TECHNICAL CASE REPORTS Primary Stenting of the Extracranial Internal Carotid Artery in a Patient with Multiple Cervical Dissections: Technical Case Report S p o n t a n e o u s d i s s e c t i o n h a s been shown to a c c o u n t fo r u p to 5 to 2 0 % of ischemic s t r o k e s in p a t i e n t s u n d e r the age of 45 y e a r s ( 10 ) a n d 2 .5 % o f p a tie n ts with first s t r o k e s (2). T h e e x t r a c r a n i a l IC A is the m o s t f r e q u e n t site o f sp o n ta n e o u s dis­ s e c tio n , w i t h b o t h I C A s in v o lv e d in a m i n o r i t y o f c a s e s ( < 1 5 % ) (13). Between o n e - f o u r t h a n d o n e - h a l f o f patients with s p o n t a n e o u s d i s s e c t i o n o f the extracra­ Domagoj Coric, M.D., John A. Wilson, M.D., John D. Regan, M.D., D. Antonio Bell, M.D. n ia l I C A s u f f e r s t r o k e (3, 8, 1 5 , 28). In a Departments of Neurosurgery (DC, JAW) and Radiology (JDR), Wake Forest University Baptist Medical Center, Winston-Salem, and Department of Radiology (DAB), Presbyterian Hospital, Charlotte, North Carolina tie n ts (5 2 % ) s u f f e r e d n e u ro lo g ic a l defi­ r e c e n t s e r i e s o f 80 c o n s e c u t i v e patients w i t h c a r o t id a r t e r y d is s e c tio n s , 42 pa­ cits, w i t h s t r o k e o c c u r r i n g u p to 1 month a f t e r r e c o g n i t i o n o f the d issectio n (1). In a s t u d y o f 3 0 c o n s e c u t i v e patients with OBJECTIVE AND IMPORTANCE: Spontaneous dissection of the extracranial internal carotid artery (ICA) and vertebral artery (VA) is a welldocumented cause of stroke in young, previously healthy patients. The majority of patients with spontaneous dissection are successfully treated with antiplatelet or anticoagulation therapy, but a significant proportion of patients progress to suffer devastating morbidity and mortality. Surgi­ cal intervention has primarily consisted of proximal ligation, extracranialintracranial bypass, or endarterectomy. Generally, these procedures are technically demanding and yield disappointing clinical results. CLIN ICAL PRESENTATION/INTERVENTION: A 36-year-old man without a significant medical history initially presented with a several-day history of episodic right upper extremity weakness and numbness and visual obscu­ rations. Cerebral angiography revealed bilateral ICA long segment nar­ rowing (95%), distal left VA high-grade (95%) stenosis compatible with dissections, and right VA proximal occlusion. While therapeutically antico­ agulated on heparin, the patient continued to experience crescendo episodes of right upper extremity paresis and paresthesias as well as aphasia. The patient underwent primary stenting of the left ICA, using a series of six overlapping stents (three Gianturco-Roubin coronary stents and three Palmaz-Schatz coronary stents). The patient remained symptom-free with­ out neurological complications, and subsequent angiography performed at the 9-month follow-up examination confirmed continued patency of the stented left ICA as well as recanalization of the right ICA and VA. CONCLUSION: Neurovascular stents offer a minimally invasive and potentially efficacious treatment for the prevention of cerebral ischemia in patients with spontaneous extracranial dissection who remain symptomatic despite ther­ apeutic anticoagulation. (Neurosurgery 4 3 : 9 5 6 - 9 5 9 , 1998) Keywords: Carotid stenting, Endovascular therapy, Spontaneous carotid dissection c a r o t id d issectio n who p r e s e n t e d w i t h a c u t e stro k e , 23% died w i t h i n 1 w e e k a n d n e a r l y h a lf (48%) of the l o n g - t e r m s u r v i v o r s s h o w e d severe n eu ro lo g ical im p airm en t w ith poor f u n c t i o n a l r e c o v e r y (3). T h e incidence of i s c h e m i c e v e n t s is g e n e r a l l y reported as b e i n g h i g h e r in c a s e s o f V A dissection ( 1 6 , 25). A p a t i e n t w i t h s p o n ta n e o u s dis­ s e c t i o n s o f b o th the e xtrac ran ial ICA a n d the left V A a s w e l l a s an iatrogenic a l l y i n d u c e d d i s s e c t i o n o f the right VA w a s tre a te d u s i n g e n d o v a s c u l a r place­ m ent of o v e rla p p in g neurovascular s t e n t s in to the m o s t s y m p t o m a t i c artery. CASE REPORT Clinical presentation A 3 6 - y e a r - o l d m a n w i t h o u t a signifi­ c a n t m e d i c a l h i s t o r y in it ia lly presented w i t h a s e v e r a l - d a y h i s t o r y o f episodic r ig h t upper extrem ity w e a k n e s s and n u m b n e s s a n d v i s u a l o b sc u ra tio n s. The p a t i e n t r e l a t e d th r e e d is c r e t e episodes, e a c h l a s t i n g 1 5 to 20 m i n u t e s , that oc­ c u r r e d d u r i n g a 3 - d a y p e r io d . The pa­ tient p r e s e n t e d to h is f a m i l y doctor and u n d e r w e n t c r a n i a l c o m p u t e d tomogra­ p h y . T h e r e s u l t s w e r e unremarkable, a n d the p a t i e n t w a s tre a te d w ith aspire fo r p r e s u m e d t r a n s ie n t is c h e m ic attacks T h e p a t i e n t s u b s e q u e n t l y returned 1° ex- o f s t r o k e ( 1 - 3 , 6, 10 , 14, 18). T h e i m p a c t w ork, artery o f the m o r b i d i t y a s s o c i a t e d w i t h s p o n - m i n u t e e p i s o d e o f r ig h t u p p e r e x tre n n h is a t a n e o u s d i s s e c t i o n is e x a c e r b a t e d b y the p a r e s t h e s i a a n d p a r e s i s a s w e ll as apha­ w e ll-d o c u m e n te d and sign ifican t c a u se y o u n g a g e o f t h o s e a fflic t e d (2, 3 , 24, 28). sia. T h e p a t i e n t then p r e s e n t e d to a re- 956 Neurosurgery, Vol. 43, No. 4, October 1998 S pontaneous t r a c r a n ia l (IC A ) an d d issectio n in te r n a l of c a r o t id vertebral artery the (V A ) w here he exp erien ced a 20- Downloaded from https://academic.oup.com/neurosurgery/article-abstract/43/4/956/2834842 by Vanderbilt University Eskind Biomedical Library - Serials Section user on 01 January 2020 spontaneous Stenting of the Internal Carotid Artery (erring e m e r g e n c y d e p a r t m e n t a n d w a s y o n d the d i s s e c t i o n a n d u s e d to p e r f o r m fo rm ed therapeutically an g io g ra p h y exam in atio n heparin. A a n tic o a g u la te d subsequent w ith w orkup in ­ to co n firm p o sitio n in g at the 9-m onth co n firm ed 957 fo llo w -u p co n tin u ed pa­ w i t h i n the tru e lu m e n . T h e p a t ie n t u n ­ t e n c y o f the s t e n t e d left I C A cluded the f o l l o w i n g : 1) m a g n e t i c r e s o ­ derw ent w e l l a s the r ig h t I C A a n d V A s . T h e p a ­ nance i m a g i n g / m a g n e t i c r e s o n a n c e a n ­ I C A , u s i n g a s e r ie s o f s ix o v e r l a p p i n g tient r e m a i n e d giography, w h i c h r e v e a l e d a p o s t e r i o r s t e n t s (2.5 X 1 2 - m m , 3 x n e u r o l o g i c a l c o m p l i c a t i o n s , r e t u r n e d to left frontal in fa rc t a s w e l l a s a r i g h t f r o n ­ 3 .5 tal infarct a n d b i l a t e r a l I C A a n d left v e r ­ nary tebral stenoses; 2) c e r e b r a l a n g i o g r a p h y , P a l m a z - S c h a t z c o r o n a r y sten ts) (Fig. 2). which r e v e a le d b i l a t e r a l I C A l o n g s e g ­ T h e G i a n t u r c o - R o u b i n sten t w a s c h o s e n ment n a r r o w in g (9 5 % ) (Fig. 2) a n d d i s t a l b e c a u s e o f the g r e a t e r f le x ib ilit y o f its left VA h i g h - g r a d e (9 5 % ) s t e n o s i s c o m ­ patible w ith d i s s e c t i o n s ( d u r i n g a n g i o g ­ raphy at the r e f e r r i n g i n s t i t u t i o n , the intima of the r i g h t V A w as com pro­ mised, r e s u ltin g in a p r o x i m a l o c c l u ­ sion); and 3) s i n g l e 20-m m s te n ts sten tin g of the 20-m m , and G ian tu rco -R o u b in and th re e left 3 .5 X coro­ 15-m m d e liv e r y system , a llo w in g p lacem en t b e ­ y o n d the c e p h a l a d e x t e n t o f the d i s s e c ­ tion in to the p r o x i m a l p e t r o u s I C A . T h e P alm az-S ch atz s te n ts w ere p la c e d w i t h i n the G i a n t u r c o - R o u b i n s te n ts to im p r o v e radial strength. T h e P a lm a z - computed t o m o g r a p h y , w h i c h r e v e a l e d S c h a t z s te n ts w e r e c h o s e n , in this c a s e , two small p e r f u s i o n d e f e c t s , o n e in the b a s e d o n th e ir b e i n g r e a d i l y a v a i l a b l e right frontal lo b e a n d o n e in th e left at o u r in stitu tio n . T h e last sten t w a s posterior fro n tal lo b e . T h e p a t i e n t d e ­ p l a c e d 2 to 3 c m a b o v e the c a r o t id b u lb . nied any h is to r y o f t r a u m a , t o b a c c o u s e , A t the e n d o f the p r o c e d u r e , b lo o d f l o w or alcohol use. L a b s t u d i e s at o u r f a c i l i t y t h r o u g h the s te n te d a r t e r y w a s m u c h induded p o l y m e r a s e c h a i n r e a c t i o n , r e ­ i m p r o v e d a n d th e re w a s s p o n t a n e o u s vealing no a b n o r m a l i t y in th e s t r u c t u r e c r o s s f ill o f the c o n t r a la t e r a l h e m i s p h e r e or biosynthesis o f T y p e s I a n d III c o l l a ­ v i a a p a t e n t a n t e r io r c o m m u n i c a t i n g a r ­ gen and a n o r m a l u r i n e h o m o c y s t e i n e te ry . A level. An o p h t h a l m o l o g i c a l e v a l u a t i o n noted showed n o r m a l l e n s e s a n d a norm al the d is s e c t io n . N o i n t e r v e n t i o n a l t r e a t ­ fundoscopic e x a m i n a t i o n . d erm ato- m e n t w a s d ir e c t e d at the o t h e r d i s s e c ­ norm al tions. A f t e r the p r o c e d u r e , the p a t i e n t 's skin without h y p e r m o b i l i t y . W h i l e h o s ­ th erap eu tic an tico ag u latio n w a s m a in ­ pitalized and r e c e i v i n g h e p a r i n ( p a r t ia l t a in e d w i t h h e p a r i n a n d th en c o u m a d i n thromboplastin t i m e = 7 0 - 8 0 s), th e p a ­ a n d ticlopidine. A t the 5 -m o n th f o ll o w - u p tient continued to e x p e r i e n c e c r e s c e n d o e x a m in a tio n , episodes of r ig h t u p p e r e x t r e m i t y p a r e ­ s y m p to m -fre e and seq u en tial D o p p le r sis and p a r e s t h e s ia s a n d a p h a s i a . s t u d i e s d o c u m e n t e d the p a t e n c y o f the e x a m in a t i o n A show ed m ild a m o u n t o f c o n t r a s t w a s to p o o l in th e the fa ls e p atien t lu m en of rem ain ed s t e n t e d left I C A a n d r e c a n a li z a t i o n o f the r ig h t I C A a n d b ila t e r a l V A s . A t the intervention 6-m onth Endovascular t r e a t m e n t w a s d i r e c t e d 0nly at the s y m p t o m a t i c le ft I C A d i s s e c ­ tion. A m ic r o c a t h e t e r w a s p laced fo llo w -u p exam in atio n , m ad in an tico agu latio n ued. Subsequent was cou­ d isco n tin ­ an g io g rap h y sym p to m -free w ith o u t fu l l- t i m e e m p l o y m e n t , a n d w a s m a i n ­ t a in e d o n a s p i r i n t h e r a p y a lo n e . DISCUSSION T h e n atu ral h isto ry o f carotid an d V A d i s s e c t i o n s g e n e r a l l y l e a d s to s p o n t a n e ­ o u s h e a l i n g o f the le s io n ( 1 7 , 1 9 , 2 1 ) , b u t th e re is a s i g n i f i c a n t p e r c e n t a g e o f c a s e s that s h o w p e r s i s t e n c e , p r o g r e s s i o n , o r r e c u r r e n c e o f the d i s s e c t i o n ( 1 , 6, 1 7 , 2 3 , 27). T h e fir s t-lin e t h e r a p y fo r e x t r a c r a ­ n ia l d i s s e c t i o n is p h a r m a c o l o g i c a l , p r i ­ m a r ily co n sistin g o f an tip latelet or a n ti­ co ag u latio n therapy (8, 20, 26). The m a jo rity o f p atien ts w ith s p o n ta n e o u s d i s s e c t i o n a r e s u c c e s s f u l l y t r e a te d w i t h this m o d a l i t y , b u t a w e l l - d o c u m e n t e d and sig n ifican t p ro p o rtio n o f p atien ts p r o g r e s s to s u f f e r d e v a s t a t i n g m o r b i d i t y a n d m o r t a l i t y (7, 1 7 , 20). T r a d i t i o n a l l y , su rg ic a l in terven tio n h as b een re se rv e d fo r p a t i e n t s w i t h p e r s i s t e n t o r w o r s e n ­ in g n e u ro lo g ic a l d eficits d e s p ite th era­ p e u t i c a n t i c o a g u l a t i o n a n d fo r p a t i e n t s in w h o m a n t i c o a g u l a t i o n is c o n t r a i n d i ­ c a te d ( 1 2 , 1 4 , 1 7 , 1 9 , 24). S u r g i c a l i n t e r ­ ve n tio n h as con sisted p r im a r ily o f p r o x ­ im a l lig a t io n , extracran ial-in tracran ial b y p a s s , o r e n d a r t e r e c t o m y ( 4 , 1 4 , 1 7 , 24). R ecen tly, M organ and Sekhon (17) (19 9 4 ) r e p o r t e d the u s e o f e x t r a c r a n i a l i n t r a c r a n i a l s a p h e n o u s v e i n b y p a s s in s ix c a s e s o f c a r o t id o r V A d i s s e c t i o n s . T h i s b y p a s s p r o c e d u r e is t e c h n i c a l l y d e - per­ be­ B 1 FIGURE 3. Follow-up angiogram, obtained 9 months after the procedure, demonstrating th patency of the left ICA. i FIGURE 1. Admission arteriogram revealing dissection of the left ICA (arrow). k f% I » FIGURE 2. A n tero p o ste rio r (left) and lateral (right) views of the left ICA after N e u r o s u r g e r y , Vol. 43, No. 4, October 1998 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/43/4/956/2834842 by Vanderbilt University Eskind Biomedical Library - Serials Section user on 01 January 2020 em issio n logical ph oton X p rim ary (Fig. 3) a s Coric et al 958 m a n d in g , re q u irin g a p terion al cra n io t­ and cost-effectiven ess of n o n in v a siv e o m y a s w e l l a s a c r o s s - c l a m p t im e o f treatm ent w ith an tico ag u latio n an d a n ­ a p p r o x i m a t e l y 60 m i n u t e s . T h e a u t h o r s tip la te le t t h e r a p y , e n d o v a s c u l a r o r s u r ­ rep orted a co m p licatio n o f e p id u ra l h e ­ g ic a l i n t e r v e n t i o n s h o u l d b e c o n s i d e r e d m a to m a req u irin g a secon d cra n io to m y o n l y in c a s e s o f d i s s e c t i o n r e c a lc it r a n t to fo r e v a c u a t i o n in o n e o f the s ix c a s e s these m odalities or in cases in w h ic h anti­ ( 1 6 % ) . T h e a u t h o r s r e c o m m e n d e d this coagulation is ab solutely contraindicated. b y p a s s p r o c e d u r e in c a s e s o f b ila t e r a l T he cau se u n d e rly in g o u r case of m u l­ c a r o t id o r v e r t e b r a l d i s e a s e o r in p a ­ t ip le s p o n t a n e o u s d i s s e c t i o n s o f the e x ­ tien ts w i t h w h ile The recu rrin g isch em ic e ven ts t r a c r a n ia l c e r e b r a l c ir c u l a t i o n th erap eu tically an tico agu lated . u n k n o w n . R e c e n t l y , G o l d s t e i n et al. (6) p a t ie n t w hose case report we rem ain s ( 19 9 5 ) r e p o r t e d a c a s e o f s p o n t a n e o u s d issectio n w a s s u c c e s s f u l l y tre a te d w i t h a m i n i ­ d e n c e o f f i b r o m u s c u l a r d y s p l a s i a that m a l l y i n v a s i v e e n d o v a s c u l a r t e c h n iq u e . w a s s u b s e q u e n t l y f o u n d to h a v e p a t h o ­ E n d o v a s c u la r tech n iq u es h a v e p r e v i­ lo g ically p ro v e n fib ro m u sc u la r d y s p la ­ o u s l y b e e n d e s c r i b e d in the t r e a t m e n t o f sia. F i b r o m u s c u l a r d y s p l a s i a h a s b e e n V A d issectio n s and p s e u d o a n e u r y s m s , r e p o r t e d in 1 0 to 2 0 % o f p a t i e n t s w i t h b u t th is h a s p r i m a r i l y c o n s i s t e d o f b a l ­ e x t r a c r a n i a l I C A d i s s e c t i o n a n d is m o r e lo o n o c c l u s i o n (7). R e c e n t l y , H i g a s h i d a c o m m o n l y a s s o c i a t e d w i t h b ila t e r a l d i s ­ et al. (9) (19 9 7 ) r e p o r t e d a c a s e o f s u c ­ s e c tio n ( 1 3 , 22). O u r c a s e i llu s t r a t e s the c e s s f u l e n d o v a s c u l a r s t e n t i n g a n d coil su ccessful p l a c e m e n t in the t r e a t m e n t o f a r u p ­ w i t h d i s s e c t i o n s o f all f o u r m a j o r e x ­ tured fu sifo rm b asilar arte ry a n e u ry s m . t r a c r a n ia l c e r e b r a l v e s s e l s . w ith o u t an g io g rap h ic m anagem ent of a e v i­ p a t ie n t Y a d a v et al. (29) (19 9 7 ) f o u n d e le c t iv e s t e n t i n g o f the e x t r a c r a n i a l c a r o t id a r t e r ­ ies in 1 0 7 p a t i e n t s to b e r e a s o n a b l y s a f e a n d e f f i c a c i o u s in p a t ie n t s w i t h c a r o tid CO N CLU SIO N N e u ro v a scu la r stents a m in i­ a r t e r y s t e n o s is . T h e y r e p o r t e d a n initial m ally m e a n s t e n o s i s r e d u c t i o n f r o m 78 to 2 % , c i o u s t r e a t m e n t fo r the p r e v e n t i o n o f w h i c h w a s m a i n t a i n e d at a m e a n o f 1 8 % c e r e b r a l i s c h e m i a s e c o n d a r y to e x t r a c r a ­ at 6 - m o n t h f o l l o w - u p e x a m i n a t i o n s a n d nial d is s e c t io n . P r o s p e c t i v e , c o n t r o l le d a s t r o k e / m o r t a l i t y i n c i d e n c e o f 9% . E n ­ e v a l u a t i o n o f this n o v e l t h e r a p e u t i c m o ­ d o vascu lar been d a l i t y w i t h l o n g - t e r m f o l l o w - u p is w a r ­ in the t r e a t m e n t o f r a n te d to e l u c i d a t e its r o le a s a p o t e n t ia l ste n t su cce ssfu lly u sed p lacem en t has in vasive and offer p o ten tially e ffica ­ m u l t i p l e a n e u r y s m s o f the e x t r a c r a n i a l altern ative IC A (12) and cervical d issectin g a n e u ­ patien ts w h o re m a in s y m p to m a tic d e ­ rysm s s p it e a n t i c o a g u l a t i o n . (11). R ecen tly, D u k e et al. (5) to s u r g i c a l in terven tio n in (19 9 7 ) u s e d e n d o v a s c u l a r s t e n t s in the t r e a t m e n t o f b lu n t c a r o tid a r t e r y in ju r y . T h e y s u c c e s s f u l l y p la c e d s te n ts in t w o p atien ts w ith trau m atic cervical IC A d is s e c t io n s . P e r e z - C r u e t et al. (19 ) r e ­ p o r t e d the s u c c e s s f u l u s e o f a w a l l stent a n d d e t a c h a b l e c o ils in the t r e a t m e n t o f a c a s e o f p s e u d o a n e u r y s m o f the c e r v i ­ cal I C A . T h e r e h a s n o t b e e n , to o u r k n o w l e d g e , the r e p o r t o f a c a s e o f s u c ­ c e s s fu l sten t i m p l a n t a t i o n in the tre a t­ m ent of spon tan eous cervical c a r o t id d is s e c t io n . T h e r is k s a s s o c i a t e d w i t h ste n t i m ­ p la n t a t io n i n c l u d e d is t a l m i g r a t i o n o r e m b o l i z a t i o n a n d v e s s e l r u p t u r e at the tim e o f stent p l a c e m e n t ( 1 1 ) a s w e l l a s e a r l y t h r o m b o t ic o c c lu s i o n a n d la te s t e ­ n o s is c a u s e d b y n e o in t i m a l h y p e r p l a s i a (12 ) . C o n s i d e r i n g the p r o v e n efficacy Received, January 13, 1998. Accepted, April 20, 1998. Reprint requests: John A. Wilson, M.D., De­ partment of Neurosurgery, Wake Forest Uni­ versity Baptist Medical Center, WinstonSalem, NC 27157-1029. REFERENCES 1. B i o u s s e V , D ' A j n g l e j a n - C h a t i l l o n J, T o u b o u l P J , A m a r e n c o P, B o u s s e r M G : T i m e c o u r s e o f s y m p ­ t o m s in e x t r a c r a n i a l c a r o t i d a r t e r y d i s s e c t i o n s : A series o f 8 0 p atien ts. S t r o k e 2 6 :2 3 5 -2 3 9 , 1995. 2. B o g o u s s l a v s k y J , R e g l i F: I s c h e m i c s t r o k e in ad u lts y o u n g e r th an 30 y ears o f age: C a u s e an d p r o g n o s i s . A r c h N e u r o l 4 4 : 4 7 9 —4 8 2 , 1 9 8 7 . 3 . B o g o u s s l a v s k y J, P e s p l a n d P - A , R e g l i F: S p o n ­ ta n e o u s caro tid d isse ctio n w ith a c u te stro k e. A rch N eu ro l 4 4 :1 3 7 -1 4 0 , 1987. 4. B r a n c h C l Jr, D a v i s C H : F a l s e a n e u r y s m c o m p lica tin g caro tid e n d a rte re c to m y . 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H i g a s h i d a R T , S m i t h W , G r e s s D , U r w in R, D o w d C F , B a l o u s e k P A , H a l b a c h W : Intravas­ c u l a r s t e n t a n d e n d o v a s c u l a r c o i l p l a c e m e n t for a r u p t u r e d f u s i f o r m a n e u r y s m o f th e basilar a r t e r y : C a s e r e p o r t a n d r e v i e w o f t h e literature. J N e u ro su rg 8 7 :9 4 4 -9 4 9 , 1997. 1 0 . L i s o v o s k i F , R o u s s e a u x P : C e r e b r a l in fa rctio n in y o u n g p e o p l e : A s t u d y o f 1 4 8 p a t i e n t s with e a r l y c e r e b r a l a n g i o g r a p h y . J N e u r o l N e u ro ­ su rg P sy ch ia try 5 4 :5 7 6 -5 7 9 , 1991. 1 1 . M a r k s M P , D a k e M D , S t e i n b e r g G K , N orbash A M , L a n e B : S t e n t p l a c e m e n t f o r a rte ria l and v e n o u s c e r e b r o v a s c u l a r d i s e a s e : P relim in ary e x p e r i e n c e . R a d i o l o g y 1 9 1 : 4 4 1 ^ 4 4 6 , 1994. 1 2 . 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N e u r o s u r g e r y 4 0 :6 2 2 - 6 2 6 , 1997. 20 . P e s s i n M S , A d e l m a n L S , B a r b a d s N R : Sponta­ n e o u s i n t r a c r a n i a l c a r o t i d a r t e r y d issectio n . Stenting of the Internal Carotid Artery 23. S c h i e v i n k W I , M o k r i B , O F a l l a n W M : R e c u r ­ rent s p o n t a n e o u s c e r v i c a l - a r t e r y d i s s e c t i o n . N Engl J M e d 3 3 0 :3 9 3 -3 9 7 , 1994. 24. S c h i e v i n k W I , P i e p g r a s D C ., M c C a f f r e y T V , M o k ri B: S u r g i c a l t r e a t m e n t o f e x t r a c r a n i a l i n ­ 4 ternal c a r o t i d a r t e r y d i s s e c t i n g a n e u r y s m s . seN eurosurgery 3 5 :8 0 9 -8 1 6 , 1994. 1 25. Six E G , S t r i n g e r W L , C o w l e y A R , D a v i s C H : P osttrau m atic b ila te r a l v e r t e b r a l a r te r y o c c l u ­ Of sion: C a s e r e p o r t . J N e u r o s u r g 5 4 : 8 1 4 - 8 1 7 , 1 9 8 1 . ■ 26. S tr in g e r W L , K e l l y D L J r : T r a u m a t i c d i s s e c t i o n of th e e x t r a c r a n i a l i n t e r n a l c a r o t i d a r t e r y . N e u ­ rosurgery 6 :1 2 3 - 1 3 0 , 1 9 8 0 . II 27. S t u r z e n e g g e r M : U l t r a s o u n d f i n d i n g s i n s p o n ­ 1,1 ta n e o u s c a r o t i d a r t e r y d i s s e c t i o n : T h e v a l u e o f d u p le x s o n o g r a p h y . A r c h N e u r o l 4 8 : 1 0 5 7 - 1 0 6 3 , nl 1991. * 28. S t u r z e n e g g e r M : S p o n t a n e o u s i n t e r n a l c a r o t i d I artery d i s s e c t i o n : E a r l y d i a g n o s i s a n d m a n a g e ­ :ai m e n t in 4 4 p a t i e n t s . ) N e u r o l 2 4 2 : 2 3 1 - 2 3 8 , 1 9 9 5 . 29. Y a d a v J S , R o u b i n G S , I y e r S , V i t e k J, K i n g P , :4 Jo rd a n W D , F i s h e r W S : E l e c t i v e s t e n t i n g o f t h e * extracranial caro tid arteries. C ircu latio n M 95:376-381, 1 9 9 7 . i I 959 w ith flu ctu atin g n e u ro lo g ica l deficits re­ ro tid arteries and fe r a b le to the left c a r o t id c ir c u la t io n a n d tem s). D esp ite w a s f o u n d to h a v e s e v e r e o c c l u s i o n o f t h e r a p y , h e c o n t i n u e d to h a v e c r e s c e n d o th re e v e s s e l s (both c a r o t id a r t e r i e s a n d a n eu ro lo g ical s i n g l e v e r t e b r a l a r t e r y ) , a ft e r w h i c h the f u l l y tre a te d w i t h a n g i o p l a s t y a n d ste n t rem ain in g vertebral p lacem en t artery was iatro - g e n ic a lly o cclu d e d . W h en h ep arin ther­ b o th m axim al events. of vertebral these He sys­ m ed ical was o cclu d ed success­ vessels, w i t h e x c e l l e n t c lin ic a l o u t c o m e . a p y fa ile d fo r this p a tie n t , the t r e a t in g C u r r e n t l y , c a r o t id a r t e r y a n g i o p l a s t y p h y s i c i a n s c h o s e to p l a c e a s e r i e s o f a n d s t e n t i n g is a n e x t r e m e l y c o n t r o v e r ­ s te n ts in the o f f e n d i n g left in te r n a l c a ­ sial to p ic fo r a t h e r o s c l e r o t i c o c c l u s i v e ro tid a r t e r y a n d to p u r s u e a c o n s e r v a ­ d isease. t iv e c o u r s e o f t r e a t m e n t fo r the d i s e a s e t r a u m a t i c d i s s e c t i o n s o f the e x t r a c r a n i a l in the r e m a i n i n g v e s s e l s . A s u c c e s s f u l c a r o t id a n d v e r t e b r a l a r t e r i e s a r e m o s t c lin ic a l o u t c o m e w a s a c h i e v e d . l i k e l y a n e x c e ll e n t i n d i c a t i o n T h e t r e a t m e n t p la n is r a t io n a l, a n d the H ow ever, spontaneous and fo r this ty p e o f p ro c e d u re . T h e rep o rted litera­ au th o rs ach ieved a su ccessfu l o u tco m e tu r e o f a d if f ic u lt s itu a tio n . M y s i n g l e r e s e r ­ s t e n t i n g fo r o c c l u s i v e d i s e a s e i n d i c a t e s v a t i o n r e g a r d i n g this a r tic le is that I c a n ­ a n a p p r o x i m a t e l y 4 % n e u r o l o g i c a l r is k n o t b e c e r ta in that the le s io n i d e n t ifie d p e r tre a te d a r t e r y a n d , in s o m e s e r ie s , a s in Figure 1 is t r u l y a c a r o t id d is s e c t io n . It h i g h a s a 9 % n e u r o l o g i c a l r is k d u r i n g m a y be s im p ly a lo n g se g m e n t of a th er­ the p e r i o p e r a t i v e p e r i o d . H o w e v e r , the o m a t o u s d i s e a s e or, a s the a u t h o r s m e n ­ su rgical treatm ent of sp o n ta n e o u s d is ­ t io n e d , T h is s e c t io n s that a r e r e c a lc it r a n t to m e d i c a l in s p e c u l a t i o n h a s n o b e a r i n g o n the t r e a t ­ th e ra p y h a v e an e x tre m e ly h ig h m o r b id ­ conditions that o t h e r w i s e w o u l d b e v e r y m e n t p r o v i d e d n o r o n the v a l u e o f the ity w i t h u n i f o r m l y p o o r o u t c o m e s . O u r difficult to treat. W it h r e s u l t s li k e t h o s e c a s e r e p o rt. In c a s e s o f c a r o tid d is s e c t io n op in io n reported in this c a s e , o n e m i g h t p r e d i c t in w h i c h n e u r o l o g i c a l s y m p t o m s p e r s i s t w h e r e i n t e r v e n t i o n a l c a p a b i l i t i e s e x is t, that this t e c h n iq u e in d e s p i t e a n t i c o a g u l a n t t h e r a p y , I t h in k this s h o u l d b e th e t r e a t m e n t o f c h o ic e J other types o f c a r o t i d o c c l u s i v e d i s e a s e . this so rt o f e n d o v a s c u l a r a p p r o a c h is fo r s p o n t a n e o u s a n d t r a u m a t i c d i s s e c ­ via S< Stanley L. Barnwell r e a s o n a b l e a n d w o r t h y o f a trial. tio n s. L o n g - t e r m f o l l o w - u p is n e c e s s a r y This case s h o w s th e u s e f u l n e s s o f a n ­ gioplasty a n d sr ea p la c e m e n t o f stents w ill be u sefu l Oklahoma City , Oklahoma This is a f a s c i n a t i n g c a s e r e p o r t o f n endovascular s te n t p l a c e m e n t in a p a ­ 'ra d ysp lasia. Christopher M. Loftus Portland , Oregon ex f fib ro m u scu lar C o ric et al. d escrib e a 36 -year-old is th at extracran ial at i m p r o v e s , the h o p e s a r e that th is p r o c e ­ d u re w ill b e c o m e a p r im a r y treatm ent o f this c o n d it io n , w i t h l a s t i n g r e s u lts . tient with s e v e r e e x t r a c r a n i a l v a s c u l a r m an w h o presented w ith p re su m a b ly disease as w e l l a s a h e a l t h y d o s e o f b a d s p o n t a n e o u s d i s s e c t i o n s o f all f o u r e x ­ Robert H. Rosenwasser luck. S p e c ific a lly , th is p a t i e n t p r e s e n t e d t r a c r a n ia l v e s s e l s (i.e., b o th in te r n a l c a ­ Philadelphia , Pennsylvania of! Call for Concepts and Innovations Contributions T h e Concepts and Innovations se c tio n h a s b e e n c o n c e i v e d to e s t a b li s h a n e w d i m e n s i o n in \4 j o u r n a l i s t i c p r e s e n t a t i o n . B e c a u s e o f i n d i v i d u a l v a r i a t i o n s in the c r e a t i v e m i n d a n d the uf a rt C a b i l i t y to e f f e c t i v e l y c a r r y i d e a s t h r o u g h to fr u itio n , m a n y c o n c e p t s o r n o v e l i d e a s a r e J 15! left " o n th e s h e l f " o r a r e u n h e a r d b e c a u s e , fo r o n e r e a s o n o r a n o t h e r , i n d i v i d u a l s d o n o t h a v e the c a p a b i li t y to se e th e m th ro u g h to a b s o lu te o r p ra c tic a lly d e v e l o p e d c o m p le tio n . T h i s se c tio n o f the journal w ill o ffe r a f o r u m fo r all tho se w h o w i s h to p r e s e n t n e w c o n c e p t s o r i d e a s related to n e u r o s u r g e r y a n d n e u ro scien ce , a s a p p lie d to n e u r o lo g ic a l d i s o r d e r s a n d w ill o ffe r the o p p o r t u n i t y fo r the logical a n d s u b s t a n tiv e p re se n ta tio n o f art rS re­ c u r r e n t s t e n o s is , a n d a s ste n t t e c h n o l o g y 1 at* i n s t it u t io n s r e g a r d i n g i n t im a l h y p e r p l a s i a a n d rac »nt m any c a r o t id id e a s a n d n o v e l is s u e s w it h o u t a b so lu te co n firm atio n w ith in clinical o r la b o r a to ry sectors. N e w c o n c e p ts w it h potential a p p lic a tio n to all foci o f practice w ill b e w e lc o m e d . )(3 4 is5 N e u r o s u r g e r y , Vol. 43, No. 4, October 1 998 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/43/4/956/2834842 by Vanderbilt University Eskind Biomedical Library - Serials Section user on 01 January 2020 COMMENTS reg ard in g