Ischemic stroke due to dissection of intracranial internal carotid artery: implications for early surgical treatment

Background: Intracranial ICA dissection is a rare pathology that frequently results in severe morbidity or mortality in young patients. This study examined the suitability of early surgical treatment. Methods: We present and analyze 6 of our own cases and 39 other cases reported after 1980. The clinical courses were classified into 3 types: A, single attack and severe outcome; B, single attack and mild to moderate outcome; and C, recurrent attacks and various outcomes. Results: Type A patients (n = 11) usually deteriorated quickly and severely so that early surgical treatment was not possible. Most type B patients (n = 12) did not require surgical intervention because of relatively stable courses. Only some type C patients (n = 10) are candidates for early surgery to prevent progressive deterioration. Twelve cases were unclassified because of insufficient information. We encountered 3 cases of type C, and emergency bypass surgery with parent ICA occlusion was planned in 2 patients. The surgery was successful with good prognosis in 1 patient; but the ICA and its branches were already occluded in the other patient, which precluded completion of bypass surgery and resulted in severe hemiparesis. Intraoperative findings and histologic examination of the MCA confirmed arterial dissection. Conclusion: Young patients with intracranial ICA dissection manifesting as mild ischemic stroke should be considered for early bypass surgery with occlusion of the dissected ICA if any sign of progression or recurrence occurs after the onset.