Spontaneous Intracranial Internal Carotid Artery Dissection Treated by Intra-arterial Thrombolysis and Superficial Temporal Artery-Middle Cerebral Artery Anastomosis in the Acute Stage-Case Report-

Abstract

A 22-year-old man presented with sudden onset of right retro-orbital headache followed by left hemiparesis. Right carotid angiography demonstrated almost total occlusion of the intracranial internal carotid artery (ICA) and severe stenosis of the middle cerebral artery (MCA), presumably caused by arterial dissection. Local arterial injection of urokinase was performed 2 hours after onset. The ICA became patent, but the M 2 portion of the MCA was still occluded, and the left hemiparesis did not improve. Superficial temporal artery-MCA anastomosis was immediately performed. The left hemiparesis disappeared completely 6 days after this procedure. Angiography 2 weeks after the onset revealed occlusion of the ICA, and maintenance of blood flow to the right cerebral hemisphere via the anastomosis. Magnetic resonance imaging showed small infarcts in the right cerebral cortex. Repeat angiography after 5 months showed recanalization of the right ICA and the right MCA. Combination of thrombolytic therapy and bypass surgery may be a useful treatment option for patients with sudden occlusion of the intracranial artery caused by dissection.

Hemorrhagic Complications After Off-Label Thrombolysis for Ischemic Stroke

“…49 Concerning thrombolysis for stroke after extracranial carotid dissections, 68 patients were treated, 50 with IVT 50 -54 and 18 with IAT. In the IVT group, none of the patients developed a rupture of the dissected vessel or subarachnoid hemorrhage; one patient developed an SICH 51 Mortality was 13% and favorable outcome with a modified Rankin Scale score 0 to 2 was observed in 60% of patients.…”

Two Cases of Intracranial Internal Carotid Artery Dissection Presenting with Ischemic Stroke

“…Causes of exacerbation of symptoms include hemodynamic factors associated with the progression of stenosis or occlusion of the internal carotid artery, distal embolism due to thrombi formed at the site of dissection, and occlusion of penetrating branches that branch from the dissected area. 3,10,11,13) Surgical treatments are considered acceptable in patients who show progression of symptoms by medical treatment alone. 2,12,15) Regarding surgical treatments in the acute period, endovascular treatment using a stent, an approach conducted by ours, has often been reported recently.…”

“…[2][3][4][5][6][9][10][11][12][13][14][15] Concerning internal treatments, indications of antithrombotic treatment still remain controversial. 1,3,4) Although there have been reports that antithrombotic therapy should be avoided, because there is a risk, although rare, of subarachnoid hemorrhage even in intracranial internal carotid artery dissection presenting with ischemia, there have also been reports that no subarachnoid hemorrhage was observed during the period of anticoagulation therapy.…”

“…15) In such patients, emergency STA-MCA anastomosis may maintain the CBF and improve the outcome. 2,13) …”

Treatment of “Other” Stroke Etiologies

“…A number of vasoactive drugs have been identified as possible precipitants of RCVS (Box 56-4). 59 Some dissections are believed to occur without producing any symptoms and therefore are presumed to remain completely unrecognized. 53,55,56 Routine treatment of clinically asymptomatic persistent stenosis following dissection is probably not warranted given that procedural risk seems to outweigh the long-term risk of stroke with medical management.…”