Elsevier

World Neurosurgery

Volume 109, January 2018, Pages 409-412
World Neurosurgery

Case Report
Advantages of Staged Angioplasty in a Patient with Internal Carotid Artery Pseudo-Occlusion Besides Prevention of Cerebral Hyperperfusion Syndrome

https://doi.org/10.1016/j.wneu.2017.10.096Get rights and content

Background

Staged angioplasty for carotid artery stenosis has been reported to be effective in preventing postoperative cerebral hyperperfusion syndrome (CHS) in patients with severe carotid stenosis; thus, it is also recommended for patients with internal carotid artery (ICA) pseudo-occlusion, the treatment strategy for which is controversial.

Case Description

This study reports the case of an Asian man in his 50s who had motor aphasia and right-side weakness caused by pseudo-occlusion of the left ICA. After medical treatment, he underwent a staged angioplasty. After the first stage of percutaneous transluminal angioplasty, anterograde blood flow to the left ICA increased but the distal ICA remained partially collapsed. Initially, the second stage of carotid artery stenting (CAS) was planned for 2 weeks after the first stage; however, hemorrhagic infarction was observed the day before the CAS, and it was postponed by 2 weeks, after adjustment of antiplatelet therapy. At the time of the CAS, the diameter of the initially collapsed left distal ICA was remodeled and it was fully dilated; thus, we used a balloon-type embolic protection device and conducted CAS successfully without apparent embolic complications. The postoperative course was uneventful. The patient did not develop CHS.

Conclusions

Besides preventing CHS, staged angioplasty has advantages when used for treating patients with ICA pseudo-occlusions in that the extent of dilation of the distal ICA after percutaneous transluminal angioplasty can be confirmed and the development of a possible hemorrhagic infarction can be assessed before stent placement.

Introduction

Staged angioplasty has been reported to be effective in preventing postoperative cerebral hyperperfusion syndrome (CHS) in patients with severe carotid artery stenosis1, 2; thus, it is also recommended in patients with internal carotid artery (ICA) pseudo-occlusion.

Here, we report on a patient with left ICA pseudo-occlusion that was successfully treated by staged angioplasty. Some previously unreported advantages of staged angioplasty in patients with acute ICA pseudo-occlusion are discussed.

Section snippets

Onset and Course

An Asian man in his 50s presented at the emergency room with the chief complaint of motor aphasia and severe motor weakness (manual muscle test score of 2/5) mainly in his right upper extremity. Magnetic resonance imaging showed a high-intensity area in his left frontal lobe on diffusion-weighted imaging–fluid-attenuated inversion recovery, suggesting acute cerebral infarction (Figure 1C and D). The time of symptom onset was unknown, and the patient could not be treated by intravenous injection

Discussion

Pseudo-occlusion of the ICA is characterized by an extremely narrow residual lumen and a collapsed distal portion induced by hypoperfusion.3 The treatment strategy for ICA pseudo-occlusion is controversial, and data from 2 major clinical trials (i.e., ECST [European Carotid Surgery Trial] and NASCET [North American Symptomatic Carotid Endarterectomy Trial]4) have shown that the rate of stroke among patients with pseudo-occlusion is not higher than that among patients with high-grade ICA

Conclusions

We treated a patient with progressing ICA pseudo-occlusion by means of a staged angioplasty. In the present case, besides preventing CHS, staged angioplasty allowed us to ensure full dilatation of the distal ICA before stent placement. Thus, we emphasize that staged angioplasty is advantageous in treating patients with ICA pseudo-occlusion because the extent of dilation of the distal ICA after PTA can be assessed before stent placement.

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There are more references available in the full text version of this article.

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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