Endovascular treatment of acute internal carotid artery dissections: technical considerations, clinical and angiographic outcome.

Abstract

In acute internal carotid artery dissection (a-ICAD) with concomitant intracranial large vessel occlusion or haemodynamic impairment, the effectiveness of medical treatment is limited and endovascular therapy (EVT) can be considered. Feasibility, safety and outcome of EVT in a-ICAD are not well described yet. From an institutional database, we retrospectively selected consecutive patients treated for a-ICAD between January 2007 and July 2015. We assessed recanalization results defining <50% residual stenosis and mTICI ≥2b as successful. Procedural adverse events and symptomatic haemorrhages were reported as well as clinical outcome at 90days defining a mRS ≤2 as favourable. Follow-up angiographies were reviewed and retreatments reported. In the defined period, 73 patients (mean age 48years (31-73), mean NIHSS 11 (0-27)) received EVT for a-ICAD. The majority (60%) had tandem occlusions. Cervical artery reconstruction was successful in 100% and intracranial thrombectomy in 85%. Thrombus formation (18%) and thromboembolism (20%) were the most frequent adverse events but clinically relevant only in 8%. Symptomatic haemorrhage occurred in 5%. Clinical outcome was favourable in 64%, with a lower chance after tandem occlusion (55 vs. 79%, p=0.047). Death rate was 10%. None of the patients developed recurrent ischaemic symptoms, but control angiography revealed abnormal findings of the reconstructed ICA in 38% leading to retreatment in 17%. EVT of a-ICAD is feasible with a predominantly favourable clinical outcome. Improvement of devices and techniques is warranted to reduce the risk of thrombus formation and thromboembolism during treatment and insufficient vessel wall healing thereafter.