LAUSR

To the Editor, We describe a patient who presented with spontaneous internal carotid artery (ICA) dissection complicated by a progressive pseudoaneurysm, definitively managed using a stent-graft. A 41-year-old male with untreated hypertension presented with a two-week history of headaches, expressive dysphasia, facial asymmetry, and tongue weakness. Plain CT did not demonstrate acute or established cerebral infarction. However, contrast-enhanced CT angiography (CTA) demonstrated extensive luminal narrowing and crescenteric mural soft tissue consistent with dissection in the upper cervical and petrous temporal ICA (Fig. 1A). No pseudoaneurysm or extravasation was seen at this stage. Aortic arch to Circle of Willis magnetic resonance angiography at four days confirmed the dissection flap (Fig. 1B), but also identified a 6 9 10 mm pseudoaneurysm located 2 cm distal to the carotid bulb (Fig. 1C, D). Following discussion between the tertiary centre neurology and vascular teams, it was agreed to continue blood pressure control with amlodipine 5 mg OD, antiplatelet therapy with aspirin 75 mg OD, and surveillance imaging. Four months later, CTA showed remodelling of the intracranial dissection but increase in the ICA pseudoaneurysm to 8 9 12 mm. Our vascular multi-disciplinary team recommended covered carotid stenting to exclude the pseudoaneurysm and prevent the risk of haemorrhage. The patient was consented, and the procedure undertaken 2 weeks later. Pre-operative clopidogrel loading dose (300 mg) was given. Under local anaesthetic, via femoral endovascular access, selective catheterisation of the left common carotid artery was performed using a 5 French Sidewinder catheter (SIM1 Tempo, Cordis , Buckinghamshire, the UK) with angiography confirming the left proximal ICA pseudoaneurysm, measuring 9 9 17 mm. 5000 units IV heparin was given. Through a 6 French long sheath (Flexor Ansel, Cook Medical, Bloomington, the USA), the pseudoaneurysm was then crossed using a 5 French Headhunter catheter (Tempo Cordis , Cardinal Health, Buckinghamshire, the UK) and 0.035 Advantage glidewire (Terumo UK Ltd). A 6 9 38 mm balloon-mounted stent-graft (JOTEC E-ventus BX, Hechingen, Germany) was deployed to successfully exclude the pseudoaneurysm and maintain good forward flow into the distal ICA and Circle of Willis (Fig. 2). There were no peri-procedural complications, and he was discharged after 24 h with aspirin 75 mg OD and clopidogrel 75 mg OD for three months. At four weeks follow-up, the patient had no neurological sequelae or procedural complications. CTA at 2 months showed no evidence of pseudoaneurysm re-filling, with good flow through the stent-graft. He was maintained on amlodipine and clopidogrel. Whilst there is no consensus on management of spontaneous dissection-related carotid pseudoaneurysm, endovascular strategies are growing in popularity [1]. Treatments include uncovered stenting with coil packing of the pseudoaneurysm [2], and stent-graft deployment across the lesion [3, 4]. & Simon Arian Zakeri [email protected]