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Jang, Kim, Lee, Choi, Yoon, and Park: Carotid Artery Stenting in Patients with Critical Stenosis of Proximal Internal Carotid Artery and Large Distal Arterial Thrombus: 2 Case Reports
Head and Neck Radiology

Journal of the Korean Society of Radiology 2013; 69(6): 427-431.

Published online: 5 December 2013

DOI: https://doi.org/10.3348/jksr.2013.69.6.427

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

Ji Hye Jang, MD1, 2, Eui Jong Kim, MD2, Kyung Mi Lee, MD2, Woo Suk Choi, MD2, Sung-Sang Yoon, MD3, Key Jung Park, MD3

1Department of Radiology, Kyung Hee University College of Medicine, Seoul, Korea.

2Department of Radiology, Kyung Hee University Hospital, Seoul, Korea.

3Department of Neurology, Kyung Hee University Hospital, Seoul, Korea.

Corresponding author: Eui Jong Kim, MD. Department of Radiology, Kyung Hee University Hospital, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-702, Korea. Tel. 82-2-958-8611, Fax. 82-2-968-0787, euijkim@hanmail.net

Received 18 July 2013       Accepted 2 September 2013

Copyright © 2013 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Carotid Artery Stenting, Tandem Lesion

Figures and Tables

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
jksr-69-427-g001
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
jksr-69-427-g002

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