Ces radiol. 2020, 74(2):131-138 | DOI: 10.55095/CesRadiol2020/023

Spontaneous dissection of internal carotid arteryOriginal article

Miroslav Šercl¹, Zuzana Eichlová², Pavel Barsa³, Veronika Mellanová¹, Vít Macháčka¹, Ladislav Endrych¹

¹ RDG oddělení, Krajská nemocnice Liberec, a.s.

² Neurologie, Krajská nemocnice Liberec, a.s.

³ Neurochirurgie, Krajská nemocnice Liberec, a.s.

Introduction: Systematic examination using CTA in patients after a sudden neurological deficit has led to increased detection and diagnosis of internal carotid artery (ICA) dissection. We present an analysis of our patients, focusing on effectiveness and safety in treating this disease.

Method: Patients treated in our hospital for acute neurological symptoms due to diagnosis of spontaneous dissection of the extracranial section of the ICA in 2011-2019 were evaluated by retrospective analysis. We analyzed baseline clinical symptomatology and NIHSS in all patients, findings on CTA, selected acute-phase therapy, brain imaging, medication at discharge, 3-month follow-up with NIHSS and carotid artery imaging by US or CTA. Asymptomatic patients after recurring TIA or patients with low NIHSS ≤ 3 were treated conservatively with anti-platelet therapy, in the case of a thrombus present in the carotid artery lumen or fresh ischemic lesion detected by MR by anticoagulants. Patients with significant neurological deficiency (NIHSS ≥ 4) were treated by intravenous thrombolysis, or by the implantation of stents into the cervical dissection, with a subsequent mechanical thrombectomy of possible intracranial embolization.

Results: A total of 29 patients were treated in the Regional Hospital Liberec a.s. for acute neurological symptomatology by diagnosis of spontaneous internal carotid dissection from 1/2011 to 6/2019. Bilateral findings occurred in six patients in this period, findings on one side only occurred in 23 patients. We used conservative therapy in 19 patients with low neurological deficit (NIHS ≤ 3), antiplatelet therapy in 12 patients, and anticoagulation therapy in 7 patients. In 10 patients with significant neurological deficits in the range of NIHSS 4-19, intravenous thrombolysis was administered, followed by recovery in 2 cases. Intervention with planned stent implantation was performed in 8 cases. The interventional treatment was successful in 5 patients, a total of 7 stents were implanted, and 3 patients with ICA dissection underwent a mechanical thrombectomy from the intracranial arteries with a stent-retriever. The recanalization of ICA failed in 3 patients. Anti-platelet therapy was initiated in all successfully recanalized patients.
We observed a positive clinical outcome with NIHSS ≤ 3 in 19 (100%, 19/19) conservatively treated patients at 3 months after treatment. However, in a longer follow-up, the conservative therapy failed in 2 patients (11%, 2/19), who required endovascular treatment due to developing symptomatic stenosis or pseudoaneurysm. In the group of 10 patients enrolled for invasive treatment NIHSS ≤ 3 was found in 9 patients (90%, 9/10) after 3 months, a result of NIHSS 5 was observed in one unsuccessfully recanalized patient (10%, 1/10), another two unsuccessfully recanalized patients were recovered to NIHSS 1 and 2.

Conclusion: In patients with spontaneous dissection of ICA with less severe neurological symptomatology, a conservative approach with the necessity of periodic controls is generally recommended, which is supported by the data of our study. From the analysis of our patients it can be assumed that in the case of a significant neurological deficit, invasive treatment (stent implantation + mechanical thrombectomy) combined with intravenous thrombolysis is a safe method of treatment.

Keywords: carotid artery dissection, neurological symptoms, stent implantation

Accepted: April 6, 2020; Published: June 1, 2020  Show citation