Ishigami Daiichiro, Ota Takahiro
Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan.
NMC Case Rep J. 2019 May 25;6(3):71-74. doi: 10.2176/nmccrj.cr.2018-0257. eCollection 2019 Aug.
Spontaneous cervical internal carotid artery dissection (CICAD) is occasionally treated with conservative management, mainly using antithrombotics. However, we have to consider emergency interventions for bilateral CICAD occurring simultaneously and accompanied by progressive cerebral ischemia. A 46-year-old woman was brought to our hospital with a complaint of left-handed clumsiness, blurred vision in the left eye, and right hemiplegia. Acute cerebral infarction in bilateral cerebral hemispheres was evident on brain magnetic resonance imaging. Bilateral internal carotid arteries were barely visible on time-of-flight magnetic resonance angiography. Subsequent cerebral angiography demonstrated that cervical internal carotid arteries on both sides were tapered off immediately after the bifurcations, indicating CICAD. Despite management with intravenous antithrombotic agents and hydration, neurological status gradually deteriorated. After insertion of a transvenous temporary pacemaker, we performed simultaneous bilateral carotid artery stenting (sbCAS) 3 days after admission. The patient first suffered slight right-sided hemiplegia and hoarseness, but symptoms resolved after rehabilitation, and modified Rankin Scale was 0 as of 2 years after the procedure. Bilateral CICAD causes severe insufficiency of cerebral blood flow, and symptoms often persist even after administration of antithrombotic agents. In such refractory cases, early intervention should be considered, and sbCAS can be safely performed. During the procedure, a transvenous temporary pacemaker maintains hemodynamic stability and might be a favorable option.
自发性颈内动脉夹层（CICAD）偶尔采用保守治疗，主要使用抗栓药物。然而，对于同时发生且伴有进行性脑缺血的双侧CICAD，我们必须考虑紧急干预措施。一名46岁女性因左手笨拙、左眼视力模糊和右侧偏瘫被送至我院。脑磁共振成像显示双侧大脑半球急性脑梗死。在时间飞跃磁共振血管造影上双侧颈内动脉几乎不可见。随后的脑血管造影显示双侧颈内动脉在分叉后立即变细，提示CICAD。尽管给予静脉抗栓药物和补液治疗，神经功能状态仍逐渐恶化。入院3天后，在植入经静脉临时起搏器后，我们进行了同期双侧颈动脉支架置入术（sbCAS）。患者最初出现轻微右侧偏瘫和声音嘶哑，但经康复治疗后症状缓解，术后2年改良Rankin量表评分为0分。双侧CICAD导致严重的脑血流不足，即使给予抗栓药物治疗，症状往往仍会持续。在这种难治性病例中，应考虑早期干预，并且可以安全地进行sbCAS。在手术过程中，经静脉临时起搏器可维持血流动力学稳定，可能是一个不错的选择。
