Vessel wall imaging and carotid artery stenting for recurrent cervical internal carotid artery vasospasm syndrome: illustrative case

Abstract

BACKGROUND Recurrent cervical internal carotid artery vasospasm syndrome (RCICVS) causes cerebral infarction, ocular symptoms, and occasionally chest pain accompanied by coronary artery vasospasm. The etiology and optimal treatment remain unclear. OBSERVATIONS The authors report a patient with drug-resistant RCICVS who underwent carotid artery stenting (CAS). Magnetic resonance angiography revealed recurrent vasospasm in the cervical segment of the internal carotid artery (ICA). Vessel wall imaging during an ischemic attack revealed vascular wall thickening of the ICA, similar to that in reversible cerebral vasoconstriction syndrome. The superior cervical ganglion was identified at the anteromedial side of the stenosis site. Coronary artery stenosis was also detected. After CAS, the symptoms of cerebral ischemia were prevented for 2 years, but bilateral ocular and chest symptoms did occur. LESSONS Vessel wall imaging findings suggest that RCICVS is a sympathetic nervous system-related disease. CAS could be an effective treatment for drug-resistant RCICVS to prevent cerebral ischemic events.

Recurrent ischemic stroke from reversible extracranial internal carotid artery and middle cerebral artery vasospasm: A case report

“…Ganglion blocks, carotid artery stenting as well as conventional medications, such as calcium antagonist, steroid, papaverine, nitroglycerin, have not seen a long-term effective outcome. [ 1 2 4 11 12 ] The normal caliber of the ICAs had been restored in this patient using papaverine and nimodipine in the acute phase, but there were still attacks during the long-term follow-up. Further treatment measures need to be explored.…”

“…put forward an idea that the ICA stenosis at the C1-2 vertebral levels may be relevant to the superior cervical ganglion, which may explain the residual ocular symptoms after carotid artery stenting. [ 2 ] While the involvement of the MCA in idiopathic ICA vasospasm remains largely unexplored, the presentation of this patient suggests that MCA involvement is plausible, although extremely rare.…”

“…Idiopathic internal carotid artery (ICA) vasospasm remains a rare and under-recognized cause of ischemic stroke, which is clinically characterized by recurrent cerebral infarctions coupled with the reversible occlusion or stenosis of the ICA. [ 1 2 ] Despite the reports of about 30 cases to date, a common characteristic of each has been the exclusive involvement of the extracranial ICA. In this report, we present a novel case of recurrent ischemic stroke caused by the both middle cerebral artery (MCA) and the bilateral ICA vasospasm.…”