title: Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents.
abstract: Although most cervical dissections are managed medically, emergent endovascular treatment may become necessary in the presence of intracranial large-vessel occlusions, flow-limiting and long-segment dissections with impending occlusion, and/or hypoperfusion-related ischemia at risk of infarction. We investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting.
  
  
  
  We retrospectively studied long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥3 stents) and presenting with acute (<12 hours) ischemic stroke symptoms (NIHSS score, ≥4). We analyzed patient demographics, vascular risk factors, clinical presentations, imaging/angiographic findings, technical procedures/complications, and clinical outcomes.
  
  
  
  Fifteen patients (mean age, 51.5 years) with acute ischemic stroke (mean NIHSS score, 15) underwent endovascular stent reconstruction for vessel and/or ischemic tissue salvage. All carotid dissections presented with >70% flow limiting stenosis and involved the distal cervical ICA with a minimum length of 3.5 cm. Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b-3 reperfusion. Two procedural complications were limited to thromboembolic infarcts from in-stent thrombus and asymptomatic hemorrhagic infarct transformation (7% morbidity, 0% mortality). Angiographic and ultrasound follow-up confirmed normal carotid caliber and stent patency, with 2 cases of <20% in-stent stenosis. Early clinical improvement resulted in a mean discharge NIHSS score of 6, and 9/15 (60%) patients achieved a 90-day mRS of ≤2.
  
  
  
  Emergent stent reconstruction of long-segment and flow-limiting carotid dissections in acute ischemic stroke intervention is safe and effective, with favorable clinical outcomes, allowing successful thrombectomy, vessel salvage, restoration of cerebral perfusion, and/or prevention of recurrent thromboembolic stroke.
authors.affiliation: From the Departments of Radiology, Neurology, and Neurological Surgery (S.A.A., A.R.H., M.C.H., M.B.P., B.S.J., A.S.), Northwestern University Feinberg School of Medicine, Chicago, Illinois s-ansari@northwestern.edu.
authors.forename: S A
authors.identifier: 0000-0001-8176-4616
authors.initials: SA
authors.lastname: Ansari
authors.affiliation: Division of Neuroimaging and Intervention (A.L.K., M.J.G., A.K.W., A.S.P.), Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts.
authors.forename: A L
authors.identifier: 0000-0001-9512-9461
authors.initials: AL
authors.lastname: Kühn
authors.affiliation: From the Departments of Radiology, Neurology, and Neurological Surgery (S.A.A., A.R.H., M.C.H., M.B.P., B.S.J., A.S.), Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: A R
authors.identifier: 0000-0002-7491-381X
authors.initials: AR
authors.lastname: Honarmand
authors.affiliation: Department of Neurology (M.K.), Brown University, Providence, Rhode Island.
authors.forename: M
authors.identifier: 0000-0001-6329-8703
authors.initials: M
authors.lastname: Khan
authors.affiliation: From the Departments of Radiology, Neurology, and Neurological Surgery (S.A.A., A.R.H., M.C.H., M.B.P., B.S.J., A.S.), Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: M C
authors.identifier: 0000-0003-2873-4738
authors.initials: MC
authors.lastname: Hurley
authors.affiliation: From the Departments of Radiology, Neurology, and Neurological Surgery (S.A.A., A.R.H., M.C.H., M.B.P., B.S.J., A.S.), Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: M B
authors.identifier: 0000-0002-0534-5097
authors.initials: MB
authors.lastname: Potts
authors.affiliation: From the Departments of Radiology, Neurology, and Neurological Surgery (S.A.A., A.R.H., M.C.H., M.B.P., B.S.J., A.S.), Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: B S
authors.identifier: 0000-0001-5064-5278
authors.initials: BS
authors.lastname: Jahromi
authors.affiliation: From the Departments of Radiology, Neurology, and Neurological Surgery (S.A.A., A.R.H., M.C.H., M.B.P., B.S.J., A.S.), Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: A
authors.identifier: 0000-0002-9901-2903
authors.initials: A
authors.lastname: Shaibani
authors.affiliation: Division of Neuroimaging and Intervention (A.L.K., M.J.G., A.K.W., A.S.P.), Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts.
authors.forename: M J
authors.identifier: 0000-0002-8034-2785
authors.initials: MJ
authors.lastname: Gounis
authors.affiliation: Division of Neuroimaging and Intervention (A.L.K., M.J.G., A.K.W., A.S.P.), Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts.
authors.forename: A K
authors.identifier: 0000-0003-2126-4155
authors.initials: AK
authors.lastname: Wakhloo
authors.affiliation: Division of Neuroimaging and Intervention (A.L.K., M.J.G., A.K.W., A.S.P.), Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts.
authors.forename: A S
authors.identifier: 0000-0002-6978-6457
authors.initials: AS
authors.lastname: Puri
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000601:surgery*; D002340:Carotid Artery Diseases / Q000150:complications / Q000601:surgery*; D057510:Endovascular Procedures / Q000295:instrumentation* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome