Urgent carotid stenting before cardiac surgery in a young male patient with acute ischemic stroke caused by aortic and carotid dissection

Rade Popovic; Sonja Radovinović-Tasić; Siniša Rusović; Toplica Lepić; Radoje Ilić; Ranko Raičević; Dragana Obradović

doi:10.2298/VSP150402091P

Rade Popovic Clinic for Neurology, Military Medical Academy, Belgrade, Serbia
Sonja Radovinović-Tasić Institute for Radiology, Military Medical Academy, Belgrade, Serbia
Siniša Rusović Institute for Radiology, Military Medical Academy, Belgrade, Serbia
Toplica Lepić Clinic for Neurology, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Radoje Ilić Clinic for Cardiosurgery, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Ranko Raičević Clinic for Neurology, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia
Dragana Obradović Clinic for Neurology, Military Medical Academy, Belgrade, Serbia; Faculty of Medicine of the Military Medical Academy, University of Defence, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP150402091P

Keywords: aorta, carotid artery, internal, dissection, stroke, cardiovascular surgical procedures, stents, young adults, treatment outcome,

Abstract

Introduction. Acute aortic dissection (AD) is the most common life-threatening disorder affecting the aorta. Neurological symptoms are present in 17–40% of cases. The management of these patients is controversial. Case report. We presented a 37-year-old man admitted for complaining of left-sided weakness. Symptoms appeared two hours before admission. The patient had no headache, neither thoracic pain. Neurological examination showed mild confusion, left-sided hemiplegia, National Institutes of Health Stroke Scale (NIHSS) score was 10. Ischemic stroke was suspected, brain multislice computed tomography (MSCT) and angiography were performed and right intrapetrous internal carotid artery dissection noted. Subsequent color Doppler ultrasound of the carotid arteries showed dissection of the right common carotid artery (CCA). The patient underwent thoracic and abdominal MSCT aortography which showed ascending aortic dissection from the aortic root, propagating in the brachiocephalic artery and the right CCA. Digital subtraction angiography was performed subsequently and two stents were successfully implanted in the brachiocephalic artery and the right CCA prior to cardiac surgery, only 6 hours after admission. The ascending aorta was reconstructed with graft interposition and the aortic valve resuspended. The patient was hemodynamically stable and with no neurologic deficit after surgery. Unfortinately, at the operative day 6, mediastinitis developed and after intensive treatment the patients died 35 days after admission. Conclusion. In young patients with suspected stroke and oscillatory neurological impairment urgent MSCT angiography of the brain and neck and/or Doppler sonography of the carotid and vertebral artery are mandatory to exclude carotid and aortic dissection. The prompt diagnosis permits urgent carotid stenting and cardiosurgery. To the best of our knowledge, this is the first published case of immediate carotid stenting in acute ischemic stroke after the diagnosis of carotid and aortic dissection and prior to cardiac surgery.

References

Braverman AC. Aortic dissection: prompt diagnosis and emer-gency treatment are critical. Cleve Clin J Med 2011; 78(10): 685−96.

Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ. Neurological symptoms in type A aortic dissections. Stroke 2007; 38(2): 292−7.

Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2013; 44(3): 870−947.

Patel RR, Adam R, Maldjian C, Lincoln CM, Yuen A, Arneja A. Cervical carotid artery dissection: current review of diagnosis and treatment. Cardiol Rev 2012; 20(3): 145−52.

Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Egge-brecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).Eur Heart J 2014; 35(41): 2873−926.

Lentini S, Tancredi F, Benedetto F, Gaeta R. Type A aortic dissection involving the carotid arteries: carotid stenting during open aortic arch surgery. Interact Cardiovasc Thorac Surg 2009; 8(1): 157−9.

Roseborough GS, Murphy KP, Barker PB, Sussman M. Correction of symptomatic cerebral malperfusion due to acute type I aor-tic dissection by transcarotid stenting of the innominate and carotid arteries. J Vasc Surg 2006; 44(5): 1091−6.

Cardaioli P, Rigatelli G, Giordan M, Faggian G, Chinaglia M, Roncon L. Multiple carotid stenting for extended thoracic aorta dissection after initial aortic surgical repair. Cardiovasc Revasc Med 2007; 8(3): 213−5.

Munakata H, Okada K, Kano H, Izumi S, Hino Y, Matsumori M, et al. Controlled earlier reperfusion for brain ischemia caused by acute type A aortic dissection. Ann Thorac Surg 2009; 87(4): 27−8.

Micovic S, Nezic D, Vukovic P, Jovanovic M, Lozuk B, Jagodic S, et al. Concomitant Reconstruction of Arch Vessels during Repair of Aortic Dissection. Tex Heart Inst J 2014; 41(4): 421−4.

Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Mehta RH, et al. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg 2005; 129(1): 112−22.

Braverman AC. Acute aortic dissection: clinician update. Circulation 2010; 122(2): 184−8.

Criado FJ. Aortic dissection: a 250-year perspective. Tex Heart Inst J 2011; 38(6): 694−700.

Harris KM, Strauss CE, Eagle KA, Hirsch AT, Isselbacher EM, Tsai TT, et al. Correlates of delayed recognition and treatment of acute type A aortic dissection: the International Registry of Acute Aortic Dissection (IRAD). Circulation 2011; 124(18): 1911−8.