A 31-year-old right-handed woman, who was 4-month postpartum, presented to the emergency department with a thirty-five-minute history of left-sided face, arm and leg weakness, along with slurred speech. She reported right-sided neck pain for the preceding three days, with no history of trauma or neck manipulation. Two days prior to presentation, she had experienced transient loss of vision in her right eye.
On examination, she had left upper motor neuron pattern facial weakness, left upper and lower limb MRC grade 0/5 power, sensory inattention, and cumulative NIH Stroke Scale (NIHSS) score of 14. Horner's syndrome was absent.
CT brain imaging performed 1 hour after symptom onset showed a hyperdense middle cerebral artery (MCA) sign (), and CT angiogram showed a right internal carotid artery dissection (ICAD). MRI confirmed the internal carotid artery dissection and demonstrated restricted diffusion limited to the lenticulostriate distribution of the MCA.
Figure 1 (a) Prethrombolysis CT showing hyperdense vessel sign in right MCA. (b) Angiogram after right ICA stenting and before Solitaire AB deployment showing pseudoaneurysm at the dissection site (white arrowhead) and thrombus within the ACA and M1 (black arrowheads). (more ...)
The intravenous thrombolysis (IVT) was initiated 2 hours 20 minutes following symptom onset, but following IV tPA administration the patient continued to display persistent left hemiparesis, dysarthria, and sensory inattention. NIHSS score was 10.
The patient was transferred to a hospital with interventional neuroradiology expertise in view of the persisting disability and presumed persistent proximal artery occlusion. Informed consent was obtained and the patient was placed under general anaesthesia. The initial angiogram via a 5
Fr catheter showed a normal left carotid, left anterior circulation, vertebral artery, and posterior circulation. Absence of cross-flow via the anterior communicating artery precluded the assessment of the right anterior circulation from the left side. There was some retrograde collateral filling of the right anterior cerebral and MCA territories.
At 6 hours 12 minutes following symptom onset, the right common carotid artery was accessed via an 8 Fr flow arresting guide catheter. Initial angiography demonstrated tapered occlusion of the proximal right internal carotid artery (ICA) consistent with dissection. A microwire was successfully passed beyond the dissection after several attempts. After confirming the intraluminal position of the wire, a 6
mm carotid stent was placed across the occlusion. Repeat angiography revealed a patent right ICA with a pseudoaneurysm at the dissection site and thrombus in the right anterior cerebral artery (ACA) and M1 (). Three passes were made with a 4
mm Solitaire AB (ev3 Inc, Irvine, C.A, USA), a self-expanding and fully retrievable stent and ACA and M1 thrombus retrieved (). Early neurological improvement was noted after procedure. At discharge 7 days later the patient's NIHSS score was 2, and she made an excellent functional recovery.