Staged endovascular reconstruction of complex traumatic intracranial carotid artery dissection

A 32-year-old-woman presented with traumatic facial injuries from a horseback riding incident. She was found to have a Glasgow Coma Score of 3T, left eyelid ptosis with a fixed-dilated pupil and a flaccid right upper extremity. CT angiogram of the head showed complex craniofacial injuries, including a transverse fracture transecting the clivus and the left petrous temporal bone, with SAH in the suprasellar cistern. There was a bilateral engorgement of the superior ophthalmic veins, suggestive of bilateral CCF formations. Digital subtraction angiography (DSA) showed a left petrocavernous internal carotid artery dissection (ICAD). MRI of the brain demonstrated multiple embolic infarcts in the left middle cerebral artery (MCA) territory, despite therapeutic anticoagulation with heparin. Follow-up DSA 1 week later showed bilateral multifocal internal carotid artery (ICA) and vertebral artery dissections, bilateral direct CCFs and cavernous ICA PAs. Because of progressing morphological distortion (figure 1), a flexible LVIS Jr. stent was placed at the anterior genu of the left cavernous ICA to provide a scaffold for the more rigid 3.5×20.0 mm self-expanding Wingspan stent (petrous ICA to distal cavernous ICA), covering the neck of the PA followed by its coil embolisation. Five days after coiling, a 5 mm residual sac was noted in the PA with extension of the left ICAD up to the ICA terminus (figure 2). The latter was treated with another 3.5×23.0 mm LVIS Jr. stent (from left the M1 MCA up to the dural junction of the left ICA). Eleven days after coiling, the PA had increased up to 15×14 mm and was treated with three PED …