Endovascular Approach in Patients with Acute Complete Occlusion Due to Middle Cerebral Artery Dissection

Objective : Dissection of the middle cerebral artery (MCA) is less common than dissection of vessels in the vertebrobasilar system or carotid artery. Acute complete occlusion related to MCA dissection is extremely rare. We report an endovascular approach in patients with acute complete occlusion due to MCA dissection. Methods : We reviewed retrospectively the endovascular procedure and clinical results for acute-stroke patients who underwent recanalization from October 2014 through December 2018. Initial imaging findings and the endovascular procedure were analyzed for patients with acute complete occlusion due to MCA dissection. Results : We undertook first-line aspiration thrombectomy using a Penumbra catheter in 294 patients with acute occlusion of the M1 segment. Of these patients, seven were confirmed to have acute complete occlusion due to MCA dissection. All patients had angiographic findings of an intimal flap at the proximal occlusion site of the MCA. One patient complained of severe headache during microcatheter passage through the occluded lesion and died due to massive bleeding caused by rupture of the false lumen. The remaining patients underwent initial contact aspiration thrombectomy without microcatheter passage. After aspiration thrombectomy, six patients had delayed flow through the MCA. One patient underwent stenting of the MCA because of progressive symptoms. Conclusion : An intimal flap at the proximal portion of an occluded MCA can suggest the possibility of MCA dissection. Contrast aspiration thrombectomy without microcatheter passage can reduce the risk of false lumen rupture in cases of MCA dissection.