Endovascular treatment of bilateral spontaneous, symptomatic carotid dissection, refractory to medical therapy

BackgroundCarotid dissection (CD) may, in certain cases, lead to significant stenosis, occlusion, or pseudoaneurysm formation, causing embolic stroke or hemodynamic failure, despite medical therapy.ObjectiveTo evaluate the results of endovascular treatment and clinical outcomes of patients with CD.MethodsA four-hospital retrospective study of endovascular treatment of extracranial CD in which medical treatment had failed or patients presented with a National Institute of Health Stroke Scale (NIHSS) score ≥8.ResultsThirty-eight patients (mean age 46.6±13.5 years, 78.9% male, 84.2% spontaneous CD, 44.7% left CD and 26.3% bilateral CD) were analyzed. In 24 patients (63.2%) treatment was undertaken in the acute-phase CD (APCD). IV recombinant tissue plasminogen activator was administered in 7 (29.2%) APCD cases. The patients with APCD exhibited a high rate of successful revascularization (Thrombolysis In Cerebral Infarction ≥2b; 19 patients (79.2%)), a low risk of symptomatic intracranial hemorrhage (n=2 (8.3%)), and good global functional outcomes (modified Rankin Scale (mRS) ≤2; n=17 (70.8%)). Good recanalization correlated (p=0.001) with good clinical evolution (mRS ≤2) in the patients with APCD. Of the 14 patients with non-acute phase CD (NAPCD), seven were treated for pseudoaneurysm with multiple stents (six patients) or covered prostheses, with stenosis being treated in the remaining seven patients.ConclusionsEndovascular treatment of selected cases of patients with CD associated with thromboembolic events and hemodynamic failure after unsuccessful medical therapy is a safe and effective method of restoring vessel lumen integrity, with good short-term clinical evolution.

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Faculty Opinions recommendation of Urgent best medical therapy may obviate the need for urgent surgery in patients with symptomatic carotid stenosis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718026428.793479727 ◽

2013 ◽

Author(s):

Magdy Selim ◽

Richard Goddeau

Keyword(s):

Carotid Stenosis ◽

Medical Therapy ◽

Symptomatic Carotid ◽

Urgent Surgery ◽

Symptomatic Carotid Stenosis ◽

Best Medical Therapy

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Acute Endovascular Treatment of Patients With Ischemic Stroke From Intracranial Large Vessel Occlusion and Extracranial Carotid Dissection

Frontiers in Neurology ◽

10.3389/fneur.2019.00102 ◽

2019 ◽

Vol 10 ◽

Cited By ~ 3

Author(s):

Kars C. J. Compagne ◽

R. B. Goldhoorn ◽

Maarten Uyttenboogaart ◽

Robert J. van Oostenbrugge ◽

Wim H. van Zwam ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Large Vessel ◽

Carotid Dissection ◽

Large Vessel Occlusion ◽

Vessel Occlusion

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Combined Intravenous Recombinant-Tissular Plasminogen Activator and Endovascular Treatment of Spontaneous Occlusive Internal Carotid Dissection with Tandem Intracranial Artery Occlusion

European Neurology ◽

10.1159/000278248 ◽

2010 ◽

Vol 63 (4) ◽

pp. 211-214 ◽

Cited By ~ 18

Author(s):

Alain Lekoubou ◽

Tae-Hee Cho ◽

Norbert Nighoghossian ◽

Vincent Kumako ◽

Laurent Derex ◽

...

Keyword(s):

Endovascular Treatment ◽

Plasminogen Activator ◽

Internal Carotid ◽

Artery Occlusion ◽

Intracranial Artery ◽

Carotid Dissection

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Endovascular Stenting for Symptomatic Carotid Dissection with Hemodynamic Insufficiency

World Neurosurgery ◽

10.1016/j.wneu.2017.03.086 ◽

2017 ◽

Vol 102 ◽

pp. 598-607 ◽

Cited By ~ 7

Author(s):

Youngsoo Kim ◽

Chang Hwa Choi ◽

Tae Hong Lee ◽

Han Jin Cho ◽

Sang Min Sung ◽

...

Keyword(s):

Carotid Dissection ◽

Endovascular Stenting ◽

Symptomatic Carotid

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Abstract 137: Endovascular Intervention versus Standard Medical Therapy for Patients Presenting with Large Acute Ischemic Strokes - A Large Single Center Experience

Stroke ◽

10.1161/str.43.suppl_1.a137 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Maxim Mokin ◽

Peter Kan ◽

Adib Abla ◽

Travis Dumont ◽

Shady Jahshan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Medical Therapy ◽

Endovascular Therapy ◽

Intervention Group ◽

Medical Group ◽

Standard Medical Therapy ◽

Best Medical Therapy

Objective. Endovascular interventions for acute ischemic stroke have been widely adopted on the basis of single-arm registries that reported high recanalization rates with limited complications. We conducted a retrospective cohort study to compare the clinical outcomes in acute ischemic stroke patients who underwent endovascular treatment with patients who were treated with standard medical therapy alone at our institution. Methods. The study group consisted of two cohorts of patients with acute ischemic stroke over a 4-year period: 260 patients underwent endovascular treatment and 597 patients were treated with best medical therapy alone. All patients from the medical group presented with a NIHSS score of >8 and were ineligible for IV tPA. Clinical outcomes at discharge and at 3 months were compared. Results. Compared with the medical group, the endovascular group had a significantly greater proportion of patients who were discharged home (21.2% vs 8.7%, p<0.001) and who could ambulate independently at discharge (32.1% vs 16.8%, p<0.001). Of the patients with follow-up, the proportion of patients with a good outcome (mRS score of <=2) at 3 months was also significantly higher in the endovascular group (51.9% vs 35.7%, p<0.05). Conversely, the endovascular group had a significantly smaller proportion of patients who was discharged to nursing home (11.9% vs 24.1%, p<0.01) and hospice (6.9% vs 14.1%, p=0.003). Mortality rate at discharge was not different (21.2% vs 18.9%, p=0.451). The rate of symptomatic ICH was 9.2% in the intervention group. Conclusion. In our study, endovascular therapy provides a better functional outcome compared with standard medical therapy in select patients. Ultimately, determination of efficacy of endovascular therapy for acute ischemic stroke compared with best medical therapy will depend on results of randomized trials.

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