Extracranial Internal Carotid Artery Dissection Research Articles

Lower Cranial Neuropathies as Presenting Symptom of Distal Extracranial Internal Carotid Artery Dissection Leading to Delay in Diagnosis and Treatment (P7-5.030)

Lower Cranial Neuropathies as Presenting Symptom of Distal Extracranial Internal Carotid Artery Dissection Leading to Delay in Diagnosis and Treatment (P7-5.030)

Intravascular Treatment of Extracranial Internal Carotid Artery Dissection

Objective: To evaluate the efficacy and safety of endovascular treatment of extracranial dissection of the internal carotid artery, as well as pseudoaneurysm associated with dissection.Clinical cases: In this article we report the results of endovascular treatment of 2 patients with iatrogenic and spontaneous dissection of the cervical segment of the internal carotid artery.Conclusions: Internal carotid artery dissection can lead to significant narrowing of the vessel lumen, occlusion or pseudoaneurysm followed by hemodynamic or embolic stroke despite anticoagulant therapy. In some cases, endovascular stenting for dissection is a safe and effective method of restoring vessel lumen integrity with a good clinical outcome.

A Case of Internal Carotid Artery Dissection Presenting With Dysgeusia (P12-5.014)

<h3>Objective:</h3> NA <h3>Background:</h3> A 42-year-old man presented to the emergency room (ER) with headache and neck pain associated with dysgeusia for three days. The headache was described as sudden, moderate, with throbbing pain, located in the left frontal region, and radiating to the left temporomandibular joint. The pain was not aggravated by chewing or position. He denied mechanical trauma to the neck including deep tissue massage or chiropractic manipulation. He had also incidentally noticed that orange juice tasted bitter. He denied a change in voice or difficulty swallowing. The exam was notable for left-sided ptosis and altered taste to the posterior 1/3^rd tongue to sugar water. CT angiography showed irregularity of the distal left internal carotid artery (ICA) from the C1 segment into the proximal petrosal segment associated with a 3 mm pseudo-aneurysm, concerning for dissection. <h3>Design/Methods:</h3> NA <h3>Results:</h3> The mean annual incidence of spontaneous ICA dissection is 2.9 per 100,000. The classic triad of symptoms is ipsilateral head or neck pain, partial Horner syndrome, and cerebral or retinal ischemic symptoms. Cranial nerve (CN) palsies may occur in more than 10% of patients with extracranial ICA dissections, most commonly involving CN XII, followed by V, VII, IX and X. We discuss a patient with isolated dysgeusia in the posterior 1/3^rd of the tongue with left-sided Horner syndrome in the setting of distal ICA dissection. Clinical presentation is consistent with an isolated glossopharyngeal nerve palsy and Horner syndrome. At the distal cervical level, the glossopharyngeal nerve and sympathetic tract run closely to the ICA and are susceptible to compression by the pseudoaneurysm. There exist only a few reports on loss of taste sensation caused by dissection of ICA. <h3>Conclusions:</h3> This case highlights that posterior ipsilateral dysgeusia can be a manifestation of cervical internal carotid artery dissection and should prompt appropriate evaluation and neuroimaging. <b>Disclosure:</b> Dr. Joseph has nothing to disclose. Dr. Ariza Hutchinson has nothing to disclose. Dr. Shnawa has nothing to disclose. Dr. Sehgal has nothing to disclose.

Radiological Spectrum of Pseudoaneurysms After Extracranial Internal Carotid Artery Dissection

Radiological Spectrum of Pseudoaneurysms After Extracranial Internal Carotid Artery Dissection

Isolated Abducens Nerve Palsy as a Presentation of Extracranial Internal Carotid Artery Dissection: A Case Report (P2-10.007)

Isolated Abducens Nerve Palsy as a Presentation of Extracranial Internal Carotid Artery Dissection: A Case Report (P2-10.007)

Spontaneous Extracranial Internal Carotid Artery Dissection with Complete Obstruction from Intraluminal Thrombus

A 54-year old woman, with a previous history of Prinzmetal angina, presented to the emergency department complaining of new onset severe and persistent, left-sided, frontal headache accompanied by vomiting. The patient also reported transient blurred vision of the left eye during the headache onset.

Bilateral carotid artery dissection due to Eagle syndrome in a patient with vascular Ehlers-Danlos syndrome: a case report

BackgroundPatients with vascular Ehlers-Danlos syndrome (EDS) occasionally suffer from arterial dissection. Eagle syndrome, which is caused by an elongated styloid process and also causes arterial dissection, is difficult to diagnose and could sometimes be overlooked. Little is known of the coexistence of these two diseases, and treatment strategy is not established. Here, we present a case of bilateral internal carotid artery (ICA) dissection due to Eagle syndrome in a patient with vascular EDS.Case presentationA 30-year-old man was admitted to our hospital because of sudden onset of mild sensory disturbance in his left limbs. He had a history of Ehlers-Danlos syndrome (EDS) and also had left cervical internal carotid artery (ICA) dissection 3 years before. Diffusion-weighted imaging showed acute cerebral infarcts in the right hemisphere. Cervical computed tomography angiography (CTA) revealed the right ICA narrowing at the cervical portion in addition to the previous left cervical ICA dissection. Cervical magnetic resonance imaging (MRI) revealed double-lumen and intramural hematoma at the narrowing portion of the right cervical ICA, which indicates arterial dissection. CT also revealed bilateral elongated styloid processes which are close to each side of cervical ICA. We diagnosed him as bilateral ICA dissection due to bilateral Eagle syndrome. Considering vascular complications due to vascular EDS, we performed closer follow-up with transoral carotid ultrasonography (TOCU). In 4 months, his right ICA dissection gradually improved without stroke recurrence or deterioration of dissection.ConclusionsSince patients with vascular EDS easily develop arterial dissection, Eagle syndrome may be overlooked. Clinicians should consider Eagle syndrome in the case of vascular EDS with extracranial ICA dissection and close follow-up should be prioritized in cases of Eagle syndrome with vascular EDS.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Oculomotor Nerve Palsy that Developed after Endovascular Treatment in an Acute Stroke Patient with a Dissecting Occlusion of the Extracranial Internal Carotid Artery

Oculomotor nerve palsy is underrecognized clinical manifestation of extracranial internal carotid artery (ICA) dissection. Herein we report a case of complete oculomotor nerve palsy following endovascular revascularization, which developed in a patient with acute stroke due to extracranial ICA dissecting occlusion. We also discuss about the development mechanism of oculomotor nerve palsy, considering the vascular anatomy and the possibility of periprocedural complications during endovascular treatment.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Endovascular reconstruction of extracranial traumatic internal carotid artery dissections: a systematic review.

Extracranial internal carotid artery dissection (ICAD) is a potential source of morbidity and mortality in trauma patients and requires high degree of suspicion for diagnosis after the initial presentation. Occasionally, if standard therapy is contraindicated, endovascular reconstruction is a treatment option. The aim of this systematic review was to report clinical and radiographic outcomes following endovascular repair of ICAD of traumatic and iatrogenic etiology. A comprehensive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed and Cochrane Library databases were searched. Twenty-four studies comprising 191 patients (204 lesions) were included; 179 underwent traditional carotid artery stenting (CAS), whereas 12 patients underwent flow diversion with the pipeline embolization device (PED). In total, 75.7% of the CAS group and 66.6% of the PED group presented with ICAD-related symptomatology. Concomitant pseudoaneurysms were identified in 61.9% and 78.5% of lesions in the CAS and PED group, respectively. Adverse event rates among CAS-treated lesions after 30-day follow-up were below 2.2% for stroke, transient ischemic attack, and mortality. During follow-up in the CAS group, there was no incidence of ICAD-related stroke or death and 2.2% of patients underwent a repeat CAS procedure. In the PED group, no patient suffered stroke or death in the reported follow-up. In the PED cohort, there was an adequate occlusion rate and no patient had to be retreated. Endovascular reconstruction of traumatic or iatrogenic ICAD appears safe. This approach demonstrated acceptable short- and long-term clinical and radiographic outcomes in both groups.

Late Embolism Following Recanalization of Occluded Extracranial Internal Carotid Artery Dissection

Late Embolism Following Recanalization of Occluded Extracranial Internal Carotid Artery Dissection

Electrophysiological assessment of lower cranial nerve palsy triggered by spontaneous extracranial carotid dissection

A 43-year-old man was admitted to our department for the acute onset of unilateral right throbbing headache. Neurologic examination revealed right ocular myosis and ptosis, left displacement of the uvula, dysphonia, weak left-turning of the head, right scapular winging on arm abduction and right tongue deviation, suggesting 9th through 12th cranial nerve palsy and Horner’s syndrome. Neurophysiologic examination confirmed the unilateral involvement. EMG showed loss of motor unit recruitment and denervation activity in the right sternocleidomastoid, trapezius and genioglossus muscles. MEPs and C-MAP were not excitable from those muscles. MRI demonstrated a crescent-shaped hyperintense T1 and T2 signal within the wall of the distal extracranial portion of the right internal carotid artery (ICA), suggesting an intramural hematoma causing mass effect upon the internal jugular vein. A diagnosis of spontaneous extracranial carotid dissection was made. An extended CT angiogram showed extensive luminal irregularities in the main renal arteries, with aneurysm formation at its bifurcation. Ibromuscular dysplasia was hypothesized and genetic counseling for connective tissue was carried on. Cranial nerve palsy is an unusual presentation of extracranial ICA dissection, likely mediated by compression or stretching of the nerve by the expanded artery. Neurophysiological testing provides useful information to localize the damage and to better understand the pathophysiology of the disease.

Flow-diverter Stents for Internal Carotid Artery Reconstruction Following Spontaneous Dissection: ATechnical Report.

Extracranial internal carotid artery (ICA) dissection is an important cause of ischemic stroke in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report acase series of extracranial ICA reconstruction using overlapping flow-diverter stents as arescue therapy for the treatment of symptomatic ICA dissection in patients presenting with recurrent ischemic stroke and/or severe hemispheric hypoperfusion who failed medical management. Consecutive patients undergoing endovascular reconstruction of either occluded or severely narrowed ICA due to dissection and presenting with symptoms of recurrent cerebral ischemia or cerebral hypoperfusion were included. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications and stroke recurrence rates. A total of 7patients were included. The mean age was 47years, 4 patients were male and 3 were female. All patients were symptomatic presenting with ipsilateral recurrent ischemia with or without cerebral hemodynamic compromise and necessitated reconstructive treatment. Patients were placed on dual antiplatelet therapy with aspirin and either ticagrelor or clopidogrel prior to the procedure. In cases where patients were not preloaded with dual antiplatelets intravenous abciximab was used as a bridging therapy. Post-stenting angioplasty was performed if deemed necessary. There were no symptomatic ischemic or hemorrhagic complications. No patients had recurrent ischemic events. Reconstruction of the ICA as arescue strategy for extracranial carotid dissection using flow-diverter stents is feasible and was performed without adverse events in this small series.

Contrast‐enhanced transoral carotid ultrasonography for the diagnosis and follow‐up of extracranial internal carotid artery dissection: A case report

A 56-year-old woman was admitted to our hospital because of amaurosis fugax. The carotid angiogram showed irregularly stenotic lesions of the left and right internal carotid arteries (ICAs), suggestive of dissection. Follow-up evaluation was performed by transoral carotid ultrasonography (TOCU) with contrast enhancement (CE), which yielded better vessel lumen and intramural hematoma visualization than color Doppler imaging. CE-TOCU is useful for evaluating ICA dissections that extends to the high cervical portion.

Anchoring Pipeline Flow Diverter Construct in the Treatment of Traumatic Distal Cervical Carotid Artery Injury

Background: Traumatic extracranial internal carotid artery (ICA) dissections are uncommon and can be difficult to treat. Thinning of adventitia and dilatation may occur following arterial dissection, thus resulting in a fusiform pseudoaneurysm, which can subsequently cause bleeding, expanding, or pulsatile hematoma. Currently, medical management with anticoagulation remains the first line of treatment and yields good outcomes in 75% of cases with a mortality rate of 3-4%. Endovascular intervention is indicated with failure of medical therapy, progressive enlargement of a traumatic pseudoaneurysm, acute flow-related infarcts due to vessel occlusion, or when anticoagulation is contraindicated due to risk of pseudoaneurysm rupture and hemorrhage. Recognized interventional treatments include parent artery occlusion with or without revascularization, endovascular coil embolization, and covered stenting. Summary: A wide variety of endovascular stents are available that are capable of opening a stenosed vessel while obliterating the associated false lumen and providing a scaffold for embolization of the pseudoaneurysm. The use of the Pipeline Embolization Device (PED) in the management of traumatic intracranial pseudoaneurysms has been described. However, there are few reports on the usage of the PED for treating traumatic extracranial ICA dissection and/or pseudoaneurysms. However, a potential complication of the use of PED in the extracranial ICA is a hypothetical tendency to migrate in a mobile vessel. Thus, the risk of migration of the PED has encouraged practitioners to adopt strategies to limit this risk. Key Messages: We describe different techniques employed to anchor the flow-diverting construct within tortuous, mobile vessels.

Traumatic Dissections of Bilateral Internal carotid Artery with Aneurysms Formation

Carotid artery dissection is an unusual complication of blunt neck trauma with high mortality and severe neurological deficits. Traumatic bilateral dissections and dissecting aneurysms are extremely rare. A 17‐year‐old male presented to our emergency department with sudden onset of right hemiparesis and aphasia. Initial computed tomography scan of head and neck showed no remarkable finding. On the second day, a magnetic resonance angiography of head and neck demonstrated bilateral extracranial internal carotid artery dissections. The diagnosis of traumatic carotid artery dissection for emergency physicians is difficult because of the absence or delayed onset in symptomatology. Magnetic resonance angiography is currently considered as an appropriate initial diagnostic tool for carotid artery injury. In clinical practice, early diagnosis by keeping a high index of suspicions is required by emergency physicians.

Extracranial Internal Carotid Artery Dissection Treated with Self-expandable Stents: A Single-Centre Experience.

Treatment of choice for the internal carotid artery dissection (ICAD) is anticoagulation for three to 6 months. Endovascular procedures may be a promising alternative for patients (pts) with haemodynamic impairment, recurrent ischaemic symptoms or symptomatic pseudoaneurysms. Thus, the purpose of this study was to evaluate the efficacy and safety of carotid artery stenting in treatment of selected pts with extracranial ICAD. This study involved 18 symptomatic pts with the mean age of 44.6 ± 10.4 years with ICAD treated with the use of self-expandable stents. Six months after primary procedures, pts were readmitted to hospital and physical examination followed by cerebral angiography was performed. In the late follow-up period, clinical evaluations completed by duplex Doppler ultrasonography were carried out every 6 months and at the end of the follow-up period. Nobody died and no life-threatening adverse events were observed during either the in-hospital stay or post-discharge follow-up period (median 21 months). Stent deployment immediately restored flow in the true lumen of ICA in all cases. However, residual blood flow through the false lumen was observed in one pt. Complete resolution of clinical symptoms was observed in 14 pts (78%), partial improvement in 2 (11%) and persistence of neurological deficit in 2 (11%). Implantation of self-expandable stents in treatment of selected extracranial ICAD cases is safe. This method may enable us to restore immediately and usually permanently proper arterial blood flow in the ICA and in consequence lead to significant clinical improvement in the late follow-up period.

Stroke Due To Extracranial Internal Carotid Artery Dissection After Roller Coaster Rides In A 4-Year-Old Boy (P7.343)

Stroke Due To Extracranial Internal Carotid Artery Dissection After Roller Coaster Rides In A 4-Year-Old Boy (P7.343)

The location of origin of spontaneous extracranial internal carotid artery dissection is adjacent to the skull base

The traditional view is that spontaneous extracranial internal carotid artery (ICA) dissection (CAD) extends cranially from an intimal tear located just beyond the carotid bulb. This paper demonstrates that CAD originates in and primarily involves a more distal segment of the artery. A retrospective study of 54 dissected ICAs in 50 consecutive patients with spontaneous or traumatic CAD was undertaken. The site of the dissection, presence of ICA redundancy, rate of acute or delayed ischaemic stroke and vessel remodelling were determined. Of the 51 dissections that occurred spontaneously or after indirect trauma, 25/51 (49.0%) were solely in the distal third of the artery, and 49/51 (96.1%) involved the distal two-thirds. Only 2/51 (3.9%) originated in the proximal third. ICA redundancy was seen in 27/36 (75%) of patients with spontaneous CAD, compared with only 1/11 (9.1%) of those with CAD due to indirect trauma (P = 0.0002). Acute stroke occurred in 10/12 (83.3%) of patients with ICA occlusion secondary to CAD and in 14/38 (36.8%) with non-occlusive CAD (P = 0.0074). Where follow-up was available, only 2/32 (6.3%) patients had a stroke after diagnosis, and 19/33 (57.6%) ICAs recanalised or remodelled. CAD occurring spontaneously or due to indirect trauma most frequently involves the distal extracranial ICA. Spontaneous CAD is associated with vessel redundancy, and the risk of acute stroke is greatest with occlusive CAD. The prognosis is good with treatment, with a low rate of recurrent stroke and a high rate of vessel remodelling.