Acute Internal Carotid Artery Dissection Refractory to Medical Therapy: False-to-True Lumen Reentry (Antegrade Wire Escalation), Angioplasty, MCA Thrombectomy, and Reconstruction of the Dissected Segment by Flow-Diverter Stent Implant, with a Favorable Outcome

Carotid artery dissection (CAD) is an important cause of ischemic stroke, particularly in young and healthy individuals, and can lead to severe sequelae. Most asymptomatic CADs are managed medicinally with either antithrombosis or anticoagulation therapy. However, when this therapy fails, endovascular therapy is warranted. The standard technique for endovascular CAD treatment requires direct access to the true arterial lumen. This maneuver is often blind if the true lumen is collapsed or occluded. When the true lumen cannot be accessed, stent reconstruction via extraluminal recanalization (false-lumen to true-lumen) may be considered as a bailout option. We report the case of a 47-year-old man with an unremarkable medical past who was admitted through the emergency room after visual complaints that had begun 3 days before. Neurological examination revealed right homonymous hemianopsia. His National Institutes of Health Stroke Scale (NIHSS) score at admission was 3. He denied a history of recent trauma or cervical pain. Admission CT showed a left temporomesial-occipital infarct in the territory of the left posterior cerebral artery (PCA). CT angiography (CTA) confirmed a left internal carotid artery (ICA) dissection of the tonsillar loop, causing severe focal arterial narrowing, and a fetal PCA was seen. The patient was started on dual antiplatelet therapy and remained stable for 5 days. On the 6th day, the day planned for discharge, he developed acute motor dysphasia and right arm weakness (NIHSS 8). Urgent CT-CTA and CT perfusion (CTP) imaging confirmed occlusion of the left cervical ICA and occlusion of the superior trunk of the left MCA, with a sizeable frontotemporal penumbra area. A 17 ml region of total cerebral flow reduction to less than 30% of expected levels with a low perfusion volume was located predominantly in a deep zone. The region with a time-to-maximum prolongation >6 s had a volume of 76 ml. He was urgently transferred to the neuroangiography suite and underwent intracranial stentriever-assisted thrombectomy and flow diverter-assisted ICA reconstruction. The ICA reconstruction was achieved via extraluminal recanalization, and this bailout technique is the main topic of this chapter.