Potential hemorrhagic risk of endovascular revascularization therapy due to recanalization of the dissected perforator in intracranial internal carotid artery dissection: A case report
- Departments of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan,
- Pathology, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan,
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
Hiroyuki Sakata, Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan.
DOI:10.25259/SNI_938_2021Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Tomohisa Ishida1, Hiroyuki Sakata1, Masayuki Ezura1, Takashi Inoue1, Atsushi Saito1, Hiroyoshi Suzuki2, Teiji Tominaga3. Potential hemorrhagic risk of endovascular revascularization therapy due to recanalization of the dissected perforator in intracranial internal carotid artery dissection: A case report. 25-Feb-2022;13:71
How to cite this URL: Tomohisa Ishida1, Hiroyuki Sakata1, Masayuki Ezura1, Takashi Inoue1, Atsushi Saito1, Hiroyoshi Suzuki2, Teiji Tominaga3. Potential hemorrhagic risk of endovascular revascularization therapy due to recanalization of the dissected perforator in intracranial internal carotid artery dissection: A case report. 25-Feb-2022;13:71. Available from: https://surgicalneurologyint.com/surgicalint-articles/11410/
Background: Intracranial internal carotid artery (ICA) dissection manifesting as ischemic stroke is rare. Although endovascular revascularization therapy is effective in preventing the progression of stroke, little is known about the potential risk of this therapeutic approach.
Case Description: We report a case of a 38-year-old woman who presented with acute ischemic infarcts in the territory of the left anterior choroidal artery (AChA) due to intracranial ICA dissection. She underwent balloon angioplasty, resulting in the complete resolution of the stenosis. The AChA, which was nearly occluded preoperatively, was unexpectedly recanalized after the procedure. Four hours later, she developed a parenchymal hemorrhage in the left basal ganglia without subarachnoid hemorrhage. The AChA, suspected as the hemorrhagic source during surgical hematoma removal, was revealed to have a disrupted internal elastic lamina on pathological examination, suggesting that the dissection of the ICA extended to the AChA.
Conclusion: To the best of our knowledge, this is the first case report demonstrating that the intracranial ICA dissection extends to the associated perforator. Considering the potential risk of subsequent hemorrhagic complications by recanalization of the dissected perforator, prudent postoperative management, including strict blood pressure control, is advisable following endovascular revascularization therapy against intracranial artery dissection involving perforators.
Keywords: Dissected perforator, Endovascular therapy, Hemorrhagic complication, Intracranial internal carotid artery dissection
Intracranial artery dissection is a rare entity, occurring in 3.6–4.4 per 100,000 people per year.[
Endovascular revascularization therapy has been reported to effectively counteract intracranial ICA dissection manifesting as ischemic stroke.[
Here, we report a case of intracranial ICA dissection with ischemic onset, with a complication of remote parenchymal hemorrhage due to a recanalized dissected perforator following endovascular therapy. We also sought to elucidate the mechanism underlying postoperative hemorrhagic complications and suggest a treatment strategy from both angiographic and pathological points of view.
A 38-year-old woman with no medical history presented with progressive hemiparesis on the right side and total aphasia following a sudden headache. Magnetic resonance imaging revealed acute ischemic infarcts in the territory of the left anterior choroidal artery (AChA) [
(a) Preoperative angiography revealing irregular stenosis of the left supraclinoid internal carotid artery (ICA). (b) Cone-beam computed tomography demonstrating the intimal flap at the lesion site. (c) Preoperative working angle. Note that the anterior choroidal artery (AChA) is nearly occluded (arrow). (d) Balloon angioplasty performed. (e) Postoperative working angle showing the resolution of the ICA stenosis and the complete recanalization of AChA (arrow).
We planned to perform percutaneous transluminal angioplasty (PTA) using a balloon dilatation catheter, with or without stent placement, depending on the PTA results. The patient received oral antiplatelet drugs with loading doses (aspirin 200 mg and clopidogrel 300 mg), together with intravenous heparin during the procedure to maintain the activated coagulation time in the range of 250–300 s. An 8-Fr occlusion balloon-guiding catheter (Cello; Medtronic, Minneapolis, MN, USA) was navigated to the left cervical ICA using a transfemoral approach. After a Gateway Monorail 2.5 × 12 mm (Stryker, Kalamazoo, MI, USA) was introduced into the lesion, the balloon was inflated by increasing the pressure to 6 atm for approximately 60 s [
The patient’s ischemic symptoms improved dramatically soon after the procedure; however, her consciousness level suddenly declined 4 h later. An emergency computed tomography revealed a parenchymal hemorrhage in the left basal ganglia without any evidence of subarachnoid hemorrhage [
(a and b) Computed tomography obtained after patient deterioration, showing the intraparenchymal hemorrhage in the left basal ganglia without any evidence of subarachnoid hemorrhage. (c and d) Pathological examination of the resected anterior choroidal artery by hematoxylin and eosin staining (c) and elastic Masson staining (d). Note that the internal elastic lamina is disrupted and the red blood cells are present in the subintimal planes (arrowhead).
Although the natural history of ischemic stroke due to intracranial ICA dissection has not been studied in greater detail than that of other types of steno-occlusive lesions, ICA dissection is reportedly associated with a high rate of recurrent ischemic events.[
The most interesting finding in the present case is that the resected AChA, which is probably responsible for the hemorrhagic complication, showed evidence of dissection, which was confirmed by pathological examination. Dissection in a perforator has been reported previously as the cause of parenchymal hemorrhage.[
Another possible underlying mechanism is reperfusion injury. Endovascular recanalization therapy for stenoocclusive lesions has a potential risk of hemorrhagic complications (3.1%).[
This is the first case report demonstrating that the intracranial ICA dissection extends to the associated perforator. In cases of intracranial ICA dissection involving the perforator, occasional recanalization of the perforator may increase the risk of subsequent hemorrhagic complications following endovascular recanalization therapy. Prudent postoperative management, including blood pressure control, should be advised considering the potential hemorrhagic risk due to recanalized perforators.
The authors certify that they have obtained all appropriate patient consent.
We are supported from JSPS KAKENHI (Grant Number P19K18414). No other financial support is received.
There are no conflicts of interest.
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