Acute Subarachnoid Hemorrhage and Cerebral Ischemia Due to a Spontaneous Dissection of the Supraclinoid Internal Carotid Artery; Conservative Management with Antiaggregation and Short-Term Anticoagulation, Justified by Competent Collaterals, with Remodeling of the Dissected Artery and Good Clinical Outcome

Abstract

A 27-year-old female patient presented with severe, pulsating headaches starting 6 days ago, radiating to her left eye, together with flickering in the visual field and paresthesia of her right hand. She had a history of migraines with only three attacks since she was 12 years old. The intake of sumatriptan, ibuprofen, and metamizole yielded only limited pain relief. MRI did not show blood in the subarachnoid space, but the CSF from a lumbar puncture was bloodstained with a red cell count of 238/ml and mildly elevated protein content of 690 mg/dl. MRA and DSA revealed high-grade stenosis of the left ICA’s supraclinoid segment, which was considered due to dissection. DWI MRI demonstrated small subcortical lesions with diffusion restriction. The stenotic segment of the left intradural ICA was intensely contrast enhancing. CTP showed a reduced cerebrovascular reserve capacity for the left MCA territory. Given the intracranial collaterals for the left ICA (AcomA > PcomA), the stenotic ICA segment’s morphology and the assumed underlying dissection, balloon angioplasty, and stent deployment were considered unduly hazardous. The patient was monitored on the stroke unit and medicinal treatment with 1× 100 mg ASA PO once daily for life, 2× 3000 IU certoparin sodium (Mono-Embolex, Mylan Healthcare) SC twice daily for 1 week, and 6× 60 mg nimodipine (Nimotop, Bayer Vital) PO daily for 2 weeks was started. The patient recovered entirely during a 4-week treatment in a rehabilitation institution. She eventually returned to her previous profession. Follow-up DSA 4.5 years after the SAH confirmed the remodeling of the previously dissected ICA segment. The management of spontaneous intradural dissections of the ICA is the main topic of this chapter.