Delayed Internal Carotid Artery Dissection Mimicking Cerebral Vasospasms after Subarachnoid Hemorrhage: A Case Report

Abstract

Background Delayed cerebral ischemia (DCI) is usually caused by cerebral vasospasm (CVS). To detect DCI and CVS, a cranial computed tomography (CT) scan will be performed, but cervical vessels are not necessarily displayed.

Methods A 63-year-old female patient who suffered from aneurysmal subarachnoid hemorrhage (SAH) was treated at the authors' institution. After an initially unremarkable clinical course, she developed aphasia on day 11. CT angiography (CTA) and perfusion imaging revealed significant hypoperfusion of the left hemisphere. In addition, the CTA showed a subtotal stenosis of the internal carotid artery (ICA) at the level of the petrous segment, suspicious for a dissection. This was not detectable angiographically in the final control of the intervention and was also not clinically evident until day 11.

Results Cerebral perfusion as well as the clinical symptoms normalized rapidly after stent reconstruction of the ICA.

Conclusion Even though CVS is the most common cause of hypoperfusion in patients after an SAH, a peri-interventional dissection can also lead to relevant stenosis and thus to a disturbed cerebral perfusion and corresponding neurologic deficits. The time delay between the intervention and the clinical and CTA manifestation in our case is remarkable.

Keywords

subarachnoid hemorrhage - dissection - cerebral vasospasm - endovascular treatment

Publication History

Received: 01 February 2023

Accepted: 14 August 2023

Accepted Manuscript online:
18 August 2023

Article published online:
03 July 2024

• References

• 1 Vergouwen MDI, Vermeulen M, van Gijn J. et al. Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group. Stroke 2010; 41 (10) 2391-2395
• 2 Bouzat P, Payen J-F, Crippa IA, Taccone FS. Noninvasive vascular methods for detection of delayed cerebral ischemia after subarachnoid hemorrhage. J Clin Neurophysiol 2016; 33 (03) 260-267
• 3 Connolly Jr ES, Rabinstein AA, Carhuapoma JR. et al; American Heart Association Stroke Council, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Nursing, Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; 43 (06) 1711-1737
• 4 Dankbaar JW, Slooter AJ, Rinkel GJ, Schaaf IC. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care 2010; 14 (01) R23
• 5 Macdonald RL, Kassell NF, Mayer S. et al; CONSCIOUS-1 Investigators. Clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage (CONSCIOUS-1): randomized, double-blind, placebo-controlled phase 2 dose-finding trial. Stroke 2008; 39 (11) 3015-3021
• 6 Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988; 68 (06) 985-986
• 7 Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980; 6 (01) 1-9
• 8 Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry 1991; 54 (12) 1044-1054
• 9 Molyneux AJ, Kerr RSC, Birks J. et al; ISAT Collaborators. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009; 8 (05) 427-433
• 10 Crinnion W, Bhogal P, Makalanda HLD. et al. The Woven Endobridge as a treatment for acutely ruptured aneurysms: a review of the literature. Interv Neuroradiol 2021; 27 (05) 602-608
• 11 Goertz L, Liebig T, Siebert E. et al. WEB embolization of very broad-based intracranial aneurysms with a dome-to-neck ratio ≤ 1.1. Interv Neuroradiol 2022; x: 15 910199221125102
• 12 Paramasivam S, Leesch W, Fifi J, Ortiz R, Niimi Y, Berenstein A. Iatrogenic dissection during neurointerventional procedures: a retrospective analysis. J Neurointerv Surg 2012; 4 (05) 331-335
• 13 Jovin TG, Chamorro A, Cobo E. et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372 (24) 2296-2306
• 14 Groves AP, Kansagra AP, Cross III DT, Moran CJ, Derdeyn CP. Acute management and outcomes of iatrogenic dissections during cerebral angiography. J Neurointerv Surg 2017; 9 (05) 499-501
• 15 Ito H, Uchida M, Kawaguchi K. et al. Delayed iatrogenic dissection caused by a carotid stent: a case report. NMC Case Rep J 2021; 8 (01) 241-245