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Initial findings before the first CAS treatment. Magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI) showed no cerebral infarction (A). Magnetic resonance angiography showed severe stenosis of the left internal carotid artery (B). MRI-DWI on the third day showed enlarged infarct centered on the watershed area (C).
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Magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI) showed no cerebral infarction (Fig. 1A). Magnetic resonance angiography (MRA) revealed severe stenosis of the left ICA (Fig. 1B), and dissection of the ICA was diagnosed according to digital subtraction angiography. MRI-DWI showed an infarct centered on the watershed area (Fig. 1C), and an urgent left CAS was performed because of DWI-clinical mismatch.
Intraoperative findings of left common carotid angiography. A false lumen (black arrowhead) was detected on the internal carotid artery (ICA) (A). The dissection extended from the bifurcation (black arrow) to near the petrous portion (arrowhead) of the ICA (B). Residual stenosis in the distal part of the dissection (arrowhead) after the deployment of the carotid artery stents (C). Adequate dilation of the left ICA and improvement of flow (white arrow, the distal edge of the neck-bridge stent; black arrow, the proximal edge of the neck-bridge stent) (D).
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Left common carotid angiography (CCAG) showed CAD (Fig. 2A) and a severe stenotic lesion from its bifurcation to the petrous portion of the ICA (Fig. 2B). Rx 6 x 30 mm, Precise Pro Rx 7 x 40 mm, and Precise Pro Rx 8 x 40 mm, Cordis, OH, USA) were deployed from the most distal position from which a carotid artery stent can reach the CCA (Fig. 2C). Residual dissection was detected distally to the first stent. The final imaging confirmed adequate blood flow through the CCA to the ICA (Fig. 2D).
Preoperative findings before the second CAS treatment. Magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI) showed no cerebral infarction (A). Magnetic resonance angiography showed severe stenosis of the right internal carotid artery (B). MRI-DWI showed a spotty infarct centered on the watershed area (C). Perfusion image showed low perfusion for the right middle cerebral artery territory (D).
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MRI-DWI did not show cerebral infarction (Fig. 3A). An MRA revealed severe stenosis of the right ICA (Fig. 3B), and anticoagulation (argatroban) and dual antiplatelet therapy were initiated immediately. MRI-DWI showed cerebral infarction in the right "watershed" region (Fig. 3C), and CT-perfusion imaging showed low perfusion of the right hemisphere (Fig. 3D).
Intraoperative findings of the right common carotid on angiography. A false lumen (black arrowhead) was detected on the internal carotid artery (ICA) (A). The dissection extended from the bifurcation (black arrow) to near the petrous portion (arrowhead) of the ICA (B). Residual stenosis in the distal part of the dissection (arrowhead) after the deployment of the carotid artery stents (C). Adequate dilation of the right ICA and improvement of blood flow (white arrow, the distal edge of the neck-bridge stent; black arrow, the proximal edge of the neck-bridge stent) (D).
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The right CCAG showed CAD from the bifurcation to the petrous portion of the ICA (Fig. 4A, B). Two carotid artery stents (Precise Pro Rx 6x30 mm and Precise Pro Rx 7 x 40 mm) were deployed from the proximal petrous portion to the orifice of the ICA (Fig. 4C). The final imaging confirmed that the stents were well expanded (Fig. 4D).
Multiplanar reconstruction images of three-dimensional computed tomography (A, right side; B, left side) and magnetic resonance angiography (C) showed no recanalization of the internal carotid artery dissection after 4 years.
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Neither CAD has recanalized after 4 years of follow-up (Fig. 5).