J Cerebrovasc Endovasc Neurosurg.  2024 Jun;26(2):196-203. 10.7461/jcen.2023.E2023.07.003.

Various treatment modalities for isolated intracranial middle cerebral arterial dissection with progressive ischemic symptoms: 2 case reports of endovascular stent and bypass surgery

• Eun C
• Kim H
• Cho S
• Yang K

• KMID: 2556982
• DOI: http://doi.org/10.7461/jcen.2023.E2023.07.003

Abstract

Isolated middle cerebral artery dissection (MCAD) is rare but increasingly recognized as a significant clinical entity, particularly in younger adults. Ischemic stroke is the most common manifestation in symptomatic cases but symptoms can vary in severity from headaches to severe neurologic deficits. Due to its rarity and unpredictable clinical course, there is no established treatment strategy for isolated MCAD. Through two case reports, we reviewed the post-operative clinical course of MCAD under different treatment modalities. Case 1 was a 21-year-old woman who presented to the emergency department with headaches and left-side hemiparesis. Isolated MCAD was diagnosed and she was successfully treated with the placement of a self-expandable stent and subsequent chemical angioplasty for post-stent vasospasm. Case 2 was a 35-year-old woman who presented to the emergency department with left-side hemiparesis and dysarthria. Isolated MCAD was diagnosed and she was successfully treated with superficial temporal artery (STA) to middle cerebral artery (MCA) anastomosis.

Keyword

Cerebral revascularization; Middle cerebral artery; Dissection; Stroke; Stents

Figure

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  Fig. 1. (A) A diffusion-weighted MRI showing acute infarctions in the right MCA territory; (B) TOF-MRA shows severe and diffuse narrowing of the M1 segment of the MCA and occlusion of the distal ICA. In the MRA, the “double-lumen sign” can be seen on the M1 segment of the MCA (white arrowhead). MRI, magnetic resonance imaging; MCA, middle cerebral artery; TOF-MRA, time-of-flight magnetic resonance angiography; ICA, internal carotid artery; MRA, magnetic resonance angiography

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  Fig. 2. (A) A follow-up TFCA performed on day 3 of hospitalization showing long-segment severe, irregular stenosis from the right distal ICA, just distal to the ophthalmic segment, to the M1 segment of the MCA, with symptom aggravation. Aggravated flow limitation to the right hemisphere was due to the progressive dissection of the M1 segment of the MCA which cause a decrease in collateral flow via the Acom A; (B) A post-stent angiogram (AP view) showing improved blood flow to the right hemisphere and the restoration of ICA and MCA flow. However, ACA flow cannot be seen. The patient was medicated and kept under close observation without further intervention as the patency of the Acom A and contralateral A1 segment of the ACA were good. The proximal and distal ends of the stent were marked with white arrowheads. TFCA, transfemoral cerebral angiography; ICA, internal carotid artery; MCA, middle cerebral artery; Acom A, anterior communication artery; AP, anterior to posterior; ACA, anterior cerebral artery

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  Fig. 3. A follow-up TFCA performed 6 months after the procedure showing no in-stent or stent-adjacent stenosis. There is near-normalization of the blood flow, including that from the ACA to the right hemisphere (AP view). TFCA, transfemoral cerebral angiography; ACA, anterior cerebral artery; AP, anterior to posterior

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  Fig. 4. (A) A diffusion-weighted MRI showing acute infarctions in the right MCA territory; (B) An initial TFCA showing acute proximal occlusion of the M1 segment of the MCA with no basal collateral flow (AP view). MRI, magnetic resonance imaging; MCA, middle cerebral artery; TFCA, transfemoral cerebral angiography; AP, anterior to posterior

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  Fig. 5. (A) A TFCA from postoperative day 5 showing good patency of the superficial temporal artery graft with the flow from the graft filling the M2 segment of the MCA in the right selective ECA angiogram; (B) A right selective ICA angiogram showing retrograde recanalization of the right M1 segment of the MCA with mild stenosis (white arrowhead) under the healing dissection (AP view). TFCA, transfemoral cerebral angiography; MCA, middle cerebral artery; ECA, external carotid artery; ICA, internal carotid artery; AP, anterior to posterior

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