J Cerebrovasc Endovasc Neurosurg.  2023 Sep;25(3):333-339. 10.7461/jcen.2022.E2022.06.011.

Endovascular recanalization therapy for patients with acute ischemic stroke with hidden aortic dissection: A case series

• Jeong HS
• Jeong EO
• Lee IY
• Lee HI
• Koh HS
• Kwon HJ

• KMID: 2546171
• DOI: http://doi.org/10.7461/jcen.2022.E2022.06.011

Abstract

Aortic dissection is one of the causes of acute ischemic stroke. Endovascular recanalization therapy (EVT) has emerged as an essential treatment for acute ischemic stroke due to large artery occlusion. However, it is rarely performed in the situation of hidden aortic dissection (AD). Two patients presented to the emergency room with focal neurologic deficits. The first patient was diagnosed with right internal carotid artery (ICA) occlusion. Angiography revealed that the ICA was occluded by the dissection flap. After a stent deployment in the proximal ICA, the antegrade flow was restored. The patient was diagnosed with AD on chest computed tomography (CT) after EVT. For the second patient, intraarterial thrombectomy was performed to treat left middle cerebral artery occlusion. AD was first detected on echocardiography, which was performed after EVT. Herein, we report successful endovascular recanalization therapy performed in two patients with acute ischemic stroke in the situation of undiagnosed aortic dissection. We also reviewed previous case reports and relevant literature.

Keyword

Aortic dissection; Ischemic stroke; Endovascular therapy; Thrombectomy

Figure

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  Fig. 1. (A) Brain diffusion-weighted image showing multifocal high signal intensities in the right hemisphere. (B) Perfusion imaging revealing delayed mean transit time in the entire right MCA region. (C) Blood flow of the right ICA was not visualized on MR angiography. (D) The flow void within the right ICA was invisible during T2-weighted imaging (red arrowhead). (E) Digital subtraction angiogram showing the tapered flow from the distal CCA. (F) The stent was inserted and the CCA and ICA flow was restored (G). MCA, middle cerebral artery; ICA, internal carotid artery; CCA, common carotid artery

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  Fig. 2. (A) Chest CT revealed aortic dissection originating in the ascending aorta. The flap involved the proximal innominate artery (red arrowhead). (B) The dissection propagated to the abdominal aorta (DeBakey type I) and superior mesenteric artery (red arrowhead) following its origin from the false lumen. The true lumen was compressed eccentrically along the thoraco-abdominal aorta (star marking). (C) The flap did not involve the left CCA or subclavian artery (red arrowheads), which originated from true lumen. (D) The dissection flap, which was observed in the ascending aorta and arch at diagnosis, was replaced after surgery (E). CT, Computed tomography; CCA, common carotid artery

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  Fig. 3. (A) Brain diffusion-weighted imaging showing high signal intensities in the left basal ganglia. (B) Perfusion image revealing delayed mean transit time in the superior branch region of the left MCA. (C) Digital subtraction angiogram showing occlusion in the superior branch of the left MCA (red arrowhead). (D) Intraarterial thrombectomy using a Catalyst 7 (Stryker, MI, USA) suction catheter was performed. Catheter tip is showing (red arrowhead). (E) After withdrawal of a huge thrombus, complete reperfusion was achieved (F). (G) Aorta CT showing the dissection flap (star marking) originating from the proximal descending aorta to both CIAs (DeBakey type III). (H) Important arteries to the internal organ originated from the true lumen of abdominal aorta. (I) The ascending aorta and aortic valve had already been surgically replaced. MCA, middle cerebral artery; CT, computed tomography

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