Invited commentary

Abstract

Drs Edgell, Abou-Chebl, and Yadav report a small but fascinating series of seven patients undergoing carotid stenting for the management of complications of spontaneous carotid dissection. With their experience and meticulous technique, the authors have achieved excellent results in patients facing potentially devastating strokes. The article should be read carefully. The authors are not reporting the use of stenting in all, or even in most, cases of spontaneous dissection. In their experience only 7 (5%) of approximately 135 patients presenting with spontaneous dissection were selected for intervention. In fact, the title of the article is misleading. The authors are not reporting on the endovascular management of spontaneous carotid dissection, but rather on the endovascular management of complications of spontaneous carotid dissection. It is generally accepted, and the authors re-emphasize, that 85% to 90% of patients with spontaneous dissection recover very well with medical management alone. Furthermore, in most cases, arterial recanalization and remodeling occur after dissection with restoration of a reasonable luminal diameter. Recurrent dissection is unusual, and the overall prognosis usually quite good. The small subset of patients selected for stenting in this series included those with expanding or symptomatic pseudoaneurysms or with severe flow compromise due to multivessel involvement. Other scenarios in which intervention seems reasonable include ongoing symptoms despite anticoagulation and contraindication to anticoagulation. Although this article addresses only patients with complications of spontaneous dissection, it provokes two significant questions. First, what is the role of stenting in patients who present with traumatic carotid dissection? In these patients, neurologic deficits may occur after an asymptomatic period of several hours or even days, and anticoagulation is often contraindicated. Should stenting be used early in these patients to prevent delayed neurologic sequelae and lessen concern over anticoagulation? Second, should we consider changing the default algorithm in the management of uncomplicated spontaneous dissection? The authors’ results are so good in very compromised patients that it is tempting to think that stenting for uncomplicated dissection might result in an improvement over the 85% to 90% favorable results with traditional medical therapy. Obviously, only a randomized prospective trial can properly answer this question. Although they reported only on the management of complicated spontaneous carotid dissections, the authors have demonstrated in very high-risk patients the potential of a new treatment for carotid dissection that calls into question our current management paradigm for lower-risk patients. Aggressive early stenting of traumatic and spontaneous carotid dissections now warrants careful study.