J Korean Soc Radiol.  2013 Dec;69(6):427-431.

Carotid Artery Stenting in Patients with Critical Stenosis of Proximal Internal Carotid Artery and Large Distal Arterial Thrombus: 2 Case Reports

• Jang JH
• Kim EJ
• Lee KM
• Choi WS
• Yoon SS
• Park KJ

Abstract

Determining the timing of carotid artery stenting in patients with carotid artery stenosis with a large territorial infarction is still controversial. Furthermore, it is more difficult to decide the timing of the procedure in cases with a coexisting tandem lesion, including distal arterial stenosis or thrombus. We report two cases of critical stenosis of the proximal internal carotid artery with a coexisting large distal arterial thrombus that presented as a large territorial infarction, that showed resolution of the distal arterial thrombus with stroke management after 3-4 weeks, and that were safely treated with carotid artery stenting.

MeSH Terms

Carotid Arteries*
Carotid Artery, Internal*
Carotid Stenosis
Constriction, Pathologic*
Humans
Infarction
Stents*
Stroke
Thrombosis*

Figure

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  Fig. 1 A 54-year-old man with right side weakness and dysphasia (case 1). A-C. Initial perfusion CT reveals acute infarction at the left frontal lobe, showing decreased CBV (A) and CBF (B), and increased MTT (C). D, E. And initial CT angiography shows severe stenosis of the left proximal internal carotid artery (ICA, arrow in D) and possible occlusion or severe narrowing of the left proximal M1 segment (arrow in E). F, G. Digital subtraction angiography (DSA), obtained 6 days after the initial attack, reveals severe stenosis of the left proximal ICA (arrow in F) and large amount of distal arterial thrombus at the left petrous-cavernous ICA, appearing filling defects (curved arrow in G). H, I. After 4 weeks of 'stroke management' (including dual antiplatelet therapy, lipid lowering therapy, and strict control of the blood pressure), follow-up DSA still shows severe stenosis of the left proximal ICA (arrow in H), however, large amount of filling defects are invisible (I). J. We deploy the stent with the proximal end in the distal common carotid artery (open arrow) and the distal end in the proximal ICA (arrow). DSA also reveals the marker of the protection device (dashed arrow). Note.-CBF = cerebral blood flow, CBV = cerebral blood volume, MTT = mean transit time

• 

  Fig. 2 A 70-year-old man with left side weakness (case 2). A. Initial brain DWI reveals acute focal infarction at the right parietotemporal lobes and right insular cortex (arrow) and chronic focal infarction at the right frontal lobe (open arrow). B, C. DSA shows severe focal stenosis of the right proximal ICA (arrow in B) and reveals large amount of intra-arterial thrombus at right cervical-petrous ICA (curved arrows in B and C). D, E. After 3 weeks of 'stroke management', follow-up DSA reveals no change of severe stenosis of the right proximal ICA (arrow in D), however, reveals no more previous large amount of filling defects at cervical-petrous ICA. F. We deploy the stent with the proximal end in the distal CCA (open arrow) and the distal end in the proximal ICA (arrow). DSA also reveals the marker of the protection device (dashed arrow). Note.-CCA = common carotid artery, DSA = digital subtraction angiography, DWI = diffusion weighted image, ICA = internal carotid artery

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