Endovascular Combined Neuroendovascular Stenting and Coil Embolization for Cervical Carotid Artery Dissection Causing Symptomatic Mass Effect Ryuta Saito, M.D.,* Masayuki Ezura, M.D.,* Akira Takahashi, M.D.,† and Takashi Yoshimoto, M.D.‡ *Department of Neuroendovascular Therapy, Kohnan Hospital; †Department of Neuroendovascular Therapy, Tohoku University School of Medicine; ‡Department of Neurosurgery, Tohoku University School of Medicine, Sendai, Japan Saito R, Ezura M, Takahashi A, Yoshimoto T. Combined neuroendovascular stenting and coil embolization for cervical carotid artery dissection causing symptomatic mass effect. Surg Neurol 2000;53:318 –22. KEY WORDS Dissection, Guglielmi detachable coil, internal carotid artery, mass effect, neuroendovascular therapy, pseudoaneurysm, stent. BACKGROUND Carotid artery dissection manifesting with symptomatic mass effect has been treated surgically according to the previous literature. Recently, some cases of carotid artery dissection manifesting with ischemic symptoms were treated successfully with endovascular insertion of coils after stenting. METHODS A 42-year-old man with spontaneous dissection of the left cervical internal carotid artery (ICA) presented with the major complaint of left neck swelling and pain that was considered to be the mass effect of a pseudoaneurysm caused by dissection of the ICA. Endovascular therapy using a stent and coils was performed. The self-expanding stent was deployed to cover the neck of the pseudoaneurysm. A microcatheter was then guided through the stent mesh into the aneurysm, and coils were placed to pack it. RESULTS Four months later, angiography revealed complete embolization of the aneurysm with preserved flow in the ICA. The mass effect attributable to the pseudoaneurysm was relieved symptomatically as well as radiologically. CONCLUSION Cervical artery dissection with symptomatic mass effect can be treated successfully by the combination of stent and coils. This may be considered as an alternative to conventional proximal ligation, extracranial-intracranial bypass, or direct surgical repair. © 2000 by Elsevier Science Inc. Address reprint requests to: Dr R. Saito, Department of Neuroendovascular Therapy, Kohnan Hospital, 4-20-1 Nagamachi-Minami, Taihaku-ku, Sendai 982-8523, Japan. Received October 22, 1999; accepted December 9, 1999. 0090-3019/00/$–see front matter PII S0090-3019(00)00206-8 ervical internal carotid artery (ICA) dissection frequently manifests with ischemic symptoms, and is an important underlying cause of juvenile brain ischemia, but also occasionally manifests as mass effect attributable to pseudoaneurysm associated with the dissection. Spontaneous ICA dissection has an average annual incidence of 2.6 per 100,000 population [10]. Cervical ICA dissection presenting with ischemic symptoms can be managed medically, but mass effect requires potentially difficult surgical treatment. We describe a case of spontaneous cervical ICA dissection associated with pseudoaneurysm, which was treated successfully with endovascular procedures using a stent and Guglielmi detachable coils (GDCs). C Case Report A 42-year-old man without a past history of trauma or cervical inflammation noticed swelling of the left lateral cervical region and pain extending from the jaw through the neck. Memory disturbance, transient ischemic attack (loss of strength in his right upper and lower extremities), and psychological disorders (schizophrenic behavior) were also recognized. Magnetic resonance imaging (MRI) performed at a local hospital indicated a left ICA aneu© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Combined Stenting and GDC 1 MRI on admission showing a mass in the left neck containing a large thrombus at the C2 to C5 levels. rysm in the neck, and he was referred to our hospital. Neurological examination on admission revealed no abnormality except for mild acalculia and agraphia. His major complaint was marked cervical swelling and pain extending from the jaw through the neck. MRI demonstrated a mass located to the left of the C2-5 vertebral bodies, and a thrombotic lesion surrounding the aneurysm (Figure 1). The left parieto-occipital lobe contained an infarct that had not been identified at the earlier examination. Left carotid angiography showed a dissection of the left cervical ICA 20 mm in length, and an aneurysm 20 ⫻ 20 ⫻ 40 mm in size protruding in the posterolateral superior direction and connected to the dissection. This aneurysm was considered to be a pseudoaneurysm. The left common carotid and left ICAs were shifted anteriorly by a maximum of 40 mm at the common carotid artery bifurcation, indicating the presence of a larger mass of approximately two to three times the length, width, and height of the aneurysm demonstrated by angiography (Figure 2). Surg Neurol 319 2000;53:318 –22 Internal carotid angiograms before therapy (left anteroposterior view, right lateral view) showing the left cervical ICA dissected for 20 mm and a 20 ⫻ 20 ⫻ 40 mm aneurysm protruding in the cephalo-dorsalo-lateral direction from the dissection. The aneurysm was considered to be a pseudoaneurysm. The left common carotid artery and external carotid artery were displaced by about 40 mm ventrally, and an avascular area at this point was seen in the venous phase, suggesting the presence of a large mass outside the vascular system. 2 A balloon occlusion test with temporary occlusion of the left common carotid and left external carotid arteries was performed to identify the treatment options. During the test, angiography clearly demonstrated the left anterior cerebral and left middle cerebral arteries via the anterior communicating artery, and no neurological abnormality appeared. However, single photon emission computed tomography using 99mTc-ethyl-cysteinatedimer injected during occlusion with acetazolamide loading revealed decreased cerebral vasodilatory capacity in the watershed areas of the left anterior cerebral and left middle cerebral arteries, so the patient was judged not to be able to tolerate left ICA occlusion. Consequently, the pseudoaneurysm had to be treated with preservation of the left ICA. 320 Surg Neurol 2000;53:318 –22 Endovascular treatment was selected using a stent and GDCs, to reduce the mass effect. Two 8F ultralong sheaths were inserted into the left common carotid artery via the bilateral femoral arteries. The activated coagulation time (ACT) was maintained at double the normal value by heparinization to prevent thromboembolic complications during the procedure. Cerebral angiography showed that the pseudoaneurysm was 55 mm in length, and the left ICA was 8 mm in diameter in the proximal portion and 5 mm in the distal portion. An endovascular ultrasonography probe (CVIS; Boston Scientific, Boston, MA) was navigated using a 0.025 in. guide wire through the left femoral artery. Endovascular ultrasonography confirmed blood flow into the aneurysm. A 70-mm long self-expanding stent (Wallstent; Schneider AG, Zurich, Switzerland) was deployed from the level of the central portion of the C2 vertebral body to the upper edge of the C5 vertebral body, covering the neck of the pseudoaneurysm. That stent was too long, but was the only stent available at that time. Positioning of the stent was confirmed by endovascular ultrasonography. A microcatheter (Rapid Transit; Cordis Corp., Miami, FL) was then introduced into the aneurysm through one of the interstices of the 1-mm square mesh of the stent using a guide wire (Taper 16 standard; Boston Scientific), and 14 GDCs and 9 interlocking detachable coils (IDCs) (Boston Scientific), 600 cm in total length, were inserted into the aneurysm (Figure 3). Left carotid angiography immediately after embolization revealed inflow of contrast medium to the top of the aneurysm. However, the procedure was terminated because the insertion of more coils was impossible and the remaining part of the aneurysm was expected to thrombose. After the procedure the patient received anticoagulant therapy with continuous heparinization for 48 hours, and with argatroban for 5 days after heparinization. Antiplatelet therapy with aspirin was also given after argatroban. The postoperative course was uneventful. His left lateral cervical pain disappeared and the swelling was diminished. Follow-up MRI 4 months later demonstrated marked reduction of the mass (Figure 4). Cerebral angiography showed complete obliteration of the pseudoaneurysm as well as preservation of the left common carotid artery without stenosis (Figure 5). Arterial shift attributable to the mass effect disappeared. However, a new bulge in the aneurysmal wall 8 mm in diameter was found just over the implanted stent. This aneurysm is being followed conservatively. Saito et al Plain X-ray films immediately after therapy (left anteroposterior view, right lateral view) showing a mass of GDCs filling up the aneurysm without protrusion due to support from a stent. 3 Discussion Minor trauma or primary diseases of the arterial wall are the main predisposing factors to ICA dissection. In our patient, follow-up angiography revealed a new lesion at the distal portion of the implanted stent, suggesting the presence of abnormality in the arterial wall. Ischemic events attributable to distal thromboembolism or hemodynamic stress is the most common consequence of internal carotid artery dissection. Subsequent formation of a pseudoaneurysm at the dissection may lead to mass effect. Two patients with ICA dissection had cephalocervical pain as the only manifestation [1], but cranial nerve paresis as a complication of ICA dissection could be attributable to ischemia of the nerve or mass effect attributable to the enlarged ICA [4]. Cervical ICA dissection is commonly treated with anticoagulants because the patient’s major complaint is thromboembolism, although surgical treatment is indicated when anticoagulation therapy has Combined Stenting and GDC MRI at 4-month follow-up showing that the mass was markedly reduced and the high-intensity area representing the large thrombosis had disappeared. 4 no effect or is not indicated. However, patients presenting with symptoms attributable to mass effect have been treated surgically, such as proximal ligation with or without extracranial-intracranial bypass. We performed endovascular treatment using stent and GDCs in the present case. ICA dissection can be successfully treated with stent implantation alone if correction of the stenosis at the dissection with preservation of blood flow and prevention of distal thromboembolism are intended [2,3,8,14]. However, in our patient, volume reduction of the pseudoaneurysm at the dissection was required, and stent implantation would not have achieved thrombosis of the aneurysm. Therefore, we also performed embolization using GDCs and IDCs. Although it is known that the mass of an aneurysm can be reduced with coil embolization [5,6,17], this case, to our knowledge, is the first attempt to treat the mass effect attributable to a giant pseudoaneurysm caused by carotid artery dissection. The patient’s symptoms were improved and the volume of the pseudoaneurysm was markedly reduced at 4-month follow-up examination. Based on the expe- Surg Neurol 321 2000;53:318 –22 Angiograms at 4-month follow-up (left anteroposterior view, right lateral view) showing that the pseudoaneurysm was embolized completely, and the flow in the left ICA was preserved without stenotic lesions. The carotid artery had returned to the normal position, suggesting reduction of the mass effect caused by the pseudoaneurysm. A new 8-mm diameter aneurysm was found just distal to the implanted stent. 5 rience of this case, endovascular therapy using a stent and GDCs could be a less invasive treatment for ICA dissection with mass effect because of associated pseudoaneurysm. Previously, traumatic cervical ICA dissection has been treated by GDC embolization followed by selfexpandable stent implantation [9]. A coronary balloon-expandable stent was placed across a ruptured fusiform aneurysm of the basilar artery, then a microcatheter inserted through the interstices of the stent into the aneurysm to deposit GDCs [7]. A balloon expandable stent and GDCs were used for treatment of an ICA pseudoaneurysm [13,15]. Vertebral artery aneurysms have also been treated with stents and coils [11,16]. However, none of the aneurysms in these cases caused mass effect. 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