Atormac
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 1993  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,186 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Case History
 » Discussion
 »  References
 »  Article Figures

 Article Access Statistics
    Viewed212    
    Printed2    
    Emailed0    
    PDF Downloaded2    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 185-188

Carotid Artery Stenting for the Treatment of Fatal Acute Cerebral Infarction Associated with Aortic Dissection


Affiliated Bayi Brain Hospital, The Seventh Medical Center of PLA General Hospital, Beijing, China

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Zhen-Hai Zhang
Affiliated Bayi Brain Hospital, The Seventh Medical Center of PLA General Hospital, Nanmencang, 5, Dongcheng, Beijing - 100700
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279679

Rights and Permissions

 » Abstract 


Acute aortic dissection (AAD) complicated with acute cerebral infarction lacks a unified treatment plan. We report probably the most effective treatment of a type A AAD with acute cerebral infarction leading to coma. A 43-year-old man presented with acute hemiplegia and unconsciousness. He was diagnosed as acute cerebral infarction. After an ineffective emergency intravenous thrombolysis, a Digital Subtraction Angiography (DSA) examination revealed the severe cerebral artery occlusion, and the TICI 3 level was achieved by stent implantation in the left common carotid artery with significant neurological recovery. A type A AAD was found at the 1 month follow-up ultrasound examination and a further thoracic surgery was performed successfully. Carotid ultrasound is helpful for the diagnosis of AAD from acute cerebral infarction. Carotid artery stenting followed by thoracic surgery is effective in this kind of emergency situations. Further studies are needed to determine the exact indications.


Keywords: Acute ischemic stroke, aortic dissection, endovascular treatment, stent
Key Messages: AAD complicated with acute cerebral infarction may lead to life.threatening stroke and carotid ultrasound is one of the appropriate screening tools. At critical moments, despite the risk of aortic rupture, thrombosis, etc., emergency carotid stenting may be the most effective treatment and significant neurological recovery can be achieved.


How to cite this article:
Dang YY, Zhang ZH, Shen CS. Carotid Artery Stenting for the Treatment of Fatal Acute Cerebral Infarction Associated with Aortic Dissection. Neurol India 2020;68:185-8

How to cite this URL:
Dang YY, Zhang ZH, Shen CS. Carotid Artery Stenting for the Treatment of Fatal Acute Cerebral Infarction Associated with Aortic Dissection. Neurol India [serial online] 2020 [cited 2020 Apr 7];68:185-8. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/185/279679




A cute aortic dissection (AAD) complicated with acute cerebral infarction is a life-threatening disease that is easily missed. It lacks a unified treatment plan. We report a type A AAD with acute cerebral infarction leading to coma. The patient was treated with stent implantation in the common carotid artery (CCA), followed by thoracic surgery. To the best of our knowledge, the present study is the first case treated with carotid artery stenting in this kind of patient.


 » Case History Top


Case presentation

A 43-year-old man was brought to our hospital with an acute weakness of left sided limbs after defecation for 1.5 hours. In emergency room, the patient was noted to have a dysphonia, a right gaze deviation, and a severe weakness on his left side. He also presented a left Babinski sign, redness on his left neck and chest wall skin. National Institute of Health stroke scale (NIHSS) score was 25. Computed tomography (CT) scan showed no obvious bleeding or occupying lesions. He was diagnosed as acute cerebral infarction and then underwent a full dose intravenous thrombolysis. After 1 hour of intravenous pumping, the patient gained no improvement on his hemiplegia or mental state but developed a rapidly deteriorating coma. NIHSS after intravenous thrombolysis is 31.

A recheck of CT scan was done and no intracranial hemorrhage was found. Now, the patient developed a degree of dyspnea with a right pupil dilation.

Treatment

An emergency DSA was then performed urgently under general anesthesia. Using a transfemoral approach, a right CCA and right vertebral artery occlusion and an occlusion of terminal portions of the left CCA with new embolization were found by aortic angiography. Left vertebral artery was normal and poorly compensating the anterior circulation via right posterior communicating artery. Given the imaginable poor outcome without artery recanalization, an emergency stenting of left internal carotid artery was done. An 8 F guide catheter was advanced into the terminal portions of left CCA to advance an microcatheter over a microwire through the occluded artery segment. Predilatation was done by a 2.0 mm balloon. Angiography indicated the opening of CCA with a residual severe stenosis. After a secondary dilatation with a 4.0 mm balloon, a Wallstent (Boston Scientific, Natick, MA, USA) was passed across the lesion and deployed. A repeat angiogram indicated an evident stenosis proximal to the stent, failed to respond to papaverine injection, or dilatation with a 6 × 40 mm balloon. So, another Wallstent was deployed. Angiography showed complete patency of the left internal carotid artery (ICA), the left middle cerebral artery (MCA), and the left anterior cerebral artery (ACA) with TICI3 flow, blood flow of R-MCA, and R-ACA were compensated by L-ICA via anterior communicating artery.



Outcome and follow-up

The patient's NIHSS improved to 14 after the procedures, with fully consciousness recovery, gaze deviation improvement, and residual right hemiparesis and hemisensory deficit. The magnetic resonance imaging (MRI) showed acute infarct in the bilateral frontal and parietal lobes. 2 weeks later the patient was discharged to an inpatient rehabilitation facility. One month later the NIHSS score was down to 5. A type A AAD was first observed by echocardiography and then confirmed by CT angiography (CTA) scan. The Sun's procedure (total arch replacement with stented elephant trunk implantation)[1] with ascending aorta replacement was performed soon afterward in a specialized hospital. At outpatient follow-up six months later, the NIHSS score was down to 3 [Figure 1], [Figure 2], [Figure 3].
Figure 1: Head magnetic resonance soon after the emergent carotid artery stenting. Bilateral frontal and parietal lobe infarctions were verified in the diffusion weighted imaging (DWI) sequence

Click here to view
Figure 2: (a) Aortic angiogram demonstrates moderate innominate artery narrowing, right CCA occlusion, bifurcation of left CCA occlusion. (b) The left vertebral artery is the only unobstructed artery to the brain, compensating the right vertebral artery. Angiography shows Initial part of L-ICA occlusion (c), and the subsequent stenting making L-ICA and its branches completely unobstructed (d)

Click here to view
Figure 3: Six month following CTA scan demonstrate patency of bilateral carotid artery and vertebral artery (a), and postoperative changes of ascending aortic replacement and Sun's procedure (b)

Click here to view





 » Discussion Top


Our case described an effective emergency interventional surgery approach for a life-threatening stroke, despite of a misdiagnosed type A AAD. AAD presents with neurologic complications, and one-third of patients with neurologic symptoms might be lack of typical complaints like chest pain,[2] making appropriate diagnosis and treatment complicated. In stroke unit, mechanical thrombectomy with or without intravenous thrombolysis could be performed with a diagnosis of acute ischemic stroke caused by a large vessel occlusion, evidenced by symptom, CT scan, and biochemical indices of serum.[3],[4] However, intravenous thrombolysis in stroke with AAD could have dangerous consequences. So, it is important to rule out underlying AAD rapidly and correctly. Carotid ultrasound examination is one of the applicable screening tools in a narrow therapeutic time window.[5] A time-consuming CTA or Magnetic Resonance Angiography (MRA) test is considered dispensable before emergency thrombolytic therapy in the present case, but a recent study compared MRI/MRA findings of stroke patients with and without type A AAD within 4.5 h of onset found that the right anterior circulation territory infarct and poor visualization of the right ICA are potential imaging markers of AAD in stroke patients.[6]

Treatment strategies for stroke secondary to AAD are diversifying. For acute stroke related to carotid artery dissection, endovascular interventions with or without intravenous thrombolysis are available.[7] And for Transient Ischemic Attack (TIA)/ischemic stroke patients caused by an extracranial dissection, evidence shows that thrombolysis with Recombinant Human Tissue Plasminogen Activator for Injection (rt-PA) seems to be safe and feasible.[8] Surgical treatment for acute type A AAD complicated with cerebral malperfusion tends to have a higher hospital mortality rate than patients without cerebral malperfusion, but their long-term survival rates were similar.[9] Endovascular thrombectomy in large vessel ischemic stroke has been reported to be done in patients with acute or chronic AADs, who obtained successful vascular recanalization along with improved NIHSS scores.[10] In addition to our case, there has been no report of emergency carotid stenting for AAD with fatal acute cerebral infarction. Risks of interventional procedures include aortic rupture, thrombosis, and the like. But this is probably the most effective treatment for life-threatening situations. Specific indications still need to be confirmed through further research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Luo J, Fu X, Zhou Y, Tang H, Song G, Tang T, et al. Aortic Remodeling following sun's procedure for acute type a aortic dissection. Med Sci Monit 2017;23:2143-50.  Back to cited text no. 1
    
2.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266-369.  Back to cited text no. 2
    
3.
Coutinho JM, Pereira VM. Mechanical Thrombectomy After Intravenous Thrombolysis vs mechanical thrombectomy alone in acute stroke-reply. JAMA Neurol 2017;74:1015.  Back to cited text no. 3
    
4.
Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Clark W, Dávalos A, et al. Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: A pooled analysis of the SWIFT and STAR studies. JAMA Neurol 2017;74:268-74.  Back to cited text no. 4
    
5.
Sukockienė E, Laučkaitė K, Jankauskas A, Mickevičienė D, Jurkevičienė G, Vaitkus A, et al. Crucial role of carotid ultrasound for the rapid diagnosis of hyperacute aortic dissection complicated by cerebral infarction: A case report and literature review. Medicina (Kaunas) 2016;52:378-88.  Back to cited text no. 5
    
6.
Matsubara S, Koga M, Ohara T, Iguchi Y, Minatoya K, Tahara Y, et al. Cerebrovascular imaging of cerebral ischemia in acute type A aortic dissection. J Neurol Sci 2018;38823-27.  Back to cited text no. 6
    
7.
Haussen DC, Jadhav A, Jovin T, Grossberg JA, Grigoryan M, Nahab F, et al. Endovascular management vs intravenous thrombolysis for acute stroke secondary to carotid artery dissection: Local experience and systematic review. Neurosurgery 2016;78:709-16.  Back to cited text no. 7
    
8.
Tanaka H, Okada K, Yamashita T, Morimoto Y, Kawanishi Y, Okita Y. Surgical results of acute aortic dissection complicated with cerebral malperfusion. Ann Thorac Surg 2005;80:72-6.  Back to cited text no. 8
    
9.
Vergouwen MD, Beentjes PA, Nederkoorn PJ. Thrombolysis in patients with acute ischemic stroke due to arterial extracranial dissection. Eur J Neurol 2009;16:646-9.  Back to cited text no. 9
    
10.
Reznik ME, Espinosa-Morales AD, Jumaa MA, Zaidi S, Ducruet AF, Jadhav AP. Endovascular thrombectomy in the setting of aortic dissection. J Neurointerv Surg 2017;9:17-20.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow