Background and purpose Cervical dissections are a significant cause of acute ischemic stroke, especially in young and middle aged adults. Although medical management of cervical dissections is standard treatment, emergent endovascular treatment may become necessary in the presence of acute intracranial large vessel occlusions, flow limiting and long segment lesions with impending occlusion, and/or ischemia at risk for cerebral infarction. We report our experience with the endovascular reconstruction of long segment carotid dissections using multiple tandem stents in acute ischemic stroke intervention.

Materials and methods We retrospectively studied patients with carotid artery dissections requiring stent reconstruction at our institutions between January 2011 and January 2015, presenting with acute (<12 hours), severe ischemic stroke symptoms (NIHSS >4), and requiring carotid reconstruction with multiple tandem stents (≥3 stents). We analyzed patients’ demographics, vascular risk factors, presentations, imaging and angiographic findings, technical efficacy and safety, and clinical outcomes.

Results We identified 15 patients presenting with acute ischemic stroke that underwent endovascular stent reconstruction of carotid dissections for vessel and/or ischemic tissue salvage. Mean patient age was 51.5 years with a mean presenting NIHSS of 15 and discharge NIHSS of 6. All carotid dissections presented with >70% stenosis and severe flow limitation, nearly all 14/15 involving the distal cervical segment of the ICA with a minimum length of 3.5 cm. Technical success of carotid stent reconstruction was achieved in all patients (100%) with no significant residual stenosis or flow limitation. Nine patients (60%) harbored simultaneous intracranial occlusions, and 6 patients (40%) required IA thrombolysis/thrombectomy achieving TICI 2 b-3 reperfusion in all 15 patients. There were no symptomatic intracranial hemorrhages. Procedural complications were limited to distal thromboemboli and multifocal infarcts in a single patient due to suspected in-stent thrombus, resulting in 7% procedural morbidity and 0% mortality. Follow-up 3–6 month angiographic and ultrasound imaging evaluations confirmed normalization of carotid artery caliber and stent patency in 12/14 patients, with 2 cases of only mild persistent vessel irregularity and <20% in-stent stenosis. On clinical follow-up, 9/15 (60%) of patients achieved mRS ≤ 2 at 90 days, with no interval recurrent TIAs or strokes.

Conclusion Tandem stent reconstruction for the treatment of long segment and flow limiting carotid dissections is technically safe and effective with favorable clinical outcomes in acute ischemic stroke intervention, allowing for successful thrombectomy, vessel salvage, restoration of cerebral perfusion, and prevention of recurrent thromboembolic stroke.

Disclosures S. Ansari: None. A. Kuhn: None. A. Honarmand: None. S. Hou: None. M. Khan: None. J. Chueh: None. I. van der Bom: None. M. Hurley: None. A. Shaibani: None. M. Gounis: None. M. Potts: None. B. Jahromi: None. A. Wakhloo: None. A. Puri: None.