title: Endovascular recanalization of symptomatic flow-limiting cervical carotid dissection in an isolated hemisphere.
abstract: OBJECTIVE
  Internal carotid artery dissection (ICAD) is a common cause of stroke in young patients, which may lead to major transient or permanent disability. Internal carotid artery dissection may occur spontaneously or after trauma and may present with a rapid neurological deterioration or with hemodynamic compromise and a delayed and unstable neurological deficit. Endovascular intervention using stent angioplasty can be used as an alternative to anticoagulation and open surgical therapy in this setting to restore blood flow through the affected carotid artery.
  
  
  METHODS
  The authors present the cases of 2 patients with flow-limiting symptomatic ICAD leading to near-complete occlusion and without sufficient collateral supply. Both patients had isolated cerebral hemispheres without significant blood flow from the anterior or posterior communicating arteries. In both cases, the patients demonstrated blood pressure-dependent subacute unstable neurological deficits as a result of the hemodynamic compromise resulting from the dissection.
  
  
  RESULTS
  Both patients underwent careful microwire-based selection of the true lumen followed by confirmatory microinjection and subsequent exchange-length microwire-based recanalization using tandem telescoping endovascular stenting. In both cases the neurological state improved, and no permanent neurological deficit ensued.
  
  
  CONCLUSIONS
  The treatment of ICAD may be difficult in patients with subacute unstable neurological deficits related to symptomatic hypoperfusion, especially in the setting of a hemodynamically isolated hemisphere. Anticoagulation alone may be insufficient in these patients. Although there is no widely accepted guideline for the treatment of ICAD, the authors recommend stent-mediated endovascular recanalization in cases of symptomatic flow-limiting hemodynamic compromise, especially in cases of an isolated hemisphere lacking sufficient communicating artery compensatory perfusion.
authors.affiliation: Cerebrovascular and Endovascular Division, Department of Neurosurgery, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
authors.forename: Clemens M
authors.initials: CM
authors.lastname: Schirmer
authors.forename: Basar
authors.initials: B
authors.lastname: Atalay
authors.forename: Adel M
authors.initials: AM
authors.lastname: Malek
mesh_terms: D002545:Brain Ischemia / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D020215:Carotid Artery, Internal, Dissection / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D002533:Cerebral Angiography / Q000379:methods; D002548:Cerebral Revascularization / Q000295:instrumentation* / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015607:Stents / Q000592:standards*; D016896:Treatment Outcome