Coronary and carotid occlusive disease--surgical techniques and results

In the period 1982-1996, 7,476 aortocoronary bypass surgeries were performed at the University Clinic for Cardiovascular Surgery in Novi Sad with perioperative mortality of 2.85%. In 242 patients (3.24%) an additional thrombendarterectomy procedure of carotid arteries was performed with indications such as: positive neurologic symptoms; critical morphology of carotid lesions according to Wesley-Moore symptomatology and critical stenosis. The cardiac status of patients was as follows: poor left ventricular function (EF--ejection fraction--30%) in 42 patients (19.2%), left main coronary artery stenosis in 31 patients (12.8%), endarterectomy of coronary arteries due to diffuse and distal coronary occlusive disease in 93 patients (38.5%) and isolated aortocoronary bypass in 149 patients (61.8%). The status of carotid arteries was as follows: unilateral stenosis in 156 patients and bilateral stenosis in 63. Depending on the carotid or cardiac finding, our surgical strategies differed: 65 patients (26.8%) underwent simultaneous operation, 141 patients (58.2%) underwent two-stage operation and in 36 patients (14.9%) three-stage operation was performed. Postoperative complications included: neurological deficit in 4 patients (1.7%); Transient ischemic attacks in 5 patients (2.1%); myocardial infarction in 6 patients (2.7%); hemorrhage in 2 patients (0.9%); gastrointestinal hemorrhage in 3 patients (1.4%); pulmonary complications in 2 patients (0.9%); serious rhythmic disorders in 1 patient (0.5%) and therapeutically resistant hypertension in 1 patient (0.5%). Ten patients (4.1%) died. Causes of death: cardiac in 3 patients (1.4%), neurological in 3 patients (1.4%), pulmonary embolism in 1 patient (0.5%) and other causes in 3 patients (1.4%). The operative risk in this group of polyvascular patients is higher than in the "group with isolated aortocoronary disease". Appropriate indications for surgery in one, two or three stages significantly decrease mortality in these patients. Simultaneous operation is reserved for patients with severe neurological symptoms and unstable angina.     

Somatosensory evoked potentials: a simple neurophysiological monitoring technique in supra-aortal balloon test occlusions

The aim of this study was to evaluate somatosensory evoked potentials (SEP) as a simple neurophysiological monitoring method in supra-aortal balloon test occlusions (BTO). The 13 patients examined had carcinoma of the larynx (n = 6), nasopharyngeal malignancy (n = 3), sphenoid meningioma (n = 2), mycotic aneurysm (n = 1), and a tumor of the carotid body (n = 1). Transfemoral balloon occlusion of the internal carotid artery was maintained for 30 min and monitored both clinically and by SEP. None of the 13 patients showed neurological deficits or pathological changes in the SEP. No thromboembolic complications occurred during BTO. In 11 cases the cervical vessels could be spared or reconstructed during surgery. No neurological symptoms occurred during the clinical follow-up. One patient died the day after BTO due to cardiac arrest. Neurophysiological monitoring of preoperative BTO using SEP is a technically simple method. A similar method has been shown to have a high sensitivity and reliability in carotid surgery.     

Neurological complications after open heart surgery. Risk factors identified in a retrospective study

Cerebral complications were documented in 2 per cent (133/6666) of open heart procedures performed in adults at the Karolinska hospital, during the 7-year period, 1990-96. In 32 per cent (42/133) of cases, the neurological symptoms appeared after an uneventful postoperative interval of 2-14 (median 3) days. These patients were older and were characterised by a tendency toward a greater prevalence of carotid artery disease and of postoperative atrial arrhythmia. By contrast, the subgroup whose cerebral symptoms occurred immediately after the operation was characterised by greater severity of the symptoms, long operation time, and poor preoperative left ventricular function. Aggressive postoperative anticoagulant treatment, especially in patients with supraventricular arrhythmias, would seem to be justified to reduce the risk of neurological complications.     

Extrathoracic bypass procedures for proximal common carotid artery lesions

During a 10-year period ending in December 1991, 31 extrathoracic bypass procedures were performed in 29 patients for proximal common carotid artery atherosclerotic stenosis or occlusion. This included 16 men and 13 women, with a mean age of 63 years. Indications for surgery included transient ischemic attacks in 23 patients (79%), nonfocal symptoms in 4 patients (14%), and asymptomatic proximal common carotid artery stenosis associated with near-total occlusion of the internal carotid artery in 2 patients (7%). Severe proximal stenosis or complete occlusion of the common carotid artery was demonstrated angiographically in all cases. Subclavian-to-carotid bypass was performed in 26 cases and carotid-to-carotid bypass in 5 cases. Seventy-four percent of the bypass procedures were to the common carotid artery and 26% to the external carotid artery. Endarterectomy of the common carotid bifurcation was performed in conjunction with the bypass procedure in 13 cases and vertebral artery transposition in 2 other cases. Saphenous vein was used as the bypass conduit in 65% and prosthetic grafts in 35% of cases. There were no perioperative strokes or deaths in this series, and the mean postoperative hospital stay was 5 days. Follow-up ranged from 2 to 118 months (mean: 38.4 months). Graft occlusion occurred in two cases during the follow-up period (3-year patency rate: 90%), with recurrence of symptoms in one patient, which necessitated revision. Three patients had persistence or recurrence of symptoms despite patency of the graft, one other patient sustained a posterior circulation infarct, and there was one death unrelated to carotid vascular disease during the follow-up period. This experience shows that extrathoracic bypass procedures are safe and well tolerated for symptomatic proximal common carotid artery stenosis or occlusion. This method of reconstruction has excellent long-term patency and protection against further anterior circulation neurologic events.     

Cervical epidural anesthesia for carotid mycotic aneurysms

Extracranial mycotic aneurysms of the carotid are unusual. We present such an aneurysm of the right primary carotid caused by enteritis due to Salmonella in a 75-year-old patient at high risk for surgery (myocardial ischemia evolving over 3 months) and with coexisting stenosis of 75% of the left internal carotid. Endarterectomy of the left internal carotid, with shunting, was performed, after which the right primary carotid was tied during the same operation. Epidural anesthesia to C6-C7 was provided through a catheter supplemented with an intravenous propofol infusion. Neurological and hemodynamic variables monitored during surgery were stable. No neurological deficits or myocardial ischemic changes were recorded. Three months after discharge the patient was asymptomatic.     

Endovascular treatment of carotid artery occlusion in progressive stroke syndromes: technical note

OBJECTIVE AND IMPORTANCE: We describe two patients, with progressing neurological deficits, who showed improvement after revascularization of their carotid arteries using stents. CLINICAL PRESENTATION: One patient presented clinically with the symptoms of a middle cerebral artery territory stroke. Angiography demonstrated total occlusion of the right internal carotid artery (ICA), with evidence of clot from the origin of the ICA to the middle cerebral artery trifurcation. The second patient presented with bilateral ICA occlusions and evidence of a progressing left hemispheric deficit; she was receiving therapeutic levels of heparin at the time of deterioration of her condition. INTERVENTION: Thrombolysis and stenting successfully recanalized the occluded vessels, and the deficits of the first patient were reversed. With the second patient, a dissected carotid loop was encountered. Straightening of the loop with a wire and stenting of the carotid artery using two stents allowed revascularization of the left hemisphere and resolution of most of the deficits of this patient. CONCLUSION: This report demonstrates the technical feasibility of placing stents in high-risk patients with carotid artery occlusions from either dissection or atherosclerosis. Both patients sustained much smaller infarctions than would have been expected if the carotid artery territory had been infarcted. We report on the technical feasibility of reopening acutely closed ICAs by using endovascular methods.     

Tracking the MEN1 gene

Combined carotid endarterectomy and coronary artery bypass grafting was performed in 52 patients between January 1982 and September 1994. Forty-nine patients had stable or unstable angina and three had symptom-free coronary artery disease detected by stress testing. Thirty-one patients had triple-vessel disease and 17 had left main trunk or left main equivalent coronary artery disease. Five patients had symptom-free carotid artery disease, 12 had non-specific neurological symptoms, and 35 had transient ischaemic attacks. Carotid endarterectomy was performed first, followed by coronary artery bypass grafting. There were three postoperative deaths, two cardiac and one neurological, for a mortality rate of 5.8%. One patient suffered a permanent neurological deficit (1.9%). It is concluded that combined carotid endarterectomy/coronary artery bypass grafting can be performed in selected patients with acceptable neurological morbidity, although cardiac mortality was not eliminated by the combined approach.     

Identification of 1,4-dihydropyridine binding domains within the primary structure of the alpha 1 subunit of the skeletal muscle L-type calcium channel

Damage to the spinal cord in course of the treatment of diseases of the infrarenal aorta is a rare but calamitous complication. The reported incidence is about 0.2%. The neurological loss is usually complete flaccid paraplegia with high mortality and rare full or partial recovery. Between 1980 and 1991, 1070 reconstructive procedures of the infrarenal aorta were performed: 821 due to aneurysm (316 elective procedures [mortality 1.6%] and 505 emergency procedures [mortality 24.5%]) and 249 due to aorto-iliac occlusive disease. Damage to the spinal cord occurred in 2 patients (2/1070, 0.19%). One patient had incomplete paraparesis following repair of an unruptured abdominal aortic aneurysm with gradual return of all neurological symptoms to normal. The second patient developed complete paraplegia following repair of a ruptured infrarenal aneurysm. There war no recovery of the symptoms. The patient died from septicaemia 4 months later.     

Carotid body tumor

INTRODUCTION: The carotid body tumour was first described by von Haller in 1743. The first two, unsuccessfully surgically treated carotid body tumours, were done by Reinger in 1880 (his patient died), and by Maydel in 1886 (his patient developed hemiplegia). Scudder made the first successful surgical removal of the carotid body tumour in 1903. Using data from the Cologne (Germany) Medline Research Centre, surgical treatment of carotid body tumour was not reported in Yugoslav medical literature. The aim of this study is to present 6 surgically treated carotid body tumours. MATERIAL AND METHODS: Over the period from 1982 to the end of 1996, 6 patients with carotid body tumours were operated on in the Centre of Vascular Surgery of the institute of Cardiovascular Diseases of the Clinical Centre of Serbia in Belgrade. Four of them were female and two male patients, average age 43.4 years. In all cases the tumour was an asymptomatic neck mass. Color-Duplex ultrasonography and selective carotid arteriography were used to establish the diagnosis in 5 cases. The pathohistological examination of all 6 patients revealed the benign character of tumors. Patient 1. A 52-year old man. The suspicion of symptomatic carotid artery aneurysm, was the indication for urgent operation. The intraoperative finding showed a carotid body tumour which compressed carotid arteries. The subadventitial removal of the tumour was done. The patient was followed for 14 years without signs of local recidivation. Patient 2. A 38-year old man. During the operation the tumour was removed subadventitially, without clamping or injuring the carotid arteries. The patient was followed for 8 years and 3 months, and there were no signs of local recidivation. Patient 3. A 48-year old woman. Intraoperative findings showed an infiltration of the carotid arteries and tumour was removed together with parts of internal and external carotid arteries. The internal carotid artery was reconstructed using saphenous vein graft. The follow-up period was 4 years and 6 months, without signs of local recidivation. Patient 4. A 61-year old woman was operated on (neck exploration) in other hospital 4 years before the admission to our Centre. During the primary operation, an internal carotid artery was ligated without neurological consequences. Also, histological examination was performed. We removed a tumour together with the ligated internal carotid artery without its reconstruction. Three years after the operation the patient was without signs of local recidivation. Patient 5. A 40-year old woman. After subadventitial surgical removal of the tumor without clamping or injuring the carotid arteries, the patient was followed-up for 2 years and 2 months, and was without signs of local recidivation. Patient 6. A 30-year old woman was operated on (neck exploration only) in other hospital two months before the admission to our Centre. Intraoperative findings showed tumour infiltration to the carotid arteries, and therefore, internal and external carotid arteries were removed together with the tumour. The internal carotid artery reconstruction was performed using aaphonous vein graft. The early postoperative period was unremarkable. However, 48 hours after the operation cerebrovascular insult developed with hemiplegia. There was no sign of graft thrombosis. The patient was followed-up for 2 years postoperatively. There were no signs of local recidivation. The same patient had also a small asymptomatic tumour at the other side of the carotid arteries. DISCUSSION: The carotid body tumour originates from the paraganglious tissue at the carotid artery bifurcation. There are angiomatous and adenomatous forms. All of our 6 cases had adenomatous form. It grows slowly, and can compress and/or infiltrate carotid arteries and nerves. Three of our 6 cases showed signs of carotid artery compression and 3 showed infiltration to the carotid arteries. Malignant alteration of this tumour is uncommon. (ABSTRACT T     

The placebo in modern medicine

PURPOSE: To report the results of balloon angioplasty in recurrent carotid occlusive disease and evaluate the potential for stent implantation. METHODS AND RESULTS: Between April 1991 and September 1995, 15 patients with carotid restenosis underwent 17 endoluminal procedures in 3 common carotid and 14 internal carotid arteries. Two postdilation complications (dissection and acute occlusion) required prompt stenting; one common carotid artery was stented for postdilation residual stenosis. One recurrent lesion was also stented 6 months after initial angioplasty. One stroke, 1 silent cerebral infarction, and 3 transient ischemic attacks occurred in the balloon angioplasty patients (33% neurological complication rate). The common carotid stent patient died 3 days postoperatively due to hyperperfusion syndrome. Long-term follow-up in two stent patients showed no restenosis at 18 and 48 months, respectively. The 11 balloon angioplasty patients likewise have not demonstrated restenosis. CONCLUSIONS: Balloon angioplasty alone appears too risky for treating recurrent carotid disease. Stents may offer a safer alternative, particularly when implanted primarily.     

The value of the CT scanner in intensive care

The composition of atherosclerotic plaques in the carotid artery is assumed to be related to the development of neurological symptoms. The echo patterns produced by B-mode ultrasound may be of use in the assessment of the plaques' composition. It is suggested that fibrotic and "stable" plaques are more echogenic than lipid/hemorrhagic and echolucent or "unstable" plaques. B-mode ultrasound procedures were performed 1 day prior to surgery on 46 consecutive endarterectomies. Two observers assessed the plaques according to their echo pattern and echogenicity and sorted them into three categories: 1) predominantly echolucent, 2) heterogeneous, and 3) predominantly echogenic. The intraobserver agreement was moderate (kappa = 0.44) and the interobserver agreement low (kappa = 0.38). Furthermore, subjective categorization of plaque types resulted in type 1 plaques being as fibrotic as type 2 or 3 plaques. We conclude that B-mode ultrasound and subsequent subjective categorization of atherosclerotic plaques cannot adequately determine the volume of fibrosis or lipids within the plaque.     

Feasibility and safety of 1-day postoperative hospitalization for carotid endarterectomy

OBJECTIVE: To determine whether 1-day postoperative hospitalization after carotid endarterectomy is safe and the degree to which this can be achieved. DESIGN: Consecutive sample series of all carotid endarterectomies performed by a single surgical group. SETTING: A single tertiary-care hospital. PATIENTS: All who underwent carotid endarterectomy. Patients with procedures combined with coronary revascularization and patients undergoing the first part of a staged bilateral carotid endarterectomy performed in 1 hospitalization were excluded. INTERVENTION: In December 1993, a fast-track protocol was initiated, aiming for a 1-day stay after carotid endarterectomy without admission to an intensive care unit (ICU). Before this date, postoperative care included obligatory monitoring for at least 1 night in an ICU. MAIN OUTCOME MEASURES: Length of stay, admission to and stay in the ICU, complications, and hospital readmission rate. RESULTS: Over a 21-month period, 152 patients had 163 carotid endarterectomies. Of these, 124 were elective and 39 urgent (patients with a critical stenosis). Indications were stroke (n = 14 [8.6%]), transient ischemic attack (n = 50 [30.7%]), amaurosis fugax (n = 36 [22.1%]), and asymptomatic stenosis (n = 63 [38.7%]). General anesthesia was used for 159 procedures, cervical block for 4. Mean operation time was 2.6 hours. Postoperative stay was 1 day for 82 procedures (50%), 2 days for 49 procedures (30%), 3 days for 12 procedures (7%), and longer for 20 procedures (12%). In the last half of the study, 61% of patients (50/82) were discharged on postoperative day 1 and 87% (71/82) by postoperative day 2. One hundred three patients went to a surgical floor postoperatively. Overall, 60 patients went to the ICU, but only 18 (22%) of the last 82 procedures required ICU admission. The total stay averaged 3.8 days. Twenty-one patients (13%) experienced complications, including 3 deaths within 30 days and 5 neurological deficits. There were 14 early readmissions, but none was attributable to discharge on the first or second postoperative day. CONCLUSIONS: Early discharge home after carotid endarterectomy is safe and efficacious, and obligatory admission to an ICU is not necessary. At least 60% of patients who undergo carotid endarterectomy can have a postoperative stay of 1 day, and more than 80% can be discharged by postoperative day 2. A short postoperative stay is not associated with a significant risk of readmission for complications.     

Stump pressure: an unreliable guide for shunting during carotid endarterectomy

A correlative analysis was made between the neurological status of the awake patient and the internal carotid artery stump pressure in 125 consecutive patients undergoing carotid endarterectomy. There was no mortality in this series. Twenty-four patients lost consciousness immediately after carotid cross-clamping, even though stump pressures were above 50 mm Hg in more than one third of the cases. The majority (80.8%) of the patients tolerated cross-clamping (stump pressures were between 20 and 90 mm Hg). This study demonstrated the variability of cerebral tolerance relative to absolute stump pressure guidelines, such as 25 or 50 mm Hg; reliance on these values to determine the need for intraoperative shunting could lead to stroke at operation. Our experience also showed that assessment of the awake but tranquil patient continues to be the safest and most reliable guide to selective shunting during carotid endarterectomy.     

Successfully operated case of posterior fossa tuberculoma in childhood (author's transl)

A case of intracerebellar tuberculoma is described in which a tuberculoma was removed successfully through the administration of antituberculous agents, and a full recovery was obtained. The patient was a 3-year-old boy who had been receiving antituberculous agents for about 4 months because of acute inflammation followed by osteomyelitis of his right big toe, which was suspected to be tuberculous, and because of pulmonary tuberculosis diagnosed in a chest roentgenogram taken about 1 month after osteomyelitis was cured. While his osteomyelitis was being treated, disturbance in his gait, due to progressive spastic paraparesis, was not iced, and thereafter left cerebellar symptoms with impairment of equilibrium appeared additionally. Then, he was reffered to our clinic for further neurosurgical examination, and was admitted on November 1, 1974 after right carotid and vertebral angiography was performed via the right axillar artery, in which findings suggesting left cerebellar tumor and internal hydrocephalus were obtained. After he was admitted to our clinic, a diagnosis of tumor of the left cerebellum and internal hydrocephalus was more precisely confirmed by pneumoventriculography. Suboccipital craniectomy was then carried out and the tumor, weighing 60 gm, was completely removed from the left cerbellar hemisphere. The tumor was confirmed as tuberculoma not only by histological findings but also by the vertification of tuberculous bacilli in it. Though, moderate fever lasted for about 2 weeks postoperatively, no obvious meningitic signs or new neurological deficits were noted. The patient showed marked improvement especially in his gait disturbance, and was discharged ambulatory 40 days after the operation, and has since been asymptomatic except for slight ataxic gait. The antituberculous agents have been continuously administered postoperatively.     

Postoperative stroke and late neurologic complications after carotid endarterectomy

From 1969 through 1973, 335 consecutive patients (mean age, 60 years) underwent 390 carotid endarterectomies using hypercarbic general anesthesia and no carotid shunting. Early neurologic complications were most common among patients with previous neurologic symptoms and among those with subtotal stenosis or occlusion of the contralateral internal carotid artery. The introduction of routine carotid shunting without hypercarbia during a subsequent series of 626 procedures from 1974 through 1978 has been associated with significantly fewer operative strokes in comparable groups of patients. Complete follow-up information during a mean interval of 8.6 years is available for 95% of 325 operative survivors. Late completed strokes have occurred in 17% of patients but have involved the cerebral hemisphere on the side of previous carotid endarterectomy in only 7%. Of 93 operative survivors who had subtotal stenosis of the contralateral internal carotid artery, 45 underwent contralateral endarterectomy as an elective procedure and 48 did not. The late contralateral stroke rates for these two groups of patients were 4% and 16%, respectively, although these differences did not attain statistical significance. Forty-nine (78%) of 63 patients with contralateral internal carotid occlusion have had no late neurologic symptoms following unilateral carotid endarterectomy.     

A study of 362 consecutive laparoscopic Nissen fundoplications

BACKGROUND: Open Nissen fundoplication has been shown to be a very effective operation in the treatment of intractable gastroesophageal reflux. Because of its technical rather than amputative nature, this procedure offers itself to a completely laparoscopic approach. Several studies have shown the feasibility; however, very few have dealt with the effectiveness of the laparoscopic approach. METHODS: Results of laparoscopic Nissen fundoplications performed during a 6-year period were reviewed including duration of operation, number of hospital days, number of conversions to open procedures, complications, and symptoms. All 362 patients had evidence of gastroesophageal reflux disease documented by radiographic, endoscopic, or pH monitoring testing before the operation. Patients with dysphagia or odynophagia underwent manometric evaluation before operation. Postoperative evaluation included esophagography and endoscopy at 2 to 3 months with an esophagogram yearly thereafter. Follow-up time was 6 months to 6 years. RESULTS: The mean time of operation decreased from 2.7 +/- 0.4 hours during the period from 1991 to 1994 to 1.8 +/- 0.3 hours from 1994 to 1997. During those same periods, the number of days of hospitalization decreased from 2.2 days to a mean of 1.5 days. Manometric studies done before the operation (n = 58) showed a pressure of 4 +/- 1.2 mm Hg compared with postoperative values (n = 39) of 14 +/- 1.8 mm Hg. The conversion rate was 0.8% (n = 3), and the complication rate of 1.9% (n = 7) included the 3 conversions, 2 pneumothoraces, 1 patient with postoperative bleeding, and 1 patient with a large abdominal wall hematoma. There were 5 failures of the procedure (1.2%). Thirteen patients (3.6%) described postoperative symptoms that persisted beyond 2 months, including bloating, flatulence, dysphagia, and diarrhea. CONCLUSIONS: With strict selection criteria and increasing experience and standardization of technique, laparoscopic Nissen fundoplication can provide both safe and effective results for patients with chronic symptoms of gastroesophageal reflux disease.     

Carotid sinus syndrome and embolization procedures

Two patients developed carotid sinus syndrome following embolization procedures. One patient had undergone balloon occlusion of the internal carotid artery; in the other patient, embolization of a carotid body tumor had been performed. The method of diagnosis as well as the etiology and treatment are discussed.     

Delayed full-thickness grafting of lower leg defects following removal of skin malignancies

Cerebral stroke is a serious complication related to carotid endarterectomy (CEA), being most frequently caused by thromboembolic events and less frequently on account of cerebral haemorrhage. The present series comprised five out of 857 (0.6%) patients who had undergone CEA at Oulu University Hospital between the years 1974 and 1993 and suffered a postoperative stroke four to 13 days after surgery due to intracerebral haemorrhage (IH). Preoperatively, all these patients were neurologically intact, with transient ischaemic attacked (TIA) as the main indication for CEA. All five patients had a history of arterial hypertension treated adequately preoperatively, and one patient had high blood pressure levels after surgery. Critical ipsilateral stenosis of the internal carotid artery (> 90%) was detected in the preoperative angiogram in all five cases. The primary outcome after CEA was uneventful in every case, without any signs of neurological deficiency. The symptoms, comprising severe headache, convulsions and/or hemiparesis occurred suddenly four to 13 days (mean seven days) after CEA. The diagnosis of IH was based on computed tomography (CT) findings. All five patients were treated conservatively. Three of them died. We conclude that even normotensive, neurologically intact patients without demonstrable cerebral infarction or postoperative hypertension may suffer cerebral haemorrhage after the relief of high-grade carotid stenosis. The role of possible insufficiency of the autoregulatory mechanisms of the cerebral vasculature on account of long-standing critical stenosis of the internal carotid artery and subsequent uncontrolled hyperperfusion following CEA are discussed.     

Colchicine-induced myoneuropathy in childhood

Carotid-jugular arteriovenous fistulas (AVF) are extremely rare with only 20 cases reported in the literature up to December 1996. The case of a 74-year-old man (the oldest reported in the literature) with abnormal communications between the external carotid artery and the internal jugular vein is reported. The condition was treated by platinum coil embolization via catheterization and by repeated operations to ligate the branches of the external carotid artery, besides removal of the tissue containing the fistula and ligation of the external carotid at its origin. The result was incomplete because about 6 months after the last operation the patient showed the same symptoms, although in a milder form. Until standard treatment is established, the appropriate technique should be decided on a patient-to-patient basis.     

Primary stenting of the extracranial internal carotid artery in a patient with multiple cervical dissections: technical case report

OBJECTIVE AND IMPORTANCE: Spontaneous dissection of the extracranial internal carotid artery (ICA) and vertebral artery (VA) is a well-documented cause of stroke in young, previously healthy patients. The majority of patients with spontaneous dissection are successfully treated with antiplatelet or anticoagulation therapy, but a significant proportion of patients progress to suffer devastating morbidity and mortality. Surgical intervention has primarily consisted of proximal ligation, extracranial-intracranial bypass, or endarterectomy. Generally, these procedures are technically demanding and yield disappointing clinical results. CLINICAL PRESENTATION/INTERVENTION: A 36-year-old man without a significant medical history initially presented with a several-day history of episodic right upper extremity weakness and numbness and visual obscurations. Cerebral angiography revealed bilateral ICA long segment narrowing (95%), distal left VA high-grade (95%) stenosis compatible with dissections, and right VA proximal occlusion. While therapeutically anticoagulated on heparin, the patient continued to experience crescendo episodes of right upper extremity paresis and paresthesias as well as aphasia. The patient underwent primary stenting of the left ICA, using a series of six overlapping stents (three Gianturco-Roubin coronary stents and three Palmaz-Schatz coronary stents). The patient remained symptom-free without neurological complications, and subsequent angiography performed at the 9-month follow-up examination confirmed continued patency of the stented left ICA as well as recanalization of the right ICA and VA. CONCLUSION: Neurovascular stents offer a minimally invasive and potentially efficacious treatment for the prevention of cerebral ischemia in patients with spontaneous extracranial dissection who remain symptomatic despite therapeutic anticoagulation.