

We have treated two middle-aged women who presented within an hour of spontaneous cervical internal carotid artery (ICA) dissection causing hemiplegia, forced head and eye deviation, and declining consciousness. The first patient had a carotid occlusion through which a catheter could not be passed, so intracranial thrombolysis was achieved through a microcatheter navigated through the posterior circulation. Surgical intimectomy and thrombectomy of the dissected ICA was then carried out using an intraoperative Fogarty arterial embolectomy catheter passed up the dissected ICA, followed by endovascular stenting of the reopened cervical ICA. The second patient underwent intracranial microsurgical embolectomy and, after an unsuccessful attempt of stenting the dissected and severely narrowed cervical ICA, surgical reopening again with a Fogarty catheter. Both patients suffered basal ganglionic infarcts but most of the middle cerebral artery territories were preserved and the patients made satisfactory recoveries.

Conclusion:

“Malignant” carotid artery dissection causing occlusion or near occlusion with intracranial embolism is an important cause of severe and life-threatening hemispheric ischemia. Treatment should include aggressive endovascular and microsurgical interventions when the hemisphere is at risk.

Résumé:

RÉSUMÉ:But:

La dissection de la carotide produisant une occlusion ou un rétrécissement sévère et une embolie intracrânienne massive peut produire une ischémie hémisphérique menaçant la vie. Des mesures endovasculaires et microchirurgicales agressives peuvent être nécessaires pour sauver la vie et minimiser la morbidité par accident vasculaire cérébral dans cette situation extrême.

Patients et Méthodes:

Nous avons traité deux femmes d’âge moyen qui ont présenté une hémiplégie, une déviation forcée de la tête et des yeux et une altération de l’état de conscience moins d’une heure après une dissection spontanée de la carotide interne (CI) cervicale. La première avait une occlusion carotidienne à travers laquelle un cathéter ne pouvait passer, de telle sorte que la thrombolyse intracrânienne a été effectuée au moyen d’un microcathéter introduit par la circulation postérieure. Une intimectomie chirurgicale et une thrombectomie de la CI disséquée a ensuite été effectuée au moyen d’un cathéter de Fogerty pour embolectomie artérielle placé au delà de la CI disséquée, suivie de la mise en place d’une endoprothèse dans la CI cervicale réouverte. La deuxième patiente a subi une embolectomie microchirurgicale intracrânienne et, après une tentative infructueuse de mise en place d’une endoprothèse dans la CI cervicale disséquée et sévèrement rétrécie, elle a subi une réouverture chirurgicale avec un cathéter de Fogarthy. Les deux patientes ont subi des infarctus dans les noyaux gris centraux mais la plupart des territoires de l’artère cérébrale moyenne ont été préservés et les patientes ont eu une récupération satisfaisante.

Conclusions:

La dissection “maligne” de la carotide causant une occlusion totale ou quasi totale avec embolie intracrânienne est une cause importante d’ischémie hémisphérique sévère, menaçant la vie. Le traitement devrait inclure des interventions endovasculaires et microchirurgicales agressives quand l’hémisphère est à risque.

Type
Case Report
Information
Canadian Journal of Neurological Sciences , Volume 29 , Issue 4 , November 2002 , pp. 378 - 385
Copyright
Copyright © The Canadian Journal of Neurological 2002

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