Endovascular Treatment of Spontaneous Carotid Artery Dissection

Tomoyuki Umemoto,1 *Andrea Pacchioni,1 Bernhard Reimers2

1. Department of Cardiology, Ospedale Civile Mirano, Mirano, Venice, Italy
2. Department of Invasive Cardiology, Humanitas Clinical and Research Hospital Rozzano, Milan, Italy
*Correspondence to andreapacchioni@gmail.com

Disclosure: The authors have declared no conflicts of interest.
Received: 14.03.16 Accepted: 25.04.16
Citation: EMJ Int. Cardiol. 2016;4[1]:82-90.

Abstract

Spontaneous carotid artery dissection (SCAD) is a common cause of ischaemic stroke in young patients. Though SCAD is usually defined as carotid artery dissection without trauma, a minor traumatic event is often revealed by a detailed medical interview. An association with intrinsic vessel structure has been reported in connective tissue disease, pregnancy and the postpartum period, and in infectious and inflammatory disease. Mechanisms of SCAD vary and are still unclear, but a combination of fragile vessel walls and minor trauma can result in dissection. Headache, Horner’s syndrome, transient ischaemic attack or ischaemic stroke are the most frequently seen clinical symptoms. Non-invasive diagnostic modalities including magnetic resonance imaging, computed tomography, and duplex ultrasonography have become an alternative to digital subtraction angiography, however this still remains the gold standard, with better detection of thrombus and collateral circulation. Antithrombotic therapy is the standard medical treatment for SCAD, achieving a good clinical course in most patients. Patients, including those on antithrombotic therapy, who are presenting with recurrent ischaemic symptoms, haemodynamic compromise, or expanding pseudoaneurysm should be considered for intervention therapy. As the main purpose of endovascular treatment is to avoid recurrence of ischaemic attack, performing the procedure under an embolic embolic protection device is preferable. To obtain sufficient blood flow and sealing of the thrombus, a stent is usually delivered, and coil embolisation can be performed for expanding pseudoaneurysm, if required. The most common regimen of post-procedural antiplatelet therapy is a double dose for 3 months followed by a single dose indefinitely, though a clear guideline does not exist. The clinical success rate and long-term results of endovascular treatment are acceptable. Endovascular treatment for carotid artery dissection is feasible, safe, and effective in a subgroup of patients, including those resistant to medical therapy.

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