“Malignant” Carotid Artery Dissection

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.