Urgent Off-Label Use of Flow–Diverter Stents in the Endovascular Management of Tonsillar Loop-Associated Internal Carotid Artery Dissections Presenting with Carotid Occlusion or Near-Occlusion and Major Ischemic Stroke

We present our experience with the implantation of flow diverter stents (FDSs) for the management of internal carotid artery (ICA) dissections in tortuous tonsillar loop segments. A total of 16 patients (10 women, 62.5%; mean age 39 ± 8 years; median baseline NIHSS 13; median ASPECTS 8.5) with acute ischemic stroke due to ICA dissection in a tortuous tonsillar loop segment, with/without large intracranial vessel thrombotic occlusion diagnosed between June 2015–February 2022 were included in this retrospective study under a waiver of informed consent. An FDS device was deployed from the petrous ICA toward the upper cervical ICA, completely covering the tonsillar loop. Stentriever-assisted thrombectomy was performed when indicated. A dual antiplatelet regimen was used during and after the procedure. Thrombocyte inhibition levels were evaluated before, during, and after the intervention. The ICA occlusion/near occlusion was successfully recanalized in all 16 patients with mean postangioplasty residual stenosis of 34 ± 14% (range 0–50%). Stent-assisted thrombectomy was performed in 15/16 patients (93.7%), achieving revascularization (TICI 2b–3) in all. There were no procedural complications and no intraprocedural embolic events; one asymptomatic petechial hemorrhage was detected. At 3-month follow-up, mRS 0–2 was seen in all patients. This report provides pilot data for a subsequent study on the use of flow diverter stents for ischemic cerebrovascular conditions. Our encouraging preliminary results await confirmation from further experience and prospective randomized studies.