In the setting of an acute stroke caused by arterial dissection, navigating a microcatheter and microguidewire past the dissected artery to gain access to the distal thromboembolic lesion may exacerbate the underlying pathology. We review a case report whereby successful recanalization of an acute carotid terminus occlusion due tointimal-media dissection in the cervical carotid artery was achieved using aggressive proximal guide catheter aspiration in conjunction with flow arrest from the carotid bulbproximal to the dissection. We discuss the strengths and limitations of this approach andunderscore the importance of a pathology-based approach to acute stroke therapy

Michael Chen

Frontiers in Neurology

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Mechanical Recanalization of Acute Carotid Terminus Occlusion from Traumatic Arterial Dissection

www.frontiersin.org November 2010 | Volume 1 | Article 123 | 1
Methods Article
published: 04 November 2010
doi: 10.3389/fneur.2010.00123
Mechanical recanalization of acute carotid terminus occlusion 
from traumatic arterial dissection
Michael Chen*
Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
In the setting of an acute stroke caused by arterial dissection, navigating a microcatheter 
and microguidewire past the dissected artery to gain access to the distal thromboembolic 
lesion may exacerbate the underlying pathology. We review a case report whereby successful 
recanalization of an acute carotid terminus occlusion due to intimal-media dissection in the 
cervical carotid artery emphasizing the importance of aggressive proximal guide catheter 
aspiration in conjunction with flow arrest from the carotid bulb proximal to the dissection. We 
discuss the strengths and limitations of this approach and underscore the importance of a 
pathology-based approach to acute stroke therapy.
Keywords: acute stroke, carotid terminus occlusion, aspiration, arterial dissection
Edited by:
Osama O. Zaidat, Medical College of 
Wisconsin and Froedtert Hospital, USA
Reviewed by:
Osama O. Zaidat, Medical College of 
Wisconsin and Froedtert Hospital, USA
Aamir Badruddin, Medical College of 
Wisconsin, USA
Thanh Nguyen, Boston Medical Center, 
USA
Jose R. Romero, Boston University, 
USA
*Correspondence:
Michael Chen, Department of 
Neurological Sciences, Rush University 
Medical Center, 1725 West Harrison 
Street, Suite 1121, Chicago, IL 60612, 
USA.
e-mail: michael_chen@rush.edu
tion flap at the distal cervical carotid artery (Figure 3). Subsequent 
angiography showed a more proximal occlusive lesion, suggesting 
that the intimal flap had extended into the petrous carotid with 
further compromise of the luminal diameter (Figure 4).
Using a Merci 8F balloon guide catheter (Concentric Medical, 
Mountain View, CA, USA), a Merci 18L (Concentric Medical, 
Mountain View, CA, USA) microcatheter was advanced over a 
microguidewire into the M1 segment. Using standard technique, 
with a pull lasting 2–3 min, an L6 Merci retrieval device (Concentric 
Medical, Mountain View, CA, USA) retrieved some clot but only 
TIMI 1 anterograde flow was achieved. The microcatheter was again 
advanced up into the M1 segment, a L5 Merci retriever (Concentric 
Medical, Mountain View, CA, USA) deployed, the balloon inflated, 
and this time, more aggressive proximal aspiration was performed 
using a 60-cc syringe. The retriever was visualized under fluoroscopy 
not to deform its shape during the entire withdrawal, which again 
lasted only about 1 min, suggesting little or no clot was engaged 
or retrieved. No clot was visualized on the retriever upon removal. 
Subsequent angiographic runs, however, demonstrated TIMI 3 reca-
nalization of the internal carotid artery with a persisting but non-oc-
clusive intimal flap along the petrous/cervical section (Figure 5).
Once flow was restored, we decided against placing a stent into 
the cervical and petrous sections of the carotid artery. The patient 
had already received 0.9 mg/kg of intravenous t-PA hours before. 
We felt that he would have an unacceptably high risk of hemor-
rhagic transformation by adding the loading dose of abciximab 
as a prerequisite for stent placement. Anticoagulation was started 
24 h after his dose of intravenous t-PA.
MRI and MRA of the head and neck was done the following day, 
showing a stable appearance to the dissection and a right superior 
division MCA territory stroke (Figure 6). He was discharged from 
the hospital 5 days later with an NIHSS of 1. Six weeks later, his 
IntroductIon
Arterial dissection is the second leading cause of stroke in patients 
younger than age 45 (Lisovoski and Rousseaux, 1991). Current 
endovascular recanalization approaches for acute stroke focus on 
either removal of the distal clot using either a retrieval device or aspi-
ration, or displacement via angioplasty and/or self-expanding stent. 
This approach is problematic in the setting of cervical carotid or verte-
bral dissection because microcatheter and microguidewire navigation 
across the dissection has the potential to enlarge the false lumen. We 
present a case of an acute carotid terminus occlusion caused by clot 
from a cervical carotid dissection initially worsened by attempts at 
gaining microcatheter access to the distal clot. However, with proximal 
flow arrest and primary aggressive proximal guide catheter aspiration, 
we were able to successfully recanalize the internal carotid artery and 
its branches, leading to a better than expected clinical outcome.
case report
A 34-year-old man was driving a car when he was hit by another 
car causing the vehicle to spin completely around. He walked away 
from the accident with neck discomfort but no neurologic deficits. 
A week later, he developed sudden onset complete left arm weakness 
and global aphasia. Intravenous thrombolytics were given, and he 
was transferred to our hospital with a National Institute of Health 
Stroke Scale score of 16.
Initial cervical carotid catheter angiography revealed a right 
posterior cervical carotid intimal flap indicating an intimal-me-
dia arterial dissection (Figure 1). Cerebral views showed delayed 
anterograde filling in the internal carotid artery associated with 
a carotid terminus occlusion (Figure 2). Attempts at advancing 
a Penumbra 41 reperfusion catheter (Penumbra Inc, Alameda, 
CA, USA) intracranially were unsuccessful because the edge of 
the reperfusion catheter could not be advanced past the dissec-
Frontiers in Neurology | Endovascular and Interventional Neurology  November 2010 | Volume 1 | Article 123 | 2
Chen Acute recanalization from arterial dissection
NIHSS score remained 1 with slight word finding difficulties and 
MRA showed persistence of the right cervical/petrous  dissection. 
He was maintained on anticoagulation for 6 months and on 
12 month followup, his NIHSS score was 0 and he was back to 
work in construction.
Figure 1 | right lateral common carotid digital subtraction angiography 
cervical view showing an intimal flap and smooth tapered cervical 
carotid dissection extending up to the cervical/petrous junction.
Figure 2 | right lateral common carotid digital subtraction angiography 
cerebral view showing markedly delayed anterograde flow in the internal 
carotid artery with a supraclinoid occlusion and flow defects in petrous 
and cavernous section of carotid artery.
Figure 3 | right lateral common carotid digital subtraction angiography 
cervical view showing microguidewire in the dissected segment of 
cervical carotid artery, worsening the underlying pathology.
Figure 4 | right lateral common carotid digital subtraction angiography 
cerebral view showing a near occlusive intimal flap at the cervical 
petrous section.
dIscussIon
In patients younger than age 45, arterial dissection is a leading 
cause of stroke (Lisovoski and Rousseaux, 1991; Schievink et al., 
1994). Carotid artery intimal tears leading to dissection usually 
occur a few centimeters distal to the carotid bulb, at the C2–C3 
level, and the dissection usually extends distally until the carotid 
artery enters the foramen lacerum. The typical angiographic find-
ing is a relatively smooth or slightly irregular tapered mid-cervical 
narrowing (Provenzale, 1995). Carotid subintimal dissections 
are dynamic lesions, and depending on the size, can cause just 
minor luminal narrowing, or complete occlusion. As a result, 
symptoms are variable and can range from cranial nerve com-
promise, to a Horner’s syndrome, to ischemia in vascular terri-
tories distal to the lesion. Most ischemic symptoms occur within 
www.frontiersin.org November 2010 | Volume 1 | Article 123 | 3
Chen Acute recanalization from arterial dissection
ing biplane angiographic imaging. With an occlusive distal clot, 
roadmap imaging is often of poor image quality because arterial 
washout is delayed. Furthermore, in the acute phase, anterograde 
blood flow is steadily applying a force underneath the intimal flap, 
predisposing it to worsen. With conscious sedation rather than 
general anesthesia being more commonly used, patient movement 
during the procedure is not only to be expected, but adds additional 
challenge to not only discerning the false from the true lumen, 
but also navigating a microcatheter past the lesion (Abou-Chebl 
et al., 2010).
Pharmacologic, intra-arterial thrombolysis may also be prob-
lematic in the setting of acute stroke caused by arterial dissection. 
Published small case series of intra-arterial thrombolysis for acute 
stroke due to arterial dissection have not shown significant rates of 
rupture of dissected vessels, cervical or subarachnoid hemorrhage, 
intracranial hemorrhage, or peri-interventional arterial embolism 
(Arnold et al., 2000). However, chemical thrombolytics such as 
urokinase or t-PA carry the theoretical risk of extending the arterial 
wall hematoma, independent of the microcatheter inadvertently 
widening the false lumen.
Another approach to this complicated scenario is to treat 
and stabilize the cervical carotid or vertebral dissection first, 
thereby facilitating access to the distal intracranial thromboem-
bolus. Several reports have described cervical carotid angioplasty 
and stent placement as treatment option for arterial dissection 
(Abboud et al., 2005). This approach may have a role in not only 
acute recanalization, but also for secondary stroke prevention, 
permitting immediate and durable recanalization of the artery 
but associated with use of dual antiplatelet therapy instead of 
anticoagulation. A few technical drawbacks exist. First, the pas-
sage of a wire or embolic protection device and stent delivery 
catheter past the dissection may, again, widen the false lumen. 
Secondly, distal embolic protection devices may not be as eas-
ily used as the dissected segment often extends to the cervical/
petrous section. Another concern for stent placement in a dis-
sected artery is the weakened structural integrity of the vessel 
wall, unlike that of an atherosclerotic vessel wall, which is the 
pathology for which this device is designed to treat. The vessel 
may be undergo additional injury with either balloon angioplasty 
and/or stent placement. Lastly, dissected segments, unlike athero-
sclerotic lesions for which currently available stents are designed 
for, are often much longer, and difficult to accurately determine 
the proximal and distal margins. Accurately reopposing the stent 
along the entire dissected segment may require multiple over-
lapping stents.
Proximal aspiration through an 8F guiding catheter has been 
previously described in case reports to treat carotid bulb occlusion 
(Xu et al., 2005). Technical feasibility was demonstrated with a 
50-cc syringe with good clinical and angiographic results. However, 
without a proximal balloon and the ability to induce flow arrest, 
they were limited in their ability to mechanically disrupt the clot 
for fear of distal emboli. In both cases however, pretreatment angi-
ography suggested a significant clot burden that was amenable to 
aggressive proximal aspiration.
The concept behind proximal flow control to support 
retrieval of thrombus was published prior to the release of the 
Merci Retrieval system in 2004. It was based on the concept 
1 week of the onset of pain, as was the time course in this patient 
(Biousse et al., 1995). Most infarctions are territorial, rather than 
borderzone, indicating an embolic rather than hemodynamic eti-
ology (Provenzale, 1995).
Increasing familiarity with endovascular revascularization 
devices allows us to tailor our approach based on our attempts at 
understanding stroke pathophysiology. Mechanical revasculariza-
tion of severe carotid dissections using microcatheters and wires 
may worsen the underlying pathology. Dissections are delicate, 
dynamic lesions that are not easily navigated around using exist-
Figure 5 | After proximal flow arrest and aggressive proximal guiding 
catheter aspiration, TiMi 3 flow in the internal carotid is restored. The 
dissection is now seen to extend into the petrous section, but is not flow 
limiting.
Figure 6 | Diffusion weighted Mri at 24 hours showing increased signal 
in a superior division middle cerebral artery branch territory.
Frontiers in Neurology | Endovascular and Interventional Neurology  November 2010 | Volume 1 | Article 123 | 4
Chen Acute recanalization from arterial dissection
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Conflict of Interest Statement: The 
author declares that the research was 
conducted in the absence of any com-
mercial or financial relationships that 
could be construed as a potential conflict 
of interest.
Received: 25 June 2010; paper pending pub-
lished: 08 October 2010; accepted: 08 October 
2010; published online: 04 November 2010.
Citation: Chen M (2010) Mechanical reca-
nalization of acute carotid terminus occlu-
sion from traumatic arterial dissection. Front. 
Neur. 1:123. doi: 10.3389/fneur.2010.00123
This article was submitted to Frontiers in 
Endovascular and Interventional Neurology, 
a specialty of Frontiers in Neurology.
Copyright © 2010 Chen. This is an open-
access article subject to an exclusive license 
agreement between the authors and the 
Frontiers Research Foundation, which 
permits unrestricted use, distribution, and 
reproduction in any medium, provided the 
original authors and source are credited.
that anterograde flow maintained the clot in place like a cork, 
and reducing this force would then facilitate its removal (Mayer 
et al., 2002).
In our case, precious time was spent gaining access and attempting 
to retrieve the distal clot with microcatheters and wires. Furthermore, 
at one point, the dissection was worsened as a result of these 
maneuvers. We were most successful with recanalization when we 
applied proximal flow arrest followed by aggressive proximal aspi-
ration through the 8F guide catheter situated below the dissection. 
Fortunately, placing the end of the guide catheter at the level of the 
carotid bulb appears safe as most carotid dissections occur just distal 
to the bulb. Proximal flow arrest with proximal aspiration appears to 
be a safe and effective adjunctive technique for these lesions. Some 
may argue that aspiration alone may have accounted for the reca-
nalization. As such, the dissection is not mechanically disturbed by 
attempts at advancing a microcatheter past it. Furthermore, flow 
reversal is associated with a retrograde force on the intimal flap that 
may facilitate re-apposition of the normal arterial layers.
An analogous situation occurs with an occlusive lesion that 
extends from the distal cervical carotid to the supraclinoid carotid 
with intact interhemispheric flow via the anterior communicating 
artery. Again, passing any type of device through or within the dis-
tal aspect of the clot runs the risk of compromising the functioning 
circle of Willis collaterals. A proximal-to-the-clot approach may 
have an advantage of preserving the circle of Willis collaterals.
conclusIon
The use of acute endovascular stroke therapy for a large artery 
ischemic stroke secondary to arterial dissections involves unique 
modifications to the conventional procedural protocol. This case 
review highlights the importance of careful navigation of any 
microcatheters, wires, and devices across the arterial dissection, as 
well as the potential utility of aggressive aspiration via a large bore 
guiding catheter proximal to the dissection.
Ethics Approval Statement: This study was approved by Rush 
University Medical Center, Chicago, IL, USA, IRB#07110702.


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Mechanical Recanalization of Acute Carotid Terminus Occlusion from Traumatic Arterial Dissection

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