Direct carotid stenting with minimal predilation after embolic protection device crossing failure in cervical internal carotid artery dissection: A case report.

Background: Cervical internal carotid artery dissection (ICAD) may cause acute ischemic stroke requiring endovascular reperfusion. When repeated early reocclusion occurs and a distal embolic protection device (EPD) cannot cross the dissected segment after intravenous thrombolysis (IVT), the optimal strategy is uncertain. Case Description: A 70-year-old man with prior chronic subdural hematoma presented with right hemiparesis and aphasia (National Institutes of Health Stroke Scale score 18). Magnetic resonance angiography showed left cervical ICAD without intracranial large-vessel occlusion. IVT with alteplase (0.6 mg/kg) was followed by aspiration thrombectomy, which achieved only transient recanalization with repeated early reocclusion of the internal carotid artery. Although the guidewire of a distal filter-type EPD crossed the dissection, the filter system could not be delivered. Under proximal balloon occlusion, we therefore performed minimal low-pressure predilation with small balloons and directly deployed a closed-cell carotid stent, obtaining good expansion and durable reperfusion (final modified Thrombolysis in Cerebral Infarction grade 3). Because emergent stenting was unavoidable, dual antiplatelet therapy (DAPT) was loaded intraoperatively but withheld thereafter until 24-h imaging confirmed stability of a small post-procedural subarachnoid hemorrhage. No in-stent restenosis, reocclusion, or new infarcts occurred during follow-up; the modified Rankin Scale score was 3 at 3 months. Conclusion: This single-case experience suggests that, in cervical ICAD with repeated early reocclusion and distal EPD delivery failure, switching to proximal flow arrest, performing minimal low-pressure predilation, and proceeding to direct closed-cell carotid stenting can be a pragmatic bailout to secure sustained reperfusion. After prior IVT, a stepwise antiplatelet strategy - intra-procedural DAPT loading when emergent stenting is unavoidable, followed by withholding maintenance therapy until 24-h imaging confirms hemorrhagic stability - may help balance thrombotic and hemorrhagic risks, particularly in patients with a history of intracranial hemorrhage.