Internal Carotid Artery Rupture during Mechanical Thrombectomy of Tandem Occlusion

Abstract

Mechanical thrombectomy of tandem occlusion involving the internal carotid artery (ICA) is effective but complex. We discuss ICA rupture during thrombectomy of a tandem ICA occlusion. After crossing the ICA origin, manual angiography in the closed segment between proximal severe stenosis and distal thrombus leads to ICA rupture. The combination of high pressure created in a closed segment and weak structural points can lead to the rupture. The rupture can happen at the intradural segment of the ICA or an aneurysm. This complication may be avoided by an antegrade approach to tandem occlusions, low-flow microcatheter injections, and common carotid artery injections.

Keywords

ICA rupture - tandem occlusion - mechanical thrombectomy

Introduction

Strokes due to anterior circulation tandem occlusion account for 20% of large vessel occlusions. Mechanical thrombectomy of tandem occlusion is effective but complex.[1] Internal carotid artery (ICA) rupture during angiography in a closed segment is a rare fatal complication of this procedure. ICA rupture can occur at the intradural segment of the ICA or aneurysms.[2] [3] [4] Only a few case reports discussing this complication are available.

Case Report

A 68-year-old female patient, presented with left-sided hemiparesis for 4.5 hours with a National Institutes of Health Stroke Scale score of 14. She was on treatment for atrial fibrillation, diabetes mellitus, and hypertension. Magnetic resonance imaging revealed a small infarct core (The Alberta stroke program early CT score [ASPECTS] 8), a large penumbra, and complete occlusion of the right ICA and right middle cerebral artery ([Fig. 1]). The patient was taken for mechanical thrombectomy.

Fig. 1 (A) Axial magnetic resonance (MR) diffusion-weighted imaging depicts a small infarct core in the right middle cerebral artery (MCA) territory (ASPECTS M5 territory). (B) Pseudocontinuous arterial spin labeling images reveal large penumbra involving the entire MCA territory. (C) MR angiography depicts complete occlusion of the right internal carotid artery (ICA) and MCA.

Under sedation, catheterization of the right common carotid artery (CCA) was achieved using an 8-Fr balloon guide catheter, 5-Fr diagnostic catheter, and 035 guidewire. Right CCA angiography revealed complete occlusion of the right ICA origin. As the 035 guidewire reached up to the cervical segment, the 5-Fr diagnostic catheter was positioned distal to the ICA origin for angiography. Manual angiographic injection of the right ICA was done from the 5-Fr catheter placed in the cervical ICA. The angiography revealed active contrast extravasation from the intradural segment of the ICA indicating ICA rupture ([Fig. 2]). Cushing reflex with hypertension and bradycardia was observed.

Fig. 2 (A) Complete occlusion of the right internal carotid artery (ICA) noted from the right common carotid artery (CCA) injection with spearhead sign at the origin (black arrow). (B) Right ICA injection through the 5-Fr catheter beyond the ICA origin revealed active extravasation from the intradural segment of the ICA (white arrow) with ICA terminus occlusion. (C) Computed tomography (CT) confirmed massive subarachnoid hemorrhage and contrast extravasation.

The extravasation was managed conservatively by lowering blood pressure and reversal of heparin. Emergency coiling could not be done due to nonavailability of coils. Postprocedure computed tomography confirmed massive contrast extravasation and subarachnoid hemorrhage ([Fig. 2]). The patient was managed in the intensive care unit and died 24 hours later with worsening hemodynamic instability and neurological dysfunction. Neurosurgical opinion regarding ventricular drainage was obtained but the patient expired before that.

Discussion

Intradural ICA rupture can rarely occur during mechanical thrombectomy if there is tandem occlusion at the ICA origin and terminus. There are very few reports documenting this complication.[2] [3] [4]

All the six cases so far reported with this complication died within a few days. Of these, four cases underwent coil embolization and two cases were palliatively managed. This complication should be aggressively managed with ICA embolization and temporary ipsilateral carotid compression in addition to conservative methods like lowering blood pressure and heparin reversal.

In our patient, the intracranial ICA was untouched by any hardware before the rupture. After the diagnostic catheter crossed the proximal occlusion at the ICA origin, a closed segment should have been created between the origin occlusion and distal thrombus ([Fig. 3]). A similar closed segment can also happen between a wedged guiding catheter and distal thrombus especially if there is associated vasospasm at the catheter tip.[2] Routine manual injection within this closed segment using a 5-Fr catheter, increased the intraluminal pressure high enough to rupture it at the weakest point.

Fig. 3 Graphic representation of the closed segment bounded by the proximal severe stenosis (white arrow) and distal thrombus (black arrow) leading to internal carotid artery (ICA) rupture.

The first weakest point in this segment is anatomically distal to the dural ring where the thickness of the adventitia decreases and the external elastic lamina is absent.[5] The second weakest point may be an occult aneurysm hidden by the thrombus.[3] Finally, chronic severe stenosis at the ICA origin can lead to distal ICA narrowing due to vascular remodeling.[6] This remodeling can make the distal ICA more susceptible to rupture by both weakening its wall and also reducing the lumen diameter. However, no obvious decrease in vessel size was observed in our case.

The experimental analysis of pressure changes within silicon models of tandem ICA occlusion has shown pressure increasing up to 200 mm Hg during manual injection from a 4-Fr catheter and 300 mm Hg from a 9-Fr guiding catheter. This is extremely high compared with the pressure increase of less than 10 mm Hg observed in ICA models with only distal occlusion.[3] The extremely high pressure generated within a closed system following manual injection can rupture the ICA at its vulnerable sites.

This complication may be prevented by an antegrade approach to tandem occlusions, which involves treating the proximal stenosis first by angioplasty; however, this is at the cost of delayed distal reperfusion. Using a microcatheter to cross the ICA stenosis followed by low-volume and low-flow injections preferably via a microcatheter could also avoid this. Guide catheter injections may be taken from the CCA if necessary, but at the expense of adequate visualization of distal ICA.

Conclusion

ICA tandem occlusions form a separate subset of large vessel occlusions with unique technical challenges and complications. ICA rupture following angiography in a closed system is a rare fatal complication. To improve the safety of mechanical thrombectomy in this subset, awareness about this complication and prompt management is required.

Conflict of Interest

None declared.

Declaration

All authors contributed to this case report.

• References

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Publication History

Article published online:
24 March 2025