User Tools

Site Tools


carotid_artery_dissection

Carotid artery dissection

Arterial dissection of the carotid artery occurs when a small tear forms in the innermost lining of the arterial wall (known as the tunica intima). Blood is then able to enter the space between the inner and outer layers of the vessel, causing narrowing (stenosis) or complete occlusion.

see Internal carotid artery dissection.


Angiographic features

Luminal stenosis (65%), occlusion (28%), pseudoaneurysm (28%), luminal irregularity (13%), embolic distal branch occlusion (13 %), intimal flap (12 %) and slow ICA - MCA flow (11 %) 1).

Management

Endovascular technique of acute ischemic stroke (AIS) in the setting of carotid artery dissection (CAD) is a feasible, safe, and promising strategy 2).

Endovascular therapy was associated with better outcomes and higher cost-recovery than IV thrombolysis in patients with large vessel strokes 3).


The initial management in the absence of ICH is intravenous heparin for 7 days followed by warfarin 4).

The goal aPTTwith heparin is 1.5 – 2.0 times the control value (50–80 sec). Warfarin is continued for 3–6 months with target INR range of 2.0 – 3.0. If anticoagulation is contraindicated, antiplatelet therapy is a consideration. In pregnant individuals, obtain obstetric consultation prior to initiating anticoagulation or anti-platelet therapy.

Indications for endovascular intervention

● Persistent ischemic symptoms despite anticoagulation therapy.

● Flow-limiting lesion with hemodynamic compromise

Contraindication to anticoagulation and/or anti-platelet therapy

● Impending risk of stroke

● Expanding pseudoaneurysm formation

● Iatrogenic dissection during endovascular procedure where flow compromise is apparent

Stenting with/without coiling

The endovascular treatment for carotid dissection is stenting. In case of intimal flap, the stent will appose the flap back to the arterial wall. Pseudoaneurysms have also been successfully occluded with stenting. Both uncovered and covered stents have been used successfully 5)

JoStent is a PTFE covered stent that is available in US. A vein covered stent has also been used 6). In case of a pseudoaneurysm that continues to show significant residual filling after stenting, coiling of the pseudoaneurysm will cause occlusion 7)

After stenting, the patient remains on dual antiplatelet therapy (ASA+Plavix) for at least a month and ASAalone indefinitely.

Follow-up

Follow-up should be arranged for patients on warfarin (e.g., “Coumadin clinic”).

Follow-up study in 3–6 months, which could be CTA, Doppler ultrasonography or catheter angiogram.

References

1)
Anson J, Crowell RM. Cervicocranial Arterial Dissection. Neurosurgery. 1991; 29:89–96
2)
Haussen DC, Jadhav A, Jovin T, Grossberg J, Grigoryan M, Nahab F, Obideen M, Lima A, Aghaebrahim A, Gulati D, Nogueira RG. Endovascular Management vs Intravenous Thrombolysis for Acute Stroke Secondary to Carotid Artery Dissection: Local Experience and Systematic Review. Neurosurgery. 2015 Oct 21. [Epub ahead of print] PubMed PMID: 26492430.
3)
Rai AT, Evans K. Hospital-based financial analysis of endovascular therapy and intravenous thrombolysis for large vessel acute ischemic strokes: the 'bottom line'. J Neurointerv Surg. 2014 Jan 29. doi: 10.1136/neurintsurg-2013-011085. [Epub ahead of print] PubMed PMID: 24476964.
4)
Hart RG, Easton JD. Dissections of Cervical and Cerebral Arteries. Neurol Clin North Am. 1983; 1:255– 282
5) , 7)
Liu AY, Paulsen RD, Marcellus ML, Steinberg GK, Marks MP. Long-term outcomes after carotid stent placement treatment of carotid artery dissection. Neurosurgery. 1999; 45:1368–73; discussion 1373- 4
6)
Marotta TR, Buller C, Taylor D, Morris C, Zwimpfer T. Autologous vein-covered stent repair of a cervical internal carotid artery pseudoaneurysm: technical case report. Neurosurgery. 1998; 42:408–12; dis- cussion 412-3
carotid_artery_dissection.txt · Last modified: 2019/07/03 18:29 by administrador