Surgical treatment of 50 carotid dissections: Indications and results

Purpose: This article analyzes the course of 48 patients with 49 chronic ca rotid dissections (who were treated surgically at our institution after a m edian anticoagulation period of 9 months because of a persistent high-grade stenosis or an aneurysm) and the course of one additional patient with acu te carotid dissection (who underwent early operative reconstruction 12 hour s after onset because of fluctuating neurologic symptoms). Methods: All medical and surgical records and imaging studies were reviewed retrospectively. All histologic specimens were reevaluated by a single pat hologist to assess the cause of dissection. Follow-up of 41 patients (85%) after 70 months (range, 1-190 months) consisted of an examination of the ex tracranial vessels in the neck by Doppler ultrasound scanning and a questio nnaire about the patients' medical history and their personal appraisals of cranial nerve function. Results: Seventy percent of the dissections had developed spontaneously; 18 % were caused by trauma; 12% of all patients (22% of the women) had a fibro muscular dysplasia. Indication for surgery was a high-grade persisting sten osis and a persisting or newly developed aneurysm. Flow restoration was ach ieved by resection and vein graft replacement in 40 cases (80%) and thrombo endarterectomy and patch angioplasty in three cases (6%). Gradual dilatatio n was performed and effective in two cases (4%). Five internal carotid arte ries (10%) had to be clipped because dissection extended into the skull bas e. One patient died of intracranial bleeding. Five patients (10%) experienc ed the development of a recurrent minor stroke (ipsilateral, 4 patients; co ntralateral, I patient). Cranial nerve damage could not be avoided in 29 ca ses (58%) but were transient in most of the cases. During follow-up, one pa tient died of unrelated reasons, and only one patient had experienced the d evelopment of a neurologic event of unknown cause. Conclusion: Chronic carotid dissection can be effectively treated by surgic al reconstruction to prevent further ischemic or thromboembolic complicatio ns, if medical treatment for 6 months with anticoagulation failed or if car otid aneurysms and/or high-grade carotid stenosis persisted or have newly d eveloped.