Spontaneous Bilateral Cervical Internal Carotid Artery Dissection Treated with Simultaneous Bilateral Carotid Artery Stenting: A Case Report

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.