Improved cerebral perfusion after stenting of a petrous carotid stenosis: Technical case report

OBJECTIVE AND IMPORTANCE: Atherosclerotic occlusive disease of the intracra nial vasculature is associated with increased risk of systemic vascular occ lusive disease and stroke. Therapeutic options have included anticoagulatio n therapy, antiplatelet therapy, or, in a limited number of patients, extra cranial-intracranial vascular bypass procedure. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after e ndovascular stenting of a severe petrous segment carotid stenosis. CLINICAL PRESENTATION: A 73-year-old man with severe coronary artery diseas e and unstable angina was referred for treatment of a 90% right petrous car otid artery stenosis before coronary artery bypass grafting. A brain single -photon emission computed tomographic scan using Tc-99m-bicisate revealed d iminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones. TECHNIQUE: The patient underwent transfemoral placement of a 7-French intro ducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No chang es were noted in lesion morphology after this infusion. A microguidewire wa s navigated across the lesion. Subsequent balloon angioplasty with a corona ry artery balloon was performed twice, followed by placement of a 4- x 12-m m coronary stent. CONCLUSION: Selective internal carotid artery angiography after stenting re vealed markedly improved flow. A brain Tc-99m-bicisate single-photon emissi on computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were no ted; both were clinically silent. The patient had uncomplicated coronary ar tery bypass grafting 72 hours later. Five months postoperatively, he remain s at home, living independently and with intact neurological function. Intr acranial stenting for severe atherosclerotic stenosis is technically possib le. However, its ultimate clinical role remains to be determined.