Aggressive Endovascular Management Of Extracranial Arterial Dissection Associated With Intracranial Thrombosis

OBJECTIVE: Spontaneous dissection of the internal carotid and vertebral artery remains an important cause of ischemic stroke in young and middle-aged patients. Intracranial arterial thrombosis secondary to dissection often results in devastating stroke and independently predicts poor outcome even after intravenous (IV) thrombolysis and anticoagulation. Herein we assess the safety and efficacy of intra-arterial thrombolysis and stent placement in the treatment of symptomatic, spontaneous carotid and vertebral artery dissection associated with intracranial vessel occlusion.
METHODS: Retrospective review of six consecutively-treated patients presenting with intracranial artery thrombosis due to extracranial dissection between July 2006 and July 2009. Indication for intervention was worsening neurologic deficit following IV thrombolytic treatment and anticoagulation with evidence of compromised intracranial blood flow.
RESULTS: Six patients (four men, two women; mean age = 51years, range 35-65) presenting with acute stroke (mean NIH Stroke Scale score = 17, range = 6 to 23) were treated with IV thrombolysis and anticoagulation. After documented worsening of symptoms, cerebral angiography demonstrated intracranial thrombosis resulting from carotid (n=5) or vertebral (n=1) dissection. Successful revascularization was achieved in all six cases following intra-arterial thrombolysis and stenting of the dissection an average of 7.9h (range = 4.1h to 12.2h) following onset of symptoms. One patient died from worsening cerebral edema. Of the remaining five, three had dramatic improvement of their neurological deficit while two had incomplete motor recovery (mean NIHSS score on discharge = 9, range = 3 to 19).
CONCLUSIONS: While most carotid and vertebral dissections heal spontaneously with anticoagulation alone, the subset of patients with both extra-/intra-cranial thrombosis has a poor prognosis. This study suggests that aggressive, rapid revascularization using intra-arterial thrombolysis and stenting improves outcome in this difficult population.