Neurol Med Chir (Tokyo) 45, 253¿258, 2005

Rescue Revascularization Therapy With a Stent-in-Stent
Technique for Acute Intracranial Internal
Carotid Artery Occlusion
—Case Report—
Toshiyuki OKAZAKI, Junichiro SATOMI, Koichi SATOH, Motohiro HIRASAWA,
and Shinji NAGAHIRO
Department of Neurosurgery, School of Medicine, The University of Tokushima, Tokushima

Abstract
A 45-year-old woman presented with progressive stroke due to occlusion of the left internal carotid
artery at the level of the cavernous portion (C3/C4). Revascularization was achieved by stent deployment
following percutaneous transluminal angioplasty. Stent thrombosis occurred 7 days after primary
stenting; it was successfully treated with the stent-in-stent technique. The patient was able to return to
her independent life with no sequelae except for slight hemiparesis. In combination with appropriate
antiplatelet treatment, the stent-in-stent technique should be considered as a rescue option in patients
with re-occlusion of an intracranial stent.
Key words:

acute internal carotid artery occlusion,

intracranial stenting,

stent-in-stent technique

Introduction

Case Presentation

Interventional revascularization of acute major
intracranial artery occlusions is rarely performed in
patients with atherosclerotic lesions and several
problems remain with respect to angioplasty and
stent deployment in intracranial vessels.1,10,13,18) On
the other hand, in coronary intervention, angioplasty and stent deployment are often used and over 20
types of stents are currently available. In patients
with acute coronary syndrome, stent placement
combined with anti-platelet drug therapy contributes to safe revascularization without hemorrhagic
complications or subacute coronary artery re-occlusion.2,6,16)
We report a patient with intracranial internal
carotid artery (ICA) occlusion who underwent
successful revascularization with intracranial stent
deployment in the acute stage, followed, in the
subacute stage, by stent-in-stent deployment for
re-occlusion of the ICA due to stent thrombosis.

This 45-year-old woman with a history of diabetes
mellitus, hypertension, and habitual alcohol consumption presented with difficulty in walking and
numbness on the right. On admission, neurological
examination revealed slight hemiparesis and
paresthesia on the right. Magnetic resonance (MR)
imaging demonstrated mismatched hemodynamic
compromise as small infarcted areas on diffusionweighted MR images; on T2-weighted MR images
there was a large misery perfusion area. MR
angiography showed occlusion of the left ICA; the
left middle cerebral artery was faintly visualized
(Fig. 1).
Despite medical treatment, she suffered progressive stroke manifesting as expressive dysphasia and
progressive weakness in addition to the pre-existing
symptoms. Cerebral angiography demonstrated
occlusion of the left ICA at the level of the cavernous
portion (C3/C4). Recanalization was achieved by
20-second percutaneous transluminal angioplasty

Received April 21, 2004;
Accepted November 22, 2004
Author's present address: J. Satomi, M.D., Department of Surgical Neurology, Research Institute for Brain and Blood
Vessels-AKITA, Akita, Japan.

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T. Okazaki et al.

254

Fig. 1

left: Diffusion-weighted magnetic resonance (MR) image obtained at admission demonstrates
high-intensity foci in the left frontoparietal cortex, indicative of fresh infarcts. center:
Perfusion-weighted MR image demonstrating a diffuse low-intensity area in the left cerebral
hemisphere, indicative of hypoperfusion of the left middle cerebral artery territory. right:
MR angiogram demonstrating occlusion of the left internal carotid artery.

Fig. 2

left: Initial left carotid angiogram, lateral view, demonstrating occlusion of the left internal
carotid artery (ICA) at the level of the cavernous portion (C3). center: Lateral craniogram
demonstrating percutaneous transluminal angioplasty (PTA) with a balloon catheter at the
level of the cavernous portion of the left ICA. right: Left carotid angiogram, lateral view,
obtained immediately after PTA demonstrating recanalization of the left ICA.

(PTA) using a 2.5 × 20-mm coronary balloon
catheter (Maverick; Boston Scientific, Natick, Mass.,
U.S.A.) inflated to 5 atm. Antegrade blood flow
was obtained and the patient improved (Fig. 2).
However, 4 hours later, she became stuporous.
Cerebral angiography demonstrated re-occlusion of
the portion treated by PTA. Following local intraarterial fibrinolysis with urokinase (240,000 IU), a
3 × 18-mm coronary stent (S670; Medtronic AVE,
Minneapolis, Minn., U.S.A.) was deployed at 8 atm
for 20 seconds in the irregularly stenosed portion of
the affected vessel. Post-dilatation was performed
with a 3.25 × 15-mm coronary balloon catheter
(Quantum Maverick Monorail; Boston Scientific)
inflated to 9 atm for 10 seconds to address the

residual narrowing of the stented portion (Fig. 3).
This procedure averted completion of the stroke.
Seven days after stent deployment, she deteriorated again despite medical treatment (heparin, thromboxane A2 antagonist, ticlopidine). Cerebral angiography demonstrated re-occlusion of the stent,
indicative of stent thrombosis. Stent thrombosis
recurred despite several reopening efforts by PTA
and the intraoperative intravenous administration
of heparin and ozagrel sodium (thromboxane A2
antagonist) (Fig. 4). Therefore, a 3.5 × 20-mm selfexpanding coronary stent (Radius; Boston Scientific) was deployed to overlap with 70% of the proximal portion of the pre-deployed S670 stent (stentin-stent technique). Post-dilatation was again per-

Neurol Med Chir (Tokyo) 45, May, 2005

Stent-in-Stent Technique for Revascularization of ICA Occlusion

Fig. 3

left: Lateral craniogram demonstrating the balloon catheter expanding the stent (S670) in the
cavernous portion (C3) of the left internal carotid artery (ICA). center: Scheme indicating the
stent (S670) as a cross-hatched area. right: Left carotid angiogram, lateral view, after the
first stent deployment demonstrating the patency of the left ICA.

Fig. 4

left: Left carotid angiogram obtained 7 days after the first stenting demonstrating re-occlusion of the left internal carotid artery (ICA). center: Left carotid angiogram obtained immediately after percutaneous transluminal angioplasty (PTA) demonstrating recanalization of
the left ICA. right: Left carotid angiogram, lateral view, obtained 15 minutes after PTA
demonstrating faint filling of the left ICA. Note the wall irregularity indicative of progressive
stent thrombosis.

formed using a 3.5 × 20-mm coronary balloon
catheter (Maverick) inflated to 6 atm for 10 seconds.
Repeat angiography demonstrated patency of the
affected artery (Fig. 5) and MR imaging showed no
further cerebral infarcts (Fig. 6). Upon discharge,
the patient was able to resume her previous independent life.

Discussion
In our patient, the initial radiological findings
suggested that acute occlusion of the left ICA had
aggravated progressive hemodynamic compromise,
resulting in her symptoms. Recanalization of the
occluded vessel in this situation may lead to distal

Neurol Med Chir (Tokyo) 45, May, 2005

255

shower embolism or hemorrhagic transformation
in the ipsilateral brain parenchyma and possibly
worsen the patient's condition. We performed
angioplasty because of her progressive symptoms.
Although we considered surgical revascularization,
e.g. extracranial-intracranial artery bypass, we were
worried that there was not enough time for this
procedure and that surgical bypass reconstruction
could not deliver adequate compensatory blood flow
to the entire ICA territory. It is also unclear whether
post-craniotomy anticoagulants can be administered
safely in the acute phase of stroke.
Following revascularization with PTA her symptoms improved remarkably for several hours,
however, she suffered re-occlusion at the same por-

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256

Fig. 5

left: Left carotid angiogram, lateral view, obtained 14 days after the stent-in-stent procedure
demonstrating recanalization of the left internal carotid artery (ICA) without further thrombosis. center: Scheme indicating the first stent (S670) as the cross-hatched area and the
second stent (radius) as the gray area. right: Plain craniogram demonstrating the stents
deployed in the ICA.

Fig. 6

Axial T2-weighted magnetic resonance (MR) images obtained 8 days after the stent-in-stent
procedure at the level of the basal ganglia (left), corona radiata (center), and centrum
semiovale (right). The patient manifested no infarcts except for the abnormalities detected on
diffusion-weighted MR imaging at the time of admission.

tion of the ICA. With respect to the PTA balloon
catheter used, it is possible that its 2.5 mm diameter
was too small and its 20-mm length too long to dilate
the curved vessel. It was difficult to determine the
appropriate catheter size. Compared to the straight
petrous portion of the ICA, in the curved, cavernous
part there is a higher risk that oversized or repeated
PTA results in vessel dissection or rupture. We
found that stent deployment was effective for
achieving long-term patency of the affected vessel.
We postulate that the repeat occlusion of the affected ICA 7 days after placement of the first stent was
due to stent thrombosis because craniography confirmed that the deployed stent was not deformed.

Stent thrombosis occurs in approximately 0.7–2.4%
of patients undergoing coronary intervention5,15)
and may be more common in cases with emergency
stent deployment.
Platelet hyperaggregability promotes stent thrombosis, which is characterized by two occurrence
peaks: the first is within 24 hours of stent deployment (acute stage) and the 2nd is at 2–14 days postdeployment (subacute stage). The antiplatelet agent
abciximab, a glycoprotein IIb/IIIa receptor antagonist, can reduce thrombogenic complications; it
is commonly used in coronary stenting in North
America and Europe.3,4,7–9,11,12,14,17) Unlike other antiplatelet agents, abciximab, which blocks the action

Neurol Med Chir (Tokyo) 45, May, 2005

Stent-in-Stent Technique for Revascularization of ICA Occlusion
of fibrinogen and the von Willebrand factor at the
glycoprotein IIb/IIIa receptor, acts quickly.
However, as its use is not yet approved in Japan, we
used ozagrel sodium (thromboxane A2 inhibitor) and
ticlopidine.
The stent thrombosis in our patient may be
attributable to the poor fit of the stent introduced in
the first procedure. We deployed a straight stent into
the curved vessel. Furthermore, the diameter of the
proximal portion of the stented vessel was different
from the distal portion. This resulted in a gap
between the stent and the intimal wall in the proximal portion. The diameter of the first stent (3 × 18
mm) may have been too small for the vessel wall and
too long for covering the curved portion of the vessel. Our case is unusual in that ICA stent thrombosis
was successfully treated with the stent-in-stent
technique. In the 2nd procedure we introduced a
self-expandable stent in the expectation that it
would fit well against the vessel wall. Despite our
satisfying result, it remains unclear what type of
stent is most suitable in these cases.
The wider use of intracranial stenting demands
awareness of potential procedure-related problems
like stent thrombosis. The development of suitable
therapeutic devices, including different types of
stents to be used exclusively for intracranial vessels,
and more experience with intracranial stenting are
required. Especially in emergency cases, the stentin-stent technique, combined with the administration of appropriate antiplatelet agents, should be
considered as a possible treatment of stent thrombosis.

5)

6)

7)

8)

9)
10)

11)

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Address reprint requests to: J. Satomi, M.D., Department of
Surgical Neurology, Research Institute for Brain and
Blood Vessels-AKITA, 6–10 Senshu-Kubota–machi,
Akita 010–0874, Japan.
e-mail: satomi＠akita-noken.go.jp

Neurol Med Chir (Tokyo) 45, May, 2005