Potential hemorrhagic risk of endovascular revascularization therapy due to recanalization of the dissected perforator in intracranial internal carotid artery dissection: A case report

Abstract

Background: Intracranial internal carotid artery (ICA) dissection manifesting as ischemic stroke is rare. Although endovascular revascularization therapy is effective in preventing the progression of stroke, little is known about the potential risk of this therapeutic approach.

Case description: We report a case of a 38-year-old woman who presented with acute ischemic infarcts in the territory of the left anterior choroidal artery (AChA) due to intracranial ICA dissection. She underwent balloon angioplasty, resulting in the complete resolution of the stenosis. The AChA, which was nearly occluded preoperatively, was unexpectedly recanalized after the procedure. Four hours later, she developed a parenchymal hemorrhage in the left basal ganglia without subarachnoid hemorrhage. The AChA, suspected as the hemorrhagic source during surgical hematoma removal, was revealed to have a disrupted internal elastic lamina on pathological examination, suggesting that the dissection of the ICA extended to the AChA.

Conclusion: To the best of our knowledge, this is the first case report demonstrating that the intracranial ICA dissection extends to the associated perforator. Considering the potential risk of subsequent hemorrhagic complications by recanalization of the dissected perforator, prudent postoperative management, including strict blood pressure control, is advisable following endovascular revascularization therapy against intracranial artery dissection involving perforators.

Keywords: Dissected perforator; Endovascular therapy; Hemorrhagic complication; Intracranial internal carotid artery dissection.

Figure 1:

Initial diffusion-weighted magnetic resonance imaging showing acute ischemic infarcts in the territory of the left anterior choroidal artery.

Figure 2:

(a) Preoperative angiography revealing irregular stenosis of the left supraclinoid internal carotid artery (ICA). (b) Cone-beam computed tomography demonstrating the intimal flap at the lesion site. (c) Preoperative working angle. Note that the anterior choroidal artery (AChA) is nearly occluded (arrow). (d) Balloon angioplasty performed. (e) Postoperative working angle showing the resolution of the ICA stenosis and the complete recanalization of AChA (arrow).

Figure 3:

(a and b) Computed tomography obtained after patient deterioration, showing the intraparenchymal hemorrhage in the left basal ganglia without any evidence of subarachnoid hemorrhage. (c and d) Pathological examination of the resected anterior choroidal artery by hematoxylin and eosin staining (c) and elastic Masson staining (d). Note that the internal elastic lamina is disrupted and the red blood cells are present in the subintimal planes (arrowhead).