47 Case History A 60-year-old man presented to the emer- gency room with acute-onset left hemipare- sis of 1-hour duration. His vital signs on arrival were notable for a blood pressure of 170/92 mmHg. His initial National Institutes of Health Stroke Scale (NIHSS) (1) scored 12 for a dense left hemiparesis, left-sided numb- ness, right gaze preference, left-sided ne- glect, and dysarthria. Routine laboratory work revealed a borderline serum creatinine level of 1.2 mg/dL. On completion of a head computed tomography (CT), which showed an ill-defined hypodensity in the right fron- tal region (Figure 1), the patient’s clinical syndrome began to improve with resolution of the gaze preference, neglect, and dysar- thria. Examination at this point demon- strated a left upper extremity pronator drift Abstract Introduction: Carotid dissection is a less common but important cause of acute ischemic stroke, which has specific treatment implications. Case record: We describe the case of a patient with acute, fluctuating neurological sym- ptoms found to be caused by carotid dissection who underwent endovascular stent- supported angioplasty of this lesion with good outcome. Discussion: Pros and cons of the various treatment options encountered in this case including intravenous thrombolysis, angioplasty and stenting, and antithrombotic therapy are discussed. Conclusion: Endovascular treatment of carotid dissection in acute stroke can be performed safely. Treatment must ultimately be individualized to each specific case. Key Words: Angioplasty; endovascular stent; dissection; carotid; acute stroke. (Neurocrit. Care 2006;04:47–53) Neurocritical Care Copyright © 2006 Humana Press Inc. All rights of any nature whatsoever are reserved. ISSN 1541-6933/06/4:47–53 DOI: 10.1385/Neurocrit. Care 2006;04:47–53 Stent-Supported Angioplasty for Acute Stroke Caused by Carotid Dissection Nazli Janjua,* ,1 Adnan I. Qureshi, 1 Jawad Kirmani, 1 and Patrick Pullicino 2 1 Zeen at Qureshi Stroke Research Center, Clinical Trails Division, Department of Neurology and Neurosciences, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ; 2 Kent Institute of Medicine and Health Sciences, Research and Development Center, Kent University, Centerbury CT2 7NZ, Kent, UK *Correspondence and reprint request to: Nazli Janjua, MD, Department of Neurology and Neurosciences, University of Medicine and Dentistry, New Jersey, 90 Bergen Street, DOC 8100, Newark, NJ 07103 E-mail: janjuana@umdnj.edu and mild sensory symptoms, for a total NIHSS score of 2. Although the patient was within 3 hours of his symptom onset, intra- venous (iv) tissue plasminogen activator (t-PA) was withheld in light of his recovery (2). Given the severity of his initial symptoms, however, diagnostic angiography was per- formed to rule out large-vessel occlusive disease as the etiology of his initial neuro- logical deficits. An aortic arch injection with radiographic imaging of the cranial structures using digi- tal subtraction angiography (DSA) revealed a marked asymmetry in the filling of the right internal carotid artery system com- pared with the left (Figure 2), without the clear presence of anterior communicating or right posterior communicating arteries. Selective right common carotid artery (CCA) Cases With Tough Decisions