31 Acute Dissection with Hemodynamic Infarctions
31.1 Case Description
31.1.1 Clinical Presentation
A 49-year-old woman presented initially with a history of blurred vision for 1 hour. Three days later, she again presented with sudden onset of blurred vision in her left eye and right-sided weakness. On examination, she had left mydriasis and a right-sided pronator drift. A CTA of the carotids and circle of Willis was performed, which demonstrated a left internal carotid artery (ICA) dissection. MRI demonstrated no evidence of acute infarct on diffusion-weighted imaging. She was initially managed with anticoagulation in the form of a heparin infusion; however, over the next 24 hours, she deteriorated neurologically with development of aphasia, worsening right arm weakness, and a right-sided facial droop, and thus MRI was repeated.
31.1.2 Imaging Studies
Sagittal reconstruction of the CT angiography (CTA) of the carotids performed at the time of presentation demonstrates abrupt narrowing, leading to occlusion of the proximal left ICA just above the carotid bulb (Fig. 31.1).
Diffusion-weighted MRI of the brain demonstrated classical deep border-zone infarctions in keeping with global left hemispheric hypoperfusion (Fig. 31.2).
Fig. 31.1 Investigations performed on re-presentation to the hospital included CTA of the carotids and MRI of the head and neck. CTAs of the carotids in the coronal (a) and sagittal (b) demonstrate the transition between the normal caliber ICA to the string-like ICA just beyond the carotid bulb, as indicated by the arrow. Fat-saturated T1-weighted MRI (c) demonstrates increased T1 signal within the left ICA wall in keeping with intramural hematoma from a dissection. The diffusion-weighted imaging (d) demonstrates no evidence of infarct. 
Fig. 31.2 Repeat MRI scan performed at the time of the patients’ deterioration demonstrates acute infarcts in the centrum semiovale in a watershed distribution on diffusion-weighted imaging (a), and ADC maps (b).
31.1.3 Diagnosis
Left internal carotid dissection with hemodynamic infarction affecting the left centrum semiovale.
31.1.4 Treatment
Once the patient developed hemodynamic infarcts while on heparin infusion, intervention was deemed necessary.
Digital subtraction angiography following injection into the left common carotid artery (CCA) demonstrated the classical appearance of an ICA dissection with a focal narrowing just above the carotid bulb with the “string sign” indicating severely compromised arterial lumen.
Immediate postprocedural final angiography demonstrated successful reconstruction of the acutely dissected left ICA using stents. The ICA was reconstructed from proximal (carotid bifurcation with two carotid Wallstents) to distal (skull base with an overlapping Pipeline stent).
Endovascular Treatment: Left Carotid Stenting
Material
8-Fr short vascular sheath.
5 Fr × 100 cm Berenstein catheter.
8-Fr MERCI balloon guide.
5-Fr VTK Slip catheter.
0.035 in × 150 cm Glide wire.
0.014 in × 200 cm Synchro-2 guidewire.
0.014 in Traxcess hydrophilic guidewire.
0.014 in × 115 cm Traxcess Docking wire.
7 × 40 mm to 6 × 48 mm carotid wall stent.
5 × 30 mm to 4 × 36 mm Carotid wall stent.
4 × 20 mm Scepter C Balloon Catheter.
4 mm × 2 cm 142 cm shaft Aviator Plus PTA Balloon.
5.0 × 25 mm Pipeline Flex Embolization Device.
Technique
The procedure was performed with general anesthesia and full systemic heparinization. The right common femoral artery was punctured and an 8-Fr short vascular sheath inserted. The 5-Fr Berenstein catheter was used to perform diagnostic angiography from the left CCA. This demonstrated the long-segment left ICA dissection with filling of the distal ICA via the left ophthalmic artery, which fills retrogradely from the external carotid artery (Fig. 31.3).
An 8-Fr MERCI balloon guide was then advanced into the distal left CCA over a 5-Fr VTK slip catheter with the aid of an angled Terumo Glide wire. A Marksman catheter, over a Synchro-2 microwire shaped with a “J” tip, was then used to cross the dissected segment into the petrous ICA. Intraluminal positioning was confirmed by microcatheter injection (Fig. 31.4).
A Traxcess microwire with the docking exchange wire was inserted via the Marksmen catheter to the level of the cavernous ICA, and used as an exchange wire to maintain access through the dissected segment, during the stenting procedure. A 7 × 40 mm carotid wall stent was then advanced over the Traxcess exchange wire and deployed in the distal ICA from the lower border of C1 to the level of the carotid bulb (Fig. 31.5, Fig. 31.6). At this point, Integrilin was commenced intravenously.
A rapid exchange maneuver was then used to deploy a second telescoped 5 × 30 mm carotid wall stent from just below the skull base. Following this, the Marksman catheter was again inserted over the Traxcess wire; through this, a 5 × 25 mm Pipeline flex device was then deployed from the petrous ICA back to telescope with the already delivered carotid wall stents (Fig. 31.7).
Although delivery of these stents resulted in improved antegrade flow through the left ICA, there was an area of narrowing in the region of the pipeline stent from the level of the skull base back to the carotid wall stent. This was in the region where the MRI demonstrated thrombus within the false lumen of the ICA and as such was thought to be secondary to compression. A 4 × 20 mm Scepter balloon was then advanced over the Traxcess wire left in place for access through the stents.
Angioplasty was performed with some improvement in caliber; however, there was persistent narrowing. Three mg of intra-arterial verapamil was administered to assess if some of the narrowing may be due to vasospasm; however, control angiography following this demonstrated increased intraluminal narrowing with associated reduced flow in the ICA. A 4 × 20 mm Aviator Plus angioplasty Balloon was then inserted and angioplasty performed with two inflations. Resolution of the stenosis and complete stent opening with good wall opposition and improved left ICA flow was achieved. Normal antegrade flow and good cerebral perfusion was also observed. (Fig. 31.8).
Hemostasis at the puncture site was achieved with an 8-Fr Angio-Seal closure device. The Integrilin was continued as an infusion for 24 hours postprocedure, and the patient was given a 600-mg loading dose of clopidogrel and 325 mg of aspirin. Clopidogrel and aspirin were continued for 6 weeks.
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