Emergent endovascular management of long-segment and flow-limiting carotid artery dissections in acute ischemic stroke intervention with multiple tandem stents

S. A. Ansari*, A. L. Kühn, A. R. Honarmand, M. Khan, M. C. Hurley, M. B. Potts, B. S. Jahromi, A. Shaibani, M. J. Gounis, A. K. Wakhloo, A. S. Puri

*Corresponding author for this work

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

BACKGROUND AND PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Original languageEnglish (US)
Pages (from-to)97-104
Number of pages8
JournalAmerican Journal of Neuroradiology
Volume38
Issue number1
DOIs
StatePublished - Jan 2017

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Carotid Arteries
Stents
Dissection
Stroke
Thrombectomy
Pathologic Constriction
Infarction
Reperfusion
Thrombosis
Ischemia
Perfusion
Morbidity
Mortality

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Clinical Neurology

Cite this

@article{b7b93b34180547388726eb09b5ed5da0,
title = "Emergent endovascular management of long-segment and flow-limiting carotid artery dissections in acute ischemic stroke intervention with multiple tandem stents",
abstract = "BACKGROUND AND PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.",
author = "Ansari, {S. A.} and K{\"u}hn, {A. L.} and Honarmand, {A. R.} and M. Khan and Hurley, {M. C.} and Potts, {M. B.} and Jahromi, {B. S.} and A. Shaibani and Gounis, {M. J.} and Wakhloo, {A. K.} and Puri, {A. S.}",
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pages = "97--104",
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Emergent endovascular management of long-segment and flow-limiting carotid artery dissections in acute ischemic stroke intervention with multiple tandem stents. / Ansari, S. A.; Kühn, A. L.; Honarmand, A. R.; Khan, M.; Hurley, M. C.; Potts, M. B.; Jahromi, B. S.; Shaibani, A.; Gounis, M. J.; Wakhloo, A. K.; Puri, A. S.

In: American Journal of Neuroradiology, Vol. 38, No. 1, 01.2017, p. 97-104.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Emergent endovascular management of long-segment and flow-limiting carotid artery dissections in acute ischemic stroke intervention with multiple tandem stents

AU - Ansari, S. A.

AU - Kühn, A. L.

AU - Honarmand, A. R.

AU - Khan, M.

AU - Hurley, M. C.

AU - Potts, M. B.

AU - Jahromi, B. S.

AU - Shaibani, A.

AU - Gounis, M. J.

AU - Wakhloo, A. K.

AU - Puri, A. S.

PY - 2017/1

Y1 - 2017/1

N2 - BACKGROUND AND PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

AB - BACKGROUND AND PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

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