Emergent stenting to treat patients with carotid artery dissection: clinically and radiologically directed therapeutic decision making.
OBJECTIVE
Carotid artery dissection (CAD) is a common cause of stroke in young patients. Clots formed at the low-flow zone in the false arterial lumen may give rise to distal emboli, and the mural hematoma may eventually occlude the artery. Anticoagulation is currently the accepted treatment, but it is unknown which patients will improve spontaneously, which will respond to anticoagulation, and which will have an exacerbation of ischemic symptoms despite therapy. Endovascular treatment of CAD may be an attractive alternative to anticoagulation, and methods of identifying patients who stand to benefit from such therapy need to be established.


METHODS
We present here 3 cases of spontaneous symptomatic CAD in which endovascular stenting procedures were performed on the basis of a paradigm aimed at identifying potentially salvageable but at-risk brain tissue by combining clinical with MRI (diffusion and perfusion) and angiographic data.


RESULTS
Diffusion-perfusion MRI mismatches and/or evidence of cerebral ischemia on angiographic parenchymography were identified in all patients. They did not respond to anticoagulation, were therefore treated with endovascular stents, and had excellent outcomes.


CONCLUSIONS
Endovascular stent placement may be an immediate, effective, and safe method of restoring vessel lumen integrity. It may be considered for selected patients who are clinically symptomatic despite anticoagulant treatment and in whom neuroimaging methods suggest that the neurological signs originate from a viable, hypoperfused, ischemic penumbra.
Cohen
José E
JE
Department of Neuroradiology, Hadassah-Hebrew University Hospital, Jerusalem, Israel.
Leker
Ronen R
RR
Gotkine
Marc
M
Gomori
Moshe
M
Ben-Hur
Tamir
T
D000792:Angiography; D019917:Blood Vessel Prosthesis Implantation; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000601:surgery; D020215:Carotid Artery, Internal, Dissection / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D002544:Cerebral Infarction / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D015607:Stents; D016896:Treatment Outcome; D014463:Ultrasonography; D014654:Vascular Patency