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|LETTERS TO EDITOR
|Year : 2018 | Volume
| Issue : 1 | Page : 228-229
Carotid stump syndrome treated with endovascular coiling: A rare cause of stroke in young patients
Anshu Mahajan1, Biplab Das1, Gaurav Goel1, Arun Garg2, Harsh Sapra3
1 Department of Neurointervention, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
2 Department of Neurology, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
3 Department of Neuroanaesthesia, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
|Date of Web Publication||11-Jan-2018|
Dr. Gaurav Goel
Department of Neurointervention, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mahajan A, Das B, Goel G, Garg A, Sapra H. Carotid stump syndrome treated with endovascular coiling: A rare cause of stroke in young patients. Neurol India 2018;66:228-9
|How to cite this URL:|
Mahajan A, Das B, Goel G, Garg A, Sapra H. Carotid stump syndrome treated with endovascular coiling: A rare cause of stroke in young patients. Neurol India [serial online] 2018 [cited 2019 Jul 16];66:228-9. Available from: http://www.neurologyindia.com/text.asp?2018/66/1/228/222861
Carotid stump syndrome (CSS) is a rare cause of cerebrovascular events. Carotid stump can be a potential source of ipsilateral microembolization and results in recurrent cerebrovascular events. CSS is a treatable cause of recurrent visual and hemispheric ischemic symptoms. We describe the case of a patient with recurrent episodes of stroke caused by left internal carotid artery (ICA) occlusion as a result of dissection. He was diagnosed to be having CSS and was successfully treated with endovascular coil occlusion. To our knowledge, this is one of the few reported cases in which coil embolization was done to obviate the turbulent flow effect due to the carotid stump.
The patient was a 36-year old male patient who presented with multiple transient episodes of right-sided numbness, one episode of slurred speech, and right- sided weakness. He had a history of heavyweight lifting 1 day prior to the onset of symptoms, which was associated with headache and neck pain. He was nonhypertensive and a nonsmoker. Magnetic resonance imaging (MRI) and time of flight (TOF) angiography was performed, which showed an acute lacunar infarct of the left internal capsule (posterior limb), along with complete left ICA occlusion beyond the carotid bulb, associated with carotid dissection [Figure 1]a and [Figure 1]b. Comprehensive diagnostic work up including laboratory test for coagulopathy, blood sugar, echocardiography, and 24-hour Holter monitoring were normal. For carotid dissection, low molecular weight heparin (injection enoxaparin 0.6 mg subcutaneously twice daily) was started. He had a recurrence of ischemic symptoms even on anticoagulation therapy. Repeat MRI of the brain showed new acute infarcts in the left corona radiata and the left frontal subcortical white matter [Figure 1]c and [Figure 1]d. Hence, digital subtraction angiography (DSA) of cerebral vessels was performed which revealed an occluded left internal carotid artery (ICA) just beyond the carotid bulb with a distal tapering suggestive of dissection. A turbulent flow was noted in the carotid stump [Figure 2]a. Left ICA territory blood circulation was subserved by the anterior and posterior communicating arteries. Left middle meningeal artery and ophthalmic artery collaterals were reforming the left supraclinoid ICA [Figure 2]b. Microemboli that had formed at the carotid stump migrated through the external and internal carotid anastomotic channels causing lacunar infarcts. A diagnosis of left CSS was made.
|Figure 1: MRI diffusion showing a focal acute infarct in the posterior limb of the left internal capsule (a); MRA showing the occluded left ICA just beyond the bulb (b); MRI (diffusion and apparent diffusion coefficient, ADC) showing new-onset acute infarcts in the left corona radiata and in the left frontal subcortical white matter (c and d)|
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|Figure 2: Cerebral angiography showing turbulent flow in the carotid stump (a); left middle meningeal artery-ophthalmic collateral was reforming the left supraclinoid internal carotid artery (b); diagrammatic presentation of pathophysiology of carotid stump syndrome (c); post-endovascular procedure angiography showing complete occlusion of the left carotid stump with redirection of flow into the left external carotid artery (d)|
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In view of repeated episodes of stroke in the patient despite his being on anticoagulation, the decision for endovascular coiling of the carotid stump was made. A 6 F long sheath was inserted via the right femoral artery and was placed in the left distal common carotid artery (CCA) over the 5 F diagnostic catheter. Selective catheterization of the carotid stump was done using the Echelon microcatheter, and the stump was occluded with multiple pushable and detachable coils. Final check angiogram of the left CCA revealed complete occlusion of the left carotid stump with redirection of flow into the left external carotid artery [Figure 2]d. He was discharged on dual antiplatelets (aspirin and clopidogrel) with minimal disability (modified Rankin scale = 1). A repeat MRI of the brain after 6 weeks showed no fresh infarcts. At a 6-month follow-up, the patient was doing well without any recurrence of ischemic symptoms.
CSS is an unusual but potential source of microembolism to the intracranial circulation. The diagnosis of CSS is considered in the presence of ipsilateral ICA occlusion with stump formation. Other possible sources for stroke such as a cardiac cause and atheromatous plaques in the arch of aorta and carotid artery should be excluded. The carotid stump is the source of microemboli. These microemboli can be distally lodged into the intracranial circulation through the trickle of blood flow via the carotid stump or through the patent collateral channels between ipsilateral external and internal carotid arteries [Figure 2]c.
Treatment of CSS include medical management (antiplatelet, anticoagulation), surgery, or the endovascular approach. Previously, surgical excision of the carotid stump was the mainstay of treatment. Endovascular treatment including the placement of covered stent; a bare stent with or without coils between the distal common and external carotid arteries to exclude the ICA stump; and, coil embolization of the carotid stump has been described in the literature. In our patient, the DSA showed a turbulent flow in the carotid stump without demonstrable trickled flow through the carotid stump. Microemboli formed in the carotid stump and travelled through the external and internal carotid artery anastomosis. He was managed with endovascular coil embolization of the carotid stump. To our knowledge, endovascular coiling as the primary treatment modality for carotid stump syndrome has not been reported in literature. This approach has the advantage of not requiring long-term antiplatelet therapy, which is unavoidable in patients receiving carotid stenting for CSS.
In conclusion, carotid stump formation due to proximal ICA occlusion is a potential and treatable cause of stroke. Endovascular coil embolization of the carotid stump is an effective treatment for CSS.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]