Purpose For patients with acute and subacute (30 days after onset) traumatic dissection of the carotid (CD) and vertebral (VD) arteries, causing progressive or fluctuating neurologic deficit in the presence of significant hemodynamic insufficiency, the endovascular treatment could be safe option. Understanding the morphology and modalities of the affected perfusion is crucial in developing optimal protocols for carotid & vertebral endovascular surveillance. Our purpose is to evaluate the safety and efficiency of endovascular treatment for acute and subacute CD and VD.
Materials and Methods Eighteen patients underwent emergent (n11) and elective (n7) endovascular treatment for CD (n5) or VD (n13) arteries. All patients harbored progressive or fluctuating neurologic deficit with significant hemodynamic insufficiency on CT/MR perfusion studies and occlusion or critical stenosis on catheter angiography. The imaging manifestation included intradural hemorrhage (n8), extradural extravasations (n5), pseudoanerysm (n6), cerebral ischemia (n3), and steal phenomenon with vertebrobasilar TIA (n1). The dissection was classified as abrupt occlusive (n11) and stenotic (n7). The treatment protocols included: (a) parent artery occlusion (n11–8 by coils, 2 by balloon, 1 by coils & glue), (b) stent alone (n2), (c) stent with coils (n4), and (d) fibrinolysis alone (n1). Nine self-expanding Wallstents (Boston Scientific) were used. Balloon test occlusion was performed for internal carotid artery (n1).
Results The parent artery occlusion was preferred for VD with intradural or extradural hemorrhage. In five patients with extended soft tissue hemorrhage a combine approach with antegrade and retrograde trapping of parent artery was managed by coils. Other five VD patients with symptomatic aneurysms have been treated by antegrade trapping or proximal occlusion. In one case with advanced fibromuscular dysplasia of both vertebral arteries and chiropractic trauma the treatment included an acute fibrinolysis of the basilar artery following by spontaneous recanalization of the VD. A case with post traumatic VD with steal phenomenon was treated by retrograde and antegrade trapping associated with glue embolization. The CD was successful treated with stent and coils through jailed microcatheter in three cases with pseudoanerysm, and with stent alone in two cases. Periprocedural complications were not observed. Complete occlusion or successful maintaining of the parent artery was obtained in all treated patients.
Conclusion The acute and subacute CD and VD are dynamic and less predictable process. The placement of stent with coils through jailed microcatheter were effective in relieving stenosis secondary to vessel dissection as well as in obliterating associated pseudoaneurysms. The long-term patency of stented vessels is a concern. However, in this study, all patients with stent treatment revealed no residual or in-stent stenosis. While the guidelines for treatment of non-ruptured CD and VD remain still controversial, the endovascular treatment for cases with pseudoaneurysm or vessel rupture raises definitely the demand for appropriate endovascular repair with parent artery occlusion, jailed Wallstents, coils, or stent alone. Our study demonstrates the feasibility and safety of this multimodality treatment paradigm in traumatic CD and VD.
Competing interests None.
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