Minor Cervical Trauma Causing Internal Carotid Artery Dissection, Near Total Occlusion, and Embolic Stroke: Urgent Arterial Reconstruction by Means of Telescoped Stents with Excellent Clinical Evolution

Traumatic carotid artery dissection (CAD) is a different clinical entity from spontaneous carotid dissection, and requires special considerations for optimal management. Compared with spontaneous CAD, traumatic CAD is associated with a higher mortality rate; consequently, increasing evidence suggests that immediate intervention is crucial. However, current guidelines on carotid disease management do not differentiate between spontaneous and traumatic dissection. Antithrombotic or antiplatelet treatment is recommended in patients with neurological symptoms, and endovascular intervention is suggested only when neurological status deteriorates under conservative medical treatment. We believe that these recommendations are imprecise and fail to provide appropriate guidance for the management of patients with traumatic internal carotid artery (ICA) dissections. The current guidelines do underscore the growing role of endovascular techniques in managing this entity. A 34-year-old woman with an unremarkable medical history, except for stage 2 chronic renal failure secondary to pyelonephritis during her childhood, was admitted to the emergency department after recurrent episodes of speech alteration described as a transient inability to recall words. Her neurological history was unremarkable, apart from repeated self-limited episodes of transient motor dysphasia that had begun 3 days before after a seemingly unrelated cervical trauma experienced during her routine morning exercises. She recalled having been accidentally hit by an elastic resistance band in her left anterolateral neck region. She subsequently experienced neck-head discomfort, and 20 h after the incident, she experienced the first of seven episodes of transient dysphasia that occurred over 72 h. Immediately after her first dysphasia episode, she self-medicated with 300 mg of acetylsalicylic acid, which alleviated her neck-auricular discomfort. On examination, subtle left ptosis was identified. Cranial computed tomography (CT) and CT angiography (CTA) of the cervical and cerebral arteries indicated a left frontal cortical infarct, an extended dissection of the left ICA causing near-total arterial occlusion at the petro-cervical junction, and hypoplasia of the right A1 segment. On magnetic resonance imaging (MRI), a left cortical prefrontal infarct was identified. The patient was administered 300 mg of aspirin and 600 mg of clopidogrel. Platelet inhibition testing (VerifyNow, Accumetrics) obtained 6 h later confirmed a value of 113 P2Y12 reaction units (PRU). Angiography of the left ICA confirmed a long string sign cervical-petrous dissection, which caused near-complete artery occlusion. The ICA was reconstructed with telescoped self-expanding and balloon-expandable stents. The procedure was uneventful, and the patient was discharged after 48 h. This clinical case illustrates the endovascular management of a traumatic ICA dissection with serial stents. The indication for endovascular treatment was based on a combination of the failure of medical therapy (repeated events under aspirin), clinical symptoms independent of hemodynamic insufficiency, impending stroke after near-total occlusion of the ICA, and an incomplete circle of Willis. Stent-assisted arterial reconstruction is the preferred approach and is commonly used for managing traumatic dissections in our center. Herein, we describe a standard revascularization procedure and present our proposed indications and limitations for endovascular treatment.