Successful Endovascular Repair of a Rare Atraumatic Extravasating Dissection of a Cervical Internal Carotid Artery
Mark Orlando1, Amre Nouh2, Michal Obrzut1
1Cleveland Clinic Florida, 2Cleveland Clinic
Background:
Spontaneous cervical carotid artery dissection is rare, often associated with trauma, cystic medial necrosis, tumors, radiation, or iatrogenic injury. In the absence of significant external damage to the carotid artery, most dissections remain contained within the media or adventitia layers. Contrast extravasation from carotid artery rupture is rare. We report a case of active extravasation from a spontaneous internal carotid artery dissection and stroke.
Results:
A 62-year-old hypertensive male presented to the emergency department with acute left hemiparesis, rightward gaze deviation, and left side neglect. Initial NIHSS was 13. Non-contrast CT of the brain showed a dense right middle cerebral artery sign and loss of grey-white differentiation in the right external capsule and temporal operculum. CT angiography demonstrated a thrombus in the supraclinoid segment of the right internal carotid artery extending into the M1 segment of the right middle cerebral artery. Tenecteplase was not given. He was taken for emergency mechanical thrombectomy and angiography confirming an internal carotid artery dissection with contrast extravasation at the mid cervical segment with TICI 3 recanalization. The dissection in the right internal carotid artery was repaired with a 5 x 40 mm precise stent. He was started on aspirin and ticagrelor without extravascular extravasation or neck hematoma. Imaging 3 weeks later was stable. His neurological status continued to improve. NIHSS was 3.
Conclusions:
Spontaneous carotid artery dissections in healthy individuals rarely extravasate. Contrast extravasation on CT and digital subtraction angiography (DSA) is primarily observed in major trauma or carotid blowout syndrome following treatment of head and neck cancer with potential causes including, surgical resection, infections and/or radiation necrosis. We report an unusual atraumatic, non-iatrogenic dissection in a patient without a history of radiation to the neck or other causes of vessel wall necrosis. The dissection was successfully treated with placement of an endovascular stent.