11/28/2023
50s y.o. male presents with a past medical history of hypertension. Patient reportedly woke normal around 5:30 AM. He describes while taking a shower around 6 AM, he noticed that he had some right eye blurriness. This was followed by left arm and leg weakness closing to feel off balance as well as feeling clumsier on the left side. He denies any recent head or neck trauma or pain/injury to the neck. (Although in retrospect, he later described regular chiropractic therapy). Initially drove himself to Urgent Care, but then realized he was getting worse, pulled over and called 911.
He presented as a code stroke and initial NIH was 4 with SBP in 190s. CT head did not reveal any evidence of acute ischemic changes or bleed and patient subsequently received Tenecteplase after blood pressure was controlled. CT perfusion was performed which showed a right holo-hemispheric mismatch. CTA demonstrated non-occlusive right distal cervical-petrous dissection with patent flow through the skull into the brain, albeit delayed. Initial plan was close post-thrombolytic monitoring, hemodynamic therapy, and no immediate Neuroendovascular neurointervention (low NIHSS, patent flow, No LVO). (Approx 9-10 AM)
At around 2pm, his exam worsened from an NIHSS of 4 to 18 (1 for commands, 2 for gaze, 4 for LUE, 4 for LLE, 1 for speech, 2 for face) for which a Code NI was re-activated. His dissection had progressed to complete occlusion (with orbital ECA collaterals to the cavernous ICA). Aspiration was non-productive. After extensive exploration to find the “True” Lumen with a Microcatheter, 2 Enterprise Stents were deployed from “normal to normal” vessel, restoring brisk ICA blood flow and “tacking” of the dissection flap (TICI 3 intracranial).
POD 1 – MRI demonstrates small distal right frontal punctate abnormalities, while CTP returned to normal. CTA reveals wide patency of the stented segments, and by POD 4, his NIHSS reduced to 2, ready for Discharge Home.
Learning points: Dissections often can be managed effectively with medical therapy (anti-platelets or anti-coagulation), however, they can occasionally rapidly progress to occlusion and profound ischemic syndromes. Emergent Neurointervention and Stenting may be considered early or at the first signs of neurologic decline with excellent results, and close neurologic monitoring should be performed in ALL patients.
