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Spontaneous dissection of the bilateral internal carotid and vertebral arteries: A rationale for endovascular management
Journal of the Neurological Sciences 350 (2015) 112–114
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Letter to the Editor Spontaneous dissection of the bilateral internal carotid and vertebral arteries: A rationale for endovascular management Keywords: Arterial dissection Cerebrovascular Headache Interventional Stroke Transient ischemic attack
1. Introduction Spontaneous cervical-artery-dissection (sCAD) is a common cause of stroke in young patients. The incidence of concurrent sCAD of more than one neck artery ranges between 10 and 28% [1]. Multi-vessel sCAD is associated with a higher risk of intracranial hemorrhage as well as a higher risk of recurrent stroke or TIA [1]. Postpartum CAD accounts for 6% of spontaneous CAD in women under 50 years of age [2]. Medical management is the primary treatment approach, while the role of endovascular intervention remains unclear. We present a case of four-vessel postpartum CAD that was treated successfully with endovascular reconstruction of the bilateral internal-carotid-arteries (ICAs).
2. Case report A 28-year-old-white-female, 2-weeks-postpartum, following a spontaneous vaginal delivery presented with right hemiparesis, gaze deviation, and mixed aphasia with a National-Institutes-ofHealth-stroke-scale score of 8 points. A computed-tomography (CT) scan of the brain demonstrated hypodensity in the left frontoparietal region. Considering ischemic changes on CT-brain, she was not considered for intravenous-thrombolysis. Diffusion-weightedimaging revealed left fronto-parietal and right parieto-occipital acute cerebral infarctions. CT-angiogram showed flow-limiting bilateral cervical ICA dissections. Digital-Subtraction-Angiography (DSA) revealed occlusive dissection of the bilateral ICAs along with non-flow-limiting bilateral cervical vertebral-artery dissections. The vertebral-arteries perfused anterior circulation via the functional posterior-communicating-arteries (Fig. 1).
Abbreviations: CT, computed tomography; CTA, CT angiogram; DSA, digital subtraction angiography; NIHSS, National Institutes of Health Stroke Scale; sCAD, spontaneous cervical artery dissection; TIA, transient ischemic attack.
http://dx.doi.org/10.1016/j.jns.2015.02.006 0022-510X/© 2015 Elsevier B.V. All rights reserved.
The patient was initially treated with bolus dose of heparin intravenously followed by a loading dose of Plavix. Three overlapping stents were deployed in the left ICA, beginning in the horizontal petrous segment with a Solitaire Fr (Covidien, Mansfield, MA) 6 mm × 30 cm followed by 2 telescoping Cordis (Bridgewater, NJ) Precise Pro RX 7 mm × 40 cm and Precise Pro RX 8 mm × 30 cm stents. Similarly, one Medtronic (Minneapolis, MN) AVE 4.0 mm × 20 mm Integrity RX coronary and two Cordis Precise Pro RX 7 mm × 40 cm carotid stents were deployed in the right ICA. Post-stenting angiography demonstrated successful reconstruction of the cervical ICAs (Fig. 1). The diagnostic work-up excluded polycystic kidney disease, or connective tissue disorders. Straining during labor was thought to be the mechanism of the four vessel sCAD of our patient. She was discharged home with NIHSS and modified-Rankin-Scale of 0 on day 5. CT angiography at 6 months demonstrated complete patency of the stents and healing of the vertebral dissections.
3. Discussion Multi-vessel flow-limiting sCAD is an unpredictable clinical presentation associated with unique management challenges. Treatment options include intravenous-thrombolysis during the first 4.5 h of acute cerebral ischemia, antiplatelet/anti-coagulation therapies and/or endovascular interventions. Medical management with antiplatelet or anti-coagulation therapy is the standard of care because most dissections heal spontaneously when treated medically and recurrent stroke rates are low on medical therapy [3]. Endovascular treatment is reserved for complicated cases or failures of medical management. The most common reason for acute endovascular therapy in the presence of non-traumatic dissection is a tandem intracranial occlusion due to embolus from the dissection site [4]. Other less frequent indications for endovascular treatment that may present weeks to months after the initial dissection include expanding pseudo aneurysm causing pain, cranial neuropathy, or recurrent stroke due to distal embolization. In our patient, we decided to proceed with stenting and reconstruction of the ICAs due to the dependence of the patient's anterior cerebral circulation on her already injured vertebral-arteries via the functional posterior-communicating-arteries as well as in fear of sudden distal embolization from the acutely thrombosed ICAs. Moreover, progression of vertebral dissections to high-grade stenosis or occlusion may have been complicated with recurrent cerebral ischemia in the anterior and/or posterior circulation. Finally, observational data indicates higher risk of recurrent cerebrovascular events in patients with multi-vessel sCAD [3]. We used Solitaire stent due to its ability to be recaptured and repositioned and this was considered to be advantageous in the petrous–cavernous ICA junction. Bilateral vertebral-artery dissections were managed medically with double antiplatelet therapy, as there was no flow limitation or free-floating thrombus. Our experience
Letter to the Editor
113
Fig. 1. MRI-brain DWI demonstrates left fronto-parietal (A) and right parieto-occipital (B) acute infarctions. Right vertebral digital-subtraction-angiogram (DSA) (C) demonstrates nonflow-limiting dissection of right cervical vertebral-artery (VA). Left vertebral DSA demonstrates non-flow-limiting dissection of left cervical VA (D), and patent intracranial portion of left VA and basilar-artery (E). Left common-carotid DSA demonstrates occlusive dissection of left cervical internal-carotid-artery (ICA) (F), and retrograde filling of the ophthalmic-artery with opacification of the intracranial circulation (G). Right common-carotid artery DSA demonstrates occlusive dissection of right cervical ICA (I), and retrograde filling of the ophthalmic-artery with opacification of the intracranial circulation (H). Left common-carotid DSA demonstrates successful reconstruction of left cervical ICA (J), and restoration of anterograde flow (K). Right common-carotid DSA demonstrates successful reconstruction of right cervical ICA (L), and restoration of anterograde flow (M).
parallels the observations of Cohen et al. [5], who reported similar favorable outcomes in 3 cases of symptomatic sCAD causing ICA occlusion that were treated with endovascular stenting. Possible complications of such an endovascular procedure are ischemic stroke caused by distal emboli, hemorrhagic stroke caused by reperfusion injury, injury to vessel wall or puncture site complications. In conclusion, our case highlights that endovascular reconstruction of the dissected cervical-arteries may be performed safely and should be considered in selected patients with multi-vessel dissections. Sources of funding There are no sources of funding to report associated with this manuscript. Disclosures The authors received no funding related with this work. Drs. Goyal, Male, and Doss have no financial relationships to disclose outside of this work. Dr. Arthur served as a consultant for Covidien, Johnson and Johnson, Siemens, Stryker, and Terumo; and received grants from Siemens and Terumo outside the submitted work. Dr. Elijovich has served as a consultant for Stryker Neurovascular,
Microvention, and Codman Neurovascular outside the submitted work. Conflict of interest The authors report no conflicts of interest in this work. Acknowledgments The authors wish to thank Andrew J. Gienapp for technical and copy editing, preparation of the manuscript and figures for publishing, and publication assistance with this manuscript. References [1] Touze E, Gauvrit JY, Moulin T, Meder JF, Bracard S, Mas JL. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology 2003;61: 1347–51. [2] Arnold M, Camus-Jacqmin M, Stapf C, Ducros A, Viswanathan A, Berthet K, et al. Postpartum cervicocephalic artery dissection. Stroke 2008;39(8):2377–9. [3] Patel RR, Adam R, Maldjian C, Lincoln CM, Yuen A, Arneja A. Cervical carotid artery dissection: current review of diagnosis and treatment. Cardiol Rev 2012;20: 145–52. [4] Seet RC, Wijdicks EF, Rabinstein AA. Stroke from acute cervical internal carotid artery occlusion: treatment results and predictors of outcome. Arch Neurol 2012;69: 1615–20.
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[5] Cohen JE, Gomori JM, Leker RR, Ben-Hur T, Grigoriadis S, Rajz G. Recanalization of symptomatic carotid artery dissections causing occlusion with multiple stents: the use of delayed double-contrast road map. Neurol Res 2010;32:293–6.
Nitin Goyal Shailesh Male Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA Vinodh T. Doss Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis TN, USA Adam Arthur Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis TN, USA Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
Lucas Elijovich Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis TN, USA Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA Corresponding author at: University of Tennessee Health Sciences Center, Semmes-Murphey Neurologic and Spine Institute, 6325 Humphreys Blvd., Memphis, TN 38120, USA. Tel.: +1 901 522 7700; fax: +1 901 259 0132. E-mail address: [email protected]. 15 October 2014
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Letter to the Editor Spontaneous dissection of the bilateral internal carotid and vertebral arteries: A rationale for endovascular management Keywords: Arterial dissection Cerebrovascular Headache Interventional Stroke Transient ischemic attack
1. Introduction Spontaneous cervical-artery-dissection (sCAD) is a common cause of stroke in young patients. The incidence of concurrent sCAD of more than one neck artery ranges between 10 and 28% [1]. Multi-vessel sCAD is associated with a higher risk of intracranial hemorrhage as well as a higher risk of recurrent stroke or TIA [1]. Postpartum CAD accounts for 6% of spontaneous CAD in women under 50 years of age [2]. Medical management is the primary treatment approach, while the role of endovascular intervention remains unclear. We present a case of four-vessel postpartum CAD that was treated successfully with endovascular reconstruction of the bilateral internal-carotid-arteries (ICAs).
2. Case report A 28-year-old-white-female, 2-weeks-postpartum, following a spontaneous vaginal delivery presented with right hemiparesis, gaze deviation, and mixed aphasia with a National-Institutes-ofHealth-stroke-scale score of 8 points. A computed-tomography (CT) scan of the brain demonstrated hypodensity in the left frontoparietal region. Considering ischemic changes on CT-brain, she was not considered for intravenous-thrombolysis. Diffusion-weightedimaging revealed left fronto-parietal and right parieto-occipital acute cerebral infarctions. CT-angiogram showed flow-limiting bilateral cervical ICA dissections. Digital-Subtraction-Angiography (DSA) revealed occlusive dissection of the bilateral ICAs along with non-flow-limiting bilateral cervical vertebral-artery dissections. The vertebral-arteries perfused anterior circulation via the functional posterior-communicating-arteries (Fig. 1).
Abbreviations: CT, computed tomography; CTA, CT angiogram; DSA, digital subtraction angiography; NIHSS, National Institutes of Health Stroke Scale; sCAD, spontaneous cervical artery dissection; TIA, transient ischemic attack.
http://dx.doi.org/10.1016/j.jns.2015.02.006 0022-510X/© 2015 Elsevier B.V. All rights reserved.
The patient was initially treated with bolus dose of heparin intravenously followed by a loading dose of Plavix. Three overlapping stents were deployed in the left ICA, beginning in the horizontal petrous segment with a Solitaire Fr (Covidien, Mansfield, MA) 6 mm × 30 cm followed by 2 telescoping Cordis (Bridgewater, NJ) Precise Pro RX 7 mm × 40 cm and Precise Pro RX 8 mm × 30 cm stents. Similarly, one Medtronic (Minneapolis, MN) AVE 4.0 mm × 20 mm Integrity RX coronary and two Cordis Precise Pro RX 7 mm × 40 cm carotid stents were deployed in the right ICA. Post-stenting angiography demonstrated successful reconstruction of the cervical ICAs (Fig. 1). The diagnostic work-up excluded polycystic kidney disease, or connective tissue disorders. Straining during labor was thought to be the mechanism of the four vessel sCAD of our patient. She was discharged home with NIHSS and modified-Rankin-Scale of 0 on day 5. CT angiography at 6 months demonstrated complete patency of the stents and healing of the vertebral dissections.
3. Discussion Multi-vessel flow-limiting sCAD is an unpredictable clinical presentation associated with unique management challenges. Treatment options include intravenous-thrombolysis during the first 4.5 h of acute cerebral ischemia, antiplatelet/anti-coagulation therapies and/or endovascular interventions. Medical management with antiplatelet or anti-coagulation therapy is the standard of care because most dissections heal spontaneously when treated medically and recurrent stroke rates are low on medical therapy [3]. Endovascular treatment is reserved for complicated cases or failures of medical management. The most common reason for acute endovascular therapy in the presence of non-traumatic dissection is a tandem intracranial occlusion due to embolus from the dissection site [4]. Other less frequent indications for endovascular treatment that may present weeks to months after the initial dissection include expanding pseudo aneurysm causing pain, cranial neuropathy, or recurrent stroke due to distal embolization. In our patient, we decided to proceed with stenting and reconstruction of the ICAs due to the dependence of the patient's anterior cerebral circulation on her already injured vertebral-arteries via the functional posterior-communicating-arteries as well as in fear of sudden distal embolization from the acutely thrombosed ICAs. Moreover, progression of vertebral dissections to high-grade stenosis or occlusion may have been complicated with recurrent cerebral ischemia in the anterior and/or posterior circulation. Finally, observational data indicates higher risk of recurrent cerebrovascular events in patients with multi-vessel sCAD [3]. We used Solitaire stent due to its ability to be recaptured and repositioned and this was considered to be advantageous in the petrous–cavernous ICA junction. Bilateral vertebral-artery dissections were managed medically with double antiplatelet therapy, as there was no flow limitation or free-floating thrombus. Our experience
Letter to the Editor
113
Fig. 1. MRI-brain DWI demonstrates left fronto-parietal (A) and right parieto-occipital (B) acute infarctions. Right vertebral digital-subtraction-angiogram (DSA) (C) demonstrates nonflow-limiting dissection of right cervical vertebral-artery (VA). Left vertebral DSA demonstrates non-flow-limiting dissection of left cervical VA (D), and patent intracranial portion of left VA and basilar-artery (E). Left common-carotid DSA demonstrates occlusive dissection of left cervical internal-carotid-artery (ICA) (F), and retrograde filling of the ophthalmic-artery with opacification of the intracranial circulation (G). Right common-carotid artery DSA demonstrates occlusive dissection of right cervical ICA (I), and retrograde filling of the ophthalmic-artery with opacification of the intracranial circulation (H). Left common-carotid DSA demonstrates successful reconstruction of left cervical ICA (J), and restoration of anterograde flow (K). Right common-carotid DSA demonstrates successful reconstruction of right cervical ICA (L), and restoration of anterograde flow (M).
parallels the observations of Cohen et al. [5], who reported similar favorable outcomes in 3 cases of symptomatic sCAD causing ICA occlusion that were treated with endovascular stenting. Possible complications of such an endovascular procedure are ischemic stroke caused by distal emboli, hemorrhagic stroke caused by reperfusion injury, injury to vessel wall or puncture site complications. In conclusion, our case highlights that endovascular reconstruction of the dissected cervical-arteries may be performed safely and should be considered in selected patients with multi-vessel dissections. Sources of funding There are no sources of funding to report associated with this manuscript. Disclosures The authors received no funding related with this work. Drs. Goyal, Male, and Doss have no financial relationships to disclose outside of this work. Dr. Arthur served as a consultant for Covidien, Johnson and Johnson, Siemens, Stryker, and Terumo; and received grants from Siemens and Terumo outside the submitted work. Dr. Elijovich has served as a consultant for Stryker Neurovascular,
Microvention, and Codman Neurovascular outside the submitted work. Conflict of interest The authors report no conflicts of interest in this work. Acknowledgments The authors wish to thank Andrew J. Gienapp for technical and copy editing, preparation of the manuscript and figures for publishing, and publication assistance with this manuscript. References [1] Touze E, Gauvrit JY, Moulin T, Meder JF, Bracard S, Mas JL. Risk of stroke and recurrent dissection after a cervical artery dissection: a multicenter study. Neurology 2003;61: 1347–51. [2] Arnold M, Camus-Jacqmin M, Stapf C, Ducros A, Viswanathan A, Berthet K, et al. Postpartum cervicocephalic artery dissection. Stroke 2008;39(8):2377–9. [3] Patel RR, Adam R, Maldjian C, Lincoln CM, Yuen A, Arneja A. Cervical carotid artery dissection: current review of diagnosis and treatment. Cardiol Rev 2012;20: 145–52. [4] Seet RC, Wijdicks EF, Rabinstein AA. Stroke from acute cervical internal carotid artery occlusion: treatment results and predictors of outcome. Arch Neurol 2012;69: 1615–20.
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[5] Cohen JE, Gomori JM, Leker RR, Ben-Hur T, Grigoriadis S, Rajz G. Recanalization of symptomatic carotid artery dissections causing occlusion with multiple stents: the use of delayed double-contrast road map. Neurol Res 2010;32:293–6.
Nitin Goyal Shailesh Male Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA Vinodh T. Doss Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis TN, USA Adam Arthur Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis TN, USA Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
Lucas Elijovich Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis TN, USA Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA Corresponding author at: University of Tennessee Health Sciences Center, Semmes-Murphey Neurologic and Spine Institute, 6325 Humphreys Blvd., Memphis, TN 38120, USA. Tel.: +1 901 522 7700; fax: +1 901 259 0132. E-mail address: [email protected]. 15 October 2014