• Users Online: 75
  • Print this page
  • Email this page

 Table of Contents  
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 106-108

Post-Operative ischaemic stroke as a sequelae of unnoticed small internal carotid artery intimal flap

Department of Neurosurgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi, India

Date of Submission09-Jan-2022
Date of Decision14-Jan-2022
Date of Acceptance14-Jan-2022
Date of Web Publication5-Apr-2022

Correspondence Address:
Dr. Amit Kumar Sharma
Department of Neurosurgery, Govind Ballabh Pant Institute of Medical Education and Research, New Delhi
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvs.jcvs_5_22

Rights and Permissions

The risk of stroke associated with aneurysm coiling can occur as a result of thromboembolic complications. The iatrogenic internal carotid artery (ICA) dissection can also lead to ischemic stroke. A 42-year-old patient was diagnosed with a left ICA paraclinoid aneurysm. The endovascular coil embolisation was done. The aneurysm was completely obliterated with preservation of parent artery and distal flow. In the post-operative period, the patient developed a left middle cerebral artery territory infarct. The patient underwent decompressive hemicraniectomy and check data structures and algorithms (DSA) showed ICA dissection with no distal flow. The retrospective examination of earlier DSA revealed a suspected small intimal flap which later progressed to complete dissection and resulted in the infarct. We are reporting this case intending to emphasize careful examination of angiogram and findings suggestive of even a small intimal flap of ICA must not be overlooked. It might progress to frank dissection, stenosis of ICA and even fatal ischaemic stroke.

Keywords: Aneurysm, coiling, internal carotid artery dissection, intimal flap, ischemic stroke

How to cite this article:
Sharma AK, Jagetia A, Srivastava AK, Singh D. Post-Operative ischaemic stroke as a sequelae of unnoticed small internal carotid artery intimal flap. J Cerebrovasc Sci 2021;9:106-8

How to cite this URL:
Sharma AK, Jagetia A, Srivastava AK, Singh D. Post-Operative ischaemic stroke as a sequelae of unnoticed small internal carotid artery intimal flap. J Cerebrovasc Sci [serial online] 2021 [cited 2022 May 23];9:106-8. Available from: http://www.jcvs.com/text.asp?2021/9/2/106/342563

  Introduction Top

Stroke commonly occurs as a result of thromboembolic phenomenon following the coiling of an intracranial aneurysm. Internal carotid artery dissection (ICAD) is a relatively rare cause of stroke. A small intimal flap can be a precursor to artery dissection and, if left unnoticed, can be fatal. We present a case of a concealed intimal flap that was diagnosed late after the infarct was developed following coiling of the paraclinoid aneurysm and address the diagnostic and management pitfalls associated with this case.

  Case Report Top

A 42-years-old female presented with intermittent headaches for 3–4 years and diminution of vision in the left eye for 1 month. Neurologic examination revealed a perception of hand movements in the left eye with optic atrophy. The systemic examination and routine investigations, including echocardiography, neck vessels Doppler, were normal. Magnetic resonance and angiography brain revealed a large saccular aneurysm measuring approximately 18 mm × 13 mm × 14 mm from the left paraclinoid internal carotid artery (ICA), causing the compression of the left optic nerve and optic chiasma, which were displaced superiorly [Figure 1]a and [Figure 1]b. Digital subtraction angiography of the brain revealed a large saccular aneurysm arising from left paraclinoid ICA, 2.3 cm × 1.6 cm × 1.8 cm directed superiorly and medially. The patient underwent coiling of the aneurysm using five coils. Post-coiling data structures and algorithms (DSA) showed normal distal flow and no filling of aneurysm [Figure 2]a and [Figure 2]b. Post-operatively, she was obeying simple commands and moving all limbs left more than right. Computed tomography (CT) of the head was done as some embolic complication was suspected, which did not reveal any infarct. The patient was given an extradose of heparin and was kept under observation. A repeat CT head after 6–8 h of the procedure showed a well-defined infarct in the left ICA territory. The patient showed signs matching CT findings, i.e., right hemiparesis and aphasia [Figure 3]. Left front-temporoparietal decompressive hemicraniectomy with duraplasty was done, and the bone was placed in the anterior abdominal wall. Check DSA showed rail tail appearance of cervical ICA and no opacification of ICA just proximal to petrous ICA [Figure 4]c. At the coiling time, the cervical angiogram was reviewed, which showed an intimal flap cervical ICA [Figure 4]a and [Figure 4]b which progressed to complete dissection with total cutoff of distal flow [Figure 4c]. The patient did not survive due to the absence of flow from the contralateral side.
Figure 1: (a and b) Magnetic resonance brain and angiography showing a large saccular aneurysm, partly thrombosed in left supraclinoid region

Click here to view
Figure 2: (a and b) Precoiling and postcoiling data structures and algorithms showed normal distal flow

Click here to view
Figure 3: Noncontrast computed tomography showing infarct on postoperative day-1 in anterior cerebral artery and middle cerebral artery territory

Click here to view
Figure 4: (a, b and c) Digital subtraction angiogram (pre-coiling) with a small intimal flap, which subsequently progressed to complete dissection with complete distal cutoff and rat tail narrowing

Click here to view

  Discussion Top

The risk of stroke associated with aneurysm coiling is 3.8% in patients with good grade SAH.[1],[2] The atherosclerotic plaques, iatrogenic dissection of parent vessels, air bubbles and thrombus or fresh clots within aneurysms and or catheters are all potential causes of stroke following coiling.[3],[4] ICA dissection can lead to ischemic stroke in 2% of cases. It happens due to a tear in the wall of a carotid artery which can be spontaneous, traumatic, or iatrogenic in origin. This results in inflow of blood in different layers of the vessel wall, creating a false lumen causing carotid stenosis, pseudoaneurysm and or both. ICA dissection can be identified using standard angiography, which illustrates an irregular, and often tapered, stenosis with the distinctive 'string sign', 'flame-shaped' occlusion, or aneurysmal dilatation.[5],[6],[7],[8],[9] On magnetic resonance imaging (T1- and T2-weighted images), it appears as a crescent-shaped hyperintensity surrounding the narrowed lumen.[9] Even contrast-enhanced ultra-sonography of the carotid artery is a readily available tool and can be done where dye injection is contraindicated such as renal failure.[10] The size of iatrogenic intimal injury is an important determinant of outcome following ICAD. Flap raised along <2 mm of the wall, heals without morphological changes. Perhaps, in the majority of cases, it goes unnoticed even if it happens secondary to catheter-induced trauma. However, if the size of arterial injury is around 4 mm, then it has a high probability to produce an aneurysm, and if the size is more than 6 mm, then it would cause complete stenosis of the injured vessel.[11] In the present case, the retrospectively analysed angiogram does reveal a possible insignificant small intimal flap; still, it resulted in carotid dissection and stenosis. Perhaps, removal of the guiding catheter resulted in further injury. The timely diagnosis of such a condition could have resulted in the restoration of blood flow before the establishment of infarct, which could be restored either by aspiration of clot using aspiration device followed by stenting or open arteriotomy and removal of clot and reinforcement of intimal flap with stent. Since the flow in distal vessels was following normal completion of the procedure, it was never anticipated to be due to an intimal flap leading to ICA Dissection; instead, an embolic complication was highly suspected. This intimal flap did not result in dissection of the artery during the final cerebral angiogram, possibly due to the presence of an in situ guiding catheter in the ICA, which maintained the patency of the ICA patent the blood flow. To avoid having such complications, besides taking a cerebral angiogram to ensure normal blood flow distally, a cervical ICA angiogram should also be performed to look for unrecognized injury to the wall of ICA, external carotid artery and common carotid artery.

  Conclusion Top

  • Risk of stroke can be a fatal postoperative complication following aneurysm coiling
  • Preoperative evaluation for atheromatous plaque and intraoperative look for suspected intimal flap or slightest irregularity and lumen narrowing
  • Even a small intimal flap can progress to complete dissection and can lead to thromboembolic events
  • Timely identification of such events can avert fatal complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Derdeyn CP, Cross DT 3rd, Moran CJ, Brown GW, Pilgram TK, Diringer MN, et al. Postprocedure ischemic events after treatment of intracranial aneurysms with Guglielmi detachable coils. J Neurosurg 2002;96:837-43.  Back to cited text no. 1
Henkes H, Fischer S, Weber W, Miloslavski E, Felber S, Brew S, et al. Endovascular coil occlusion of 1811 intracranial aneurysms: Early angiographic and clinical results. Neurosurgery 2004;54:268-80.  Back to cited text no. 2
Bendszus M, Koltzenburg M, Burger R, Warmuth-Metz M, Hofmann E, Solymosi L. Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: A prospective study. Lancet 1999;354:1594-7.  Back to cited text no. 3
Rordorf G, Bellon RJ, Budzik RE Jr., Farkas J, Reinking GF, Pergolizzi RS, et al. Silent thromboembolic events associated with the treatment of unruptured cerebral aneurysms by use of Guglielmi detachable coils: Prospective study applying diffusion-weighted imaging. AJNR Am J Neuroradiol 2001;22:5-10.  Back to cited text no. 4
Mokri B, Sundt TM Jr., Houser OW, Piepgras DG. Spontaneous dissection of the cervical internal carotid artery. Ann Neurol 1986;19:126-38.  Back to cited text no. 5
Schievink WI, Mokri B, O'Fallon WM. Recurrent spontaneous cervical-artery dissection. N Engl J Med 1994;330:393-7.  Back to cited text no. 6
Treiman GS, Treiman RL, Foran RF, Levin PM, Cohen JL, Wagner WH, et al. Spontaneous dissection of the internal carotid artery: A nineteen-year clinical experience. J Vasc Surg 1996;24:597-605.  Back to cited text no. 7
Zetterling M, Carlström C, Konrad P. Internal carotid artery dissection. Acta Neurol Scand 2000;101:1-7.  Back to cited text no. 8
Guillon B, Levy C, Bousser MG. Internal carotid artery dissection: An update. J Neurol Sci 1998;153:146-58.  Back to cited text no. 9
Li ZJ, Luo XH, Du LF. Identification of carotid artery dissection by contrast enhanced ultrasonograph. A case report. Med Ultrason 2015;17:564-5.  Back to cited text no. 10
Okamoto T, Miyachi S, Negoro M, Otsuka G, Suzuki O, Keino H, et al. Experimental model of dissecting aneurysms. AJNR Am J Neuroradiol 2002;23:577-84.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded5    
    Comments [Add]    

Recommend this journal