CASE REPORTS

Acute Neuroform Stenting of a Symptomatic Petrous Dissection

a,b,dRobert D. Ecker, MD, a,b,c,dElad I. Levy, MD, a,b,c,dL. Nelson Hopkins, MD
a,b,dRobert D. Ecker, MD, a,b,c,dElad I. Levy, MD, a,b,c,dL. Nelson Hopkins, MD
Only two therapies for acute stroke intervention have been approved by the U.S. Food and Drug Administration: intravenous tissue plasminogen activator (tPA) and the Merci retriever (Concentric Medical, Mountainview, California). Many patients fall outside the therapeutic window for tPA administration, and the benefit is marginal.1 When used alone, the Merci device is unsuccessful in approximately 35–50% of patients.2,3 Additionally, neuroimaging techniques and criteria to select optimum candidates for acute intervention have not been developed. We report a case in which a self-expanding stent designed for wide-necked aneurysm treatment was used to revascularize an acute symptomatic petrous carotid dissection.

Case Study. A 51-year-old hypertensive male developed a severe headache, right-sided hemiplegia, complete facial palsy and mutism. After evaluation at an outside emergency room, he was flown to our institution. On arrival, his deficits had been fixed for 5 hours, and his National Institutes of Health Stroke Scale score was 16. Computed tomographic perfusion imaging documented increased time-to-peak in the carotid territory, without evidence of a completed stroke (Figure 1A). After informed consent had been obtained from the patient, angiography and endovascular treatment were performed on an urgent basis. Angiography revealed a 360-degree turn and flow-limiting left petrous dissection (Figure 1B). An 0.018-inch Nautica microcatheter (ev3, Inc., Plymouth, Minnesota) and a gold-tip glide wire were used to cross the dissection into the normal distal lumen. A microcatheter run confirmed patency of the artery without significant clot burden. A 300 cm Transcend exchange wire (Boston Scientific Corp., Natick, Massachusetts) was placed into the cavernous internal carotid artery, and the microcatheter exchanged out. This wire was then used as the rail for stenting. Because of the tight proximal loop and extension of the dissection over a curve, we used a 4.5 x 30 mm Neuroform III stent (Boston Scientific), which was deployed easily across the lesion. A small residual flap was dilated with a 5 x 20 mm Aviator balloon (Cordis Endovascular, Miami, Florida), resulting in complete revascularization (Figures 1C and D). Immediately after stent deployment, a bolus dose of eptifibatide and a loading dose of clopidogrel (450 mg) were administered.

During the next 48 hours, the patient regained normal strength on the right side with only a mild drift, and his speech returned, although he had significant difficulty with phonation. Follow-up magnetic resonance imaging demonstrated patchy infarctions in the territories of the anterior cerebral and middle cerebral arteries (Figures 1E and F). At the time of discharge, the patient’s National Institutes of Health Stroke Scale score was 5.

Acknowledgment. We thank Paul H. Dressel for preparation of the illustrations.

 

 

 

 

 

 

References

References

  1. Albers GW, Bates VE, Clark WM, et al. Intravenous tissue-type plasminogen activator for treatment of acute stroke: The Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA 2000;283:1145–1150.
  2. Gobin YP, Starkman S, Duckwiler GR, et al. MERCI 1: A phase 1 study of mechanical embolus removal in cerebral ischemia. Stroke 2004;35:2848–2854.
  3. Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: Results of the MERCI trial. Stroke 2005;36:1432–1438.