Reverse flow enhancing catheterization of true lumen in carotid artery dissection: REFLECT technique

Reverse flow enhancing catheterization of true lumen in carotid artery dissection: REFLECT technique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Reverse flow enhancing catheterization of true lumen in carotid artery dissection: REFLECT technique Francesco Mistretta, Riccardo Russo, Stefano Molinaro, Umberto Amedeo Gava, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6738026/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Jul, 2025 Read the published version in Neuroradiology → Version 1 posted You are reading this latest preprint version Abstract Endovascular treatment of large vessel occlusion (LVO) caused by carotid artery dissection (CAD) is challenging due to difficulties in identifying and navigating the true lumen. Entering through the false lumen can complicate the procedure, increasing the risk of distal embolization into patent arteries (such as anterior cerebral artery) and making it harder to reach the LVO. We report a case of CAD leading to middle cerebral artery (MCA) occlusion, successfully managed with mechanical thrombectomy using a balloon guide catheter. Proximal flow arrest in the dissected carotid artery enabled flow reversal and facilitated the apposition of the false lumen, thereby enhancing visualization and navigability of the true lumen (REFLECT technique). Once the guiding catheter was positioned within the distal healthy segment of the carotid artery, it was possible to revascularize the intracranial arterial circulation. Subsequently, carotid stents were deployed within the true lumen to reconstruct the dissected carotid artery. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Carotid artery dissection (CAD) is a relatively uncommon but significant cause of ischemic stroke, particularly in young and middle-aged adults. While CAD accounts for approximately 2% of all ischemic strokes in the general population, it is responsible for up to 20% of strokes in individuals under the age of 50. 1 Its annual incidence is estimated at 2.6–3 per 100,000 people. 2 CAD originates from a tear in the arterial wall, leading to intramural hematoma, vessel narrowing or occlusion, thrombus formation, and can result in distal embolization and intracranial large vessel occlusion (LVO) - ischemic stroke. CAD may be spontaneous or trauma-induced, even in healthy individuals. 2 The best endovascular strategy in CAD-associated LVO remains debated. 3 A key challenge is identifying and navigating the true lumen. We describe a case of CAD causing middle cerebral artery (MCA) occlusion, successfully treated with mechanical thrombectomy assisted by a balloon guide catheter: REverse FLow Enhancing Catheterization of True lumen (REFLECT technique). We discuss procedural aspects and clinical outcome. CASE PRESENTATION A patient in their 50s presented with acute visual symptoms. Past medical, social, and family history were unremarkable. No chronic medications. Shortly after arrival, the patient developed right hemiplegia. Non-contrast brain CT showed an ASPECTS score of 10 and a hyperdense left MCA sign. CT angiography revealed non-opacification of the left internal carotid artery (ICA) with re-opacification at the carotid apex and M1 segment occlusion. Good collateral circulation was noted. NIHSS score: 23. IV thrombolysis was initiated 30 minutes after worsening symptom onset; emergency endovascular thrombectomy started at 60 minutes under general anesthesia. TREATMENT The preliminary angiography showed: Proximal left ICA occlusion, likely due to dissection (Fig. 1 A) Supraclinoid left ICA opacification via the left posterior communicating artery (PCom) (Fig. 1 B) and MCA M1 occlusion Azygos variant of anterior cerebral artery (ACA) and good leptomeningeal collaterals from left ACA to homolateral MCA territory From a left femoral access (6F), control angiograms were performed from the right ICA and left vertebral artery. Through a right femoral access (8F), a Walrus balloon guide catheter (Q’Apel Medical Inc., USA) was positioned at the origin of the left ICA, proximal to the occlusion. The Walrus balloon was inflated with the aim of blocking anterograde flow and facilitating retrograde flow (in this case through PCom). In the Fig. 1 B, with the Walrus deflated, the reflux reaches the supraclinoid segment of the left ICA via the PCom, whereas with the Walrus inflated, the block of the anterograde flow allows the retrograde reflux to extend to the extracranial cervical segment of the ICA, promoting the collapse of the dissection’s false lumen (Fig. 1 C). Simultaneously, a RED72 catheter (Penumbra Inc., USA) inside the Walrus was connected to an aspiration pump to remove potential thrombotic material. Angiograms (after deflation of the Walrus to prevent vessel rupture in case of unsuccessful true lumen recanalization) documented partial collapse of the false lumen and restored patency of the true lumen (Fig. 2 A, 2 B). The true lumen was successfully catheterized, and the Walrus was advanced to the healthy distal cervical ICA (Fig. 2 C). Complete reperfusion (mTICI 3) was then achieved in a single pass using ADAPT technique 4 (Fig. 3 A), approximately 40 min after the start of the procedure. Intra-procedural XperCT excluded hemorrhagic complications. Through a NeuroSlider52 catheter (Acandis GmbH, Germany) (Fig. 3 B), two partially overlapping stents—Caresto 6x50 (distal) and Caresto 8x40 (proximal), Acandis GmbH—were deployed from the petrous ICA to the healthy proximal segment (Fig. 3 C). Final angiography confirmed proper stent apposition and regular anterograde flow (Fig. 3 D). During stenting, a bolus of Cangrelor (30 µg/kg) followed by continuous infusion (2 µg/kg/min) was administered. After 24 hours, brain CT and CT angiography confirmed stent patency and absence of hemorrhage, allowing transition to Ticagrelor. OUTCOME AND FOLLOW-UP At 3-month follow-up, the patient had no motor deficits, could walk independently, and had no major speech problems. Carotid duplex confirmed regular stent patency. The patient had returned to a lifestyle comparable to pre-event conditions. DISCUSSION Although similar techniques have likely already been employed in some centres, the proximal flow arrest in the dissected carotid artery remains largely unfamiliar. Given its utility, we believe that a clear description is important to facilitate its dissemination (Fig. 4 ). In the literature, only one similar case has been described by Murata et al. in 2018, 5 where in a case of occlusive dissection of the cervical segment of the ICA, under balloon proximal occlusion of the ICA (with balloon-guiding catheter), superselective angiography via the ipsilateral maxillary artery enabled visualization of the true lumen through ECA-ICA anastomoses. Subsequent navigation of the true lumen with a microcatheter was performed without difficulty. Subsequently, angioplasty and stent placement were successfully accomplished. There are, however, some differences in our case. ECA-ICA anastomoses are not always sufficient to ensure adequate retrograde flow, especially in cases of acute dissection, which is why it is important to assess compensatory circulation through the circle of Willis (in our case, compensation was primarily via the PCom). While the balloon-guiding catheter is inflated in the healthy proximal segment of the ICA, we recommend positioning an intermediate catheter under aspiration to remove any potential thrombotic material during flow reversal and restoration of true lumen patency. Furthermore, no angioplasty of the dissection site was performed in our case. We documented that, once the true lumen was identified, it could be navigated smoothly even with the guiding catheter, and after recanalization of the intracranial occlusion, carotid stents could be deployed without difficulty. When deployed within the true lumen, the stents likely exert enough radial force to appose the dissection flap against the vessel wall, making balloon angioplasty unnecessary. Therefore, we believe that the true value of the described technique lies in selected cases—CAD with a patent ICA apex and a competent circle of Willis or ECA-ICA collaterals—where it facilitates visualization of the true lumen (Fig. 4 ). Once identified, the true lumen can be safely navigated, reducing time to reperfusion and minimizing the risk of accessing the false lumen, which could cause distal embolization. With the guide catheter positioned in the healthy distal segment of ICA, standard mechanical thrombectomy techniques can be applied for intracranial revascularization. Afterwards, the dissected ICA can be reconstructed by deploying stents within the true lumen, minimizing the risk of partial deployment in the false lumen and thereby likely reducing the risk of subsequent stent occlusion. 6 – 8 CONCLUSION In cervical carotid dissections, flow reversal using a balloon guide catheter (REFLECT technique) facilitates the collapse of the false lumen and visualization of the true lumen. The true lumen can be easily navigated, reducing procedural times for thrombectomy. Carotid stenting within the true lumen ensures optimal vessel reconstruction and minimizes the risk of incomplete stent apposition in the dissected vessel. Declarations Ethics and Consent to Participate All clinical data and accompanying materials, including images, have been fully anonymized to protect patient privacy, and no identifiable information is included. As such, the identity of the patient cannot be traced from the report. The patient provided written informed consent for the publication of the case report. The article was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki. Funding Declaration No funding was received for this article. Author Contribution F.M. wrote the main manuscript text.R.R, S.M. and U.A.G. prepared the figures.M.B. gave final approval of the manuscript.All authors reviewed the manuscript. References Hathidara MY, Saini V, Malik AM (2019) Stroke in the Young: a Global Update. Curr Neurol Neurosci Rep 19:91 Lee VH, Brown RD, Mandrekar JN et al (2006) Incidence and outcome of cervical artery dissection: a population-based study. Neurology 67:1809–1812 Yaghi S, Engelter S, Del Brutto VJ et al (2024) Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. Stroke ; 55: e91–e106 Zhang Y, Zhang Y, Hu C et al (2021) A direct aspiration first-pass technique (ADAPT) versus stent retriever for acute ischemic stroke (AIS): a systematic review and meta-analysis. J Neurol 268:4594–4606 Murata K, Yamauchi S, Kaneshiro Y et al (2018) A novel technique to visualize true lumen in endovascular treatment of the occlusive carotid dissection and the usefulness of external-internal carotid collateral channel. Interv Neuroradiol 24:533–539 Morita T, Akitaya S, Munakata R-I et al (2024) False Lumen Stenting to the Acute Occlusive Carotid Artery Dissection Combined With Intracranial Acute Embolic Stroke: A Case Report and Literature Review. Cureus 16:e75317 Farouk M, Sato K, Matsumoto Y et al (2020) Endovascular Treatment of Internal Carotid Artery Dissection Presenting with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 29:104592 Da Ros V, Pusceddu F, Lattanzi S et al (2023) Endovascular treatment of patients with acute ischemic stroke and tandem occlusion due to internal carotid artery dissection: A multicenter experience. Neuroradiol J 36:86–93 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Jul, 2025 Read the published version in Neuroradiology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6738026","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":466314458,"identity":"894c7b57-8da5-4521-a0a8-5337e32bd364","order_by":0,"name":"Francesco Mistretta","email":"data:image/png;base64,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","orcid":"","institution":"Azienda Ospedaliera Citta' della Salute e della Scienza di Torino","correspondingAuthor":true,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Mistretta","suffix":""},{"id":466314459,"identity":"4f08eca8-ccab-40f9-b81c-80cdc2b7f249","order_by":1,"name":"Riccardo Russo","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Riccardo","middleName":"","lastName":"Russo","suffix":""},{"id":466314460,"identity":"e66e918f-2f35-4374-9aa5-19d3baa4de29","order_by":2,"name":"Stefano Molinaro","email":"","orcid":"","institution":"Azienda Ospedaliera Citta' della Salute e della Scienza di Torino","correspondingAuthor":false,"prefix":"","firstName":"Stefano","middleName":"","lastName":"Molinaro","suffix":""},{"id":466314461,"identity":"88e63dc8-0aac-4573-aaf6-b0edae57ea44","order_by":3,"name":"Umberto Amedeo Gava","email":"","orcid":"","institution":"Azienda Ospedaliera Citta' della Salute e della Scienza di Torino","correspondingAuthor":false,"prefix":"","firstName":"Umberto","middleName":"Amedeo","lastName":"Gava","suffix":""},{"id":466314462,"identity":"e3aed4e3-37f9-4602-acb5-480e1a4c9971","order_by":4,"name":"Mauro Bergui","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Mauro","middleName":"","lastName":"Bergui","suffix":""}],"badges":[],"createdAt":"2025-05-24 09:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6738026/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6738026/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00234-025-03714-x","type":"published","date":"2025-07-18T16:05:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84218895,"identity":"08dfa1c3-d23a-4722-a791-d2a1180e8688","added_by":"auto","created_at":"2025-06-09 11:20:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4389080,"visible":true,"origin":"","legend":"\u003cp\u003eLeft CCA angiography (lateral view) demonstrates occlusion of the proximal segment of the left ICA, most likely due to dissection (\u003cem\u003earrowhead\u003c/em\u003e) (\u003cstrong\u003eA\u003c/strong\u003e). Left VA angiography (lateral view) reveals opacification of the supraclinoid segment of the left ICA (\u003cem\u003earrow\u003c/em\u003e) via the left PCom (\u003cstrong\u003eB\u003c/strong\u003e). Left VA angiography (lateral view), performed with the Walrus balloon inflated at the origin of the left ICA, shows that blocking anterograde flow in the dissected ICA enables retrograde reflux through the left PCom to reach the extracranial cervical segment of the ICA (\u003cem\u003earrow with dot\u003c/em\u003e), thereby promoting collapse of the dissection’s false lumen (\u003cstrong\u003eC\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Fig.11.png","url":"https://assets-eu.researchsquare.com/files/rs-6738026/v1/c8878458c7aa77710daeda0a.png"},{"id":84218894,"identity":"3a2c9f12-888b-473f-a2bd-e3a9fe9174aa","added_by":"auto","created_at":"2025-06-09 11:20:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3777862,"visible":true,"origin":"","legend":"\u003cp\u003eLeft carotid angiography, performed immediately after deflation of the Walrus balloon, demonstrates partial collapse of the false lumen and restoration of true lumen patency (arrows) - lateral view (\u003cstrong\u003eA\u003c/strong\u003e) and anteroposterior view (\u003cstrong\u003eB\u003c/strong\u003e). The true lumen was then easily navigated using a microwire, microcatheter, and intermediate catheter, enabling positioning of the Walrus guide catheter (\u003cem\u003earrow with dot\u003c/em\u003e) in the healthy distal cervical segment (\u003cstrong\u003eC\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Fig.23.png","url":"https://assets-eu.researchsquare.com/files/rs-6738026/v1/2a968b3fa54999fb0dcfa820.png"},{"id":84218897,"identity":"2cfa6c03-45cd-479e-9f8d-9cf38b965372","added_by":"auto","created_at":"2025-06-09 11:20:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4804236,"visible":true,"origin":"","legend":"\u003cp\u003eComplete vessel recanalization (mTICI 3) achieved with a single-pass mechanical thrombectomy using the ADAPT technique (\u003cstrong\u003eA\u003c/strong\u003e). Through the Walrus, a NeuroSlider52 was advanced into the intrapetrous segment of the left ICA; after retracting the Walrus to the left CCA, angiographic series from the Walrus confirmed correct positioning of the NeuroSlider within the true lumen (\u003cstrong\u003eB\u003c/strong\u003e). Subsequently, two partially overlapping carotid stents (arrows) - distally a Caresto 6×50 and proximally a Caresto 8×40 - were deployed via the NeuroSlider, extending from the intrapetrous segment of the ICA to the healthy portion of the ICA near its origin (\u003cstrong\u003eC\u003c/strong\u003e - \u003cstrong\u003eD\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Fig.31.png","url":"https://assets-eu.researchsquare.com/files/rs-6738026/v1/cd00103dd191f13deb9965f3.png"},{"id":84218896,"identity":"1a16c595-1b19-4d92-8b8c-e327f932d4a9","added_by":"auto","created_at":"2025-06-09 11:20:15","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":11600488,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representation of the Reflect technique. In the case of an ICA occlusion due to dissection, the antegrade flow enters the false lumen (where thrombotic material may accumulate), resulting in the collapse of the true lumen (\u003cstrong\u003eA\u003c/strong\u003e). In selected cases (carotid dissection with a patent apex and a sufficiently competent circle of Willis or ECA-to-ICA collateral flow), inflating a balloon catheter in the proximal segment of the dissected ICA can block the antegrade flow and potentially promote flow reversal - through the posterior communicating artery, as in the present case (which was dominant over the anterior communicating artery), or through the anterior communicating artery when it is of greater caliber, as illustrated in the accompanying schematic figure. This maneuver can facilitate the apposition of the false lumen walls, thereby improving visualization and navigability of the true lumen (\u003cstrong\u003eB\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"Fig.41.png","url":"https://assets-eu.researchsquare.com/files/rs-6738026/v1/12cd9b6662d7ae5265962d45.png"},{"id":88506126,"identity":"841544ef-b473-482d-9868-91674d6123e6","added_by":"auto","created_at":"2025-08-07 07:31:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":28034038,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6738026/v1/2c0e7dba-92e2-4d3e-9ef0-f3897ef88470.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eReverse flow enhancing catheterization of true lumen in carotid artery dissection: REFLECT technique\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCarotid artery dissection (CAD) is a relatively uncommon but significant cause of ischemic stroke, particularly in young and middle-aged adults. While CAD accounts for approximately 2% of all ischemic strokes in the general population, it is responsible for up to 20% of strokes in individuals under the age of 50.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Its annual incidence is estimated at 2.6\u0026ndash;3 per 100,000 people.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCAD originates from a tear in the arterial wall, leading to intramural hematoma, vessel narrowing or occlusion, thrombus formation, and can result in distal embolization and intracranial large vessel occlusion (LVO) - ischemic stroke. CAD may be spontaneous or trauma-induced, even in healthy individuals.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe best endovascular strategy in CAD-associated LVO remains debated.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e A key challenge is identifying and navigating the true lumen. We describe a case of CAD causing middle cerebral artery (MCA) occlusion, successfully treated with mechanical thrombectomy assisted by a balloon guide catheter: REverse FLow Enhancing Catheterization of True lumen (REFLECT technique). We discuss procedural aspects and clinical outcome.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA patient in their 50s presented with acute visual symptoms. Past medical, social, and family history were unremarkable. No chronic medications. Shortly after arrival, the patient developed right hemiplegia. Non-contrast brain CT showed an ASPECTS score of 10 and a hyperdense left MCA sign. CT angiography revealed non-opacification of the left internal carotid artery (ICA) with re-opacification at the carotid apex and M1 segment occlusion. Good collateral circulation was noted. NIHSS score: 23. IV thrombolysis was initiated 30 minutes after worsening symptom onset; emergency endovascular thrombectomy started at 60 minutes under general anesthesia.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTREATMENT\u003c/h2\u003e \u003cp\u003eThe preliminary angiography showed:\u003c/p\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eProximal left ICA occlusion, likely due to dissection (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSupraclinoid left ICA opacification via the left posterior communicating artery (PCom) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB) and MCA M1 occlusion\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAzygos variant of anterior cerebral artery (ACA) and good leptomeningeal collaterals from left ACA to homolateral MCA territory\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003eFrom a left femoral access (6F), control angiograms were performed from the right ICA and left vertebral artery. Through a right femoral access (8F), a Walrus balloon guide catheter (Q\u0026rsquo;Apel Medical Inc., USA) was positioned at the origin of the left ICA, proximal to the occlusion.\u003c/p\u003e \u003cp\u003eThe Walrus balloon was inflated with the aim of blocking anterograde flow and facilitating retrograde flow (in this case through PCom). In the Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, with the Walrus deflated, the reflux reaches the supraclinoid segment of the left ICA via the PCom, whereas with the Walrus inflated, the block of the anterograde flow allows the retrograde reflux to extend to the extracranial cervical segment of the ICA, promoting the collapse of the dissection\u0026rsquo;s false lumen (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Simultaneously, a RED72 catheter (Penumbra Inc., USA) inside the Walrus was connected to an aspiration pump to remove potential thrombotic material. Angiograms (after deflation of the Walrus to prevent vessel rupture in case of unsuccessful true lumen recanalization) documented partial collapse of the false lumen and restored patency of the true lumen (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). The true lumen was successfully catheterized, and the Walrus was advanced to the healthy distal cervical ICA (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComplete reperfusion (mTICI 3) was then achieved in a single pass using ADAPT technique\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA), approximately 40 min after the start of the procedure. Intra-procedural XperCT excluded hemorrhagic complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThrough a NeuroSlider52 catheter (Acandis GmbH, Germany) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB), two partially overlapping stents\u0026mdash;Caresto 6x50 (distal) and Caresto 8x40 (proximal), Acandis GmbH\u0026mdash;were deployed from the petrous ICA to the healthy proximal segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). Final angiography confirmed proper stent apposition and regular anterograde flow (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003eDuring stenting, a bolus of Cangrelor (30 \u0026micro;g/kg) followed by continuous infusion (2 \u0026micro;g/kg/min) was administered. After 24 hours, brain CT and CT angiography confirmed stent patency and absence of hemorrhage, allowing transition to Ticagrelor.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOUTCOME AND FOLLOW-UP\u003c/h3\u003e\n\u003cp\u003eAt 3-month follow-up, the patient had no motor deficits, could walk independently, and had no major speech problems. Carotid duplex confirmed regular stent patency. The patient had returned to a lifestyle comparable to pre-event conditions.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAlthough similar techniques have likely already been employed in some centres, the proximal flow arrest in the dissected carotid artery remains largely unfamiliar. Given its utility, we believe that a clear description is important to facilitate its dissemination (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In the literature, only one similar case has been described by Murata et al. in 2018,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e where in a case of occlusive dissection of the cervical segment of the ICA, under balloon proximal occlusion of the ICA (with balloon-guiding catheter), superselective angiography via the ipsilateral maxillary artery enabled visualization of the true lumen through ECA-ICA anastomoses. Subsequent navigation of the true lumen with a microcatheter was performed without difficulty. Subsequently, angioplasty and stent placement were successfully accomplished.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere are, however, some differences in our case. ECA-ICA anastomoses are not always sufficient to ensure adequate retrograde flow, especially in cases of acute dissection, which is why it is important to assess compensatory circulation through the circle of Willis (in our case, compensation was primarily via the PCom). While the balloon-guiding catheter is inflated in the healthy proximal segment of the ICA, we recommend positioning an intermediate catheter under aspiration to remove any potential thrombotic material during flow reversal and restoration of true lumen patency. Furthermore, no angioplasty of the dissection site was performed in our case. We documented that, once the true lumen was identified, it could be navigated smoothly even with the guiding catheter, and after recanalization of the intracranial occlusion, carotid stents could be deployed without difficulty. When deployed within the true lumen, the stents likely exert enough radial force to appose the dissection flap against the vessel wall, making balloon angioplasty unnecessary.\u003c/p\u003e \u003cp\u003eTherefore, we believe that the true value of the described technique lies in selected cases\u0026mdash;CAD with a patent ICA apex and a competent circle of Willis or ECA-ICA collaterals\u0026mdash;where it facilitates visualization of the true lumen (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Once identified, the true lumen can be safely navigated, reducing time to reperfusion and minimizing the risk of accessing the false lumen, which could cause distal embolization. With the guide catheter positioned in the healthy distal segment of ICA, standard mechanical thrombectomy techniques can be applied for intracranial revascularization. Afterwards, the dissected ICA can be reconstructed by deploying stents within the true lumen, minimizing the risk of partial deployment in the false lumen and thereby likely reducing the risk of subsequent stent occlusion.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn cervical carotid dissections, flow reversal using a balloon guide catheter (REFLECT technique) facilitates the collapse of the false lumen and visualization of the true lumen.\u003c/p\u003e \u003cp\u003eThe true lumen can be easily navigated, reducing procedural times for thrombectomy.\u003c/p\u003e \u003cp\u003eCarotid stenting within the true lumen ensures optimal vessel reconstruction and minimizes the risk of incomplete stent apposition in the dissected vessel.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eEthics and Consent to Participate\u003c/h2\u003e \u003cp\u003eAll clinical data and accompanying materials, including images, have been fully anonymized to protect patient privacy, and no identifiable information is included. As such, the identity of the patient cannot be traced from the report.\u003c/p\u003e \u003cp\u003e The patient provided written informed consent for the publication of the case report.\u003c/p\u003e \u003cp\u003eThe article was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki.\u003c/p\u003e \u003ch2\u003eFunding Declaration\u003c/h2\u003e \u003cp\u003eNo funding was received for this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eF.M. wrote the main manuscript text.R.R, S.M. and U.A.G. prepared the figures.M.B. gave final approval of the manuscript.All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHathidara MY, Saini V, Malik AM (2019) Stroke in the Young: a Global Update. Curr Neurol Neurosci Rep 19:91\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee VH, Brown RD, Mandrekar JN et al (2006) Incidence and outcome of cervical artery dissection: a population-based study. Neurology 67:1809\u0026ndash;1812\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaghi S, Engelter S, Del Brutto VJ et al (2024) Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. \u003cem\u003eStroke\u003c/em\u003e ; 55: e91\u0026ndash;e106\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Zhang Y, Hu C et al (2021) A direct aspiration first-pass technique (ADAPT) versus stent retriever for acute ischemic stroke (AIS): a systematic review and meta-analysis. J Neurol 268:4594\u0026ndash;4606\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurata K, Yamauchi S, Kaneshiro Y et al (2018) A novel technique to visualize true lumen in endovascular treatment of the occlusive carotid dissection and the usefulness of external-internal carotid collateral channel. Interv Neuroradiol 24:533\u0026ndash;539\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorita T, Akitaya S, Munakata R-I et al (2024) False Lumen Stenting to the Acute Occlusive Carotid Artery Dissection Combined With Intracranial Acute Embolic Stroke: A Case Report and Literature Review. Cureus 16:e75317\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarouk M, Sato K, Matsumoto Y et al (2020) Endovascular Treatment of Internal Carotid Artery Dissection Presenting with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 29:104592\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDa Ros V, Pusceddu F, Lattanzi S et al (2023) Endovascular treatment of patients with acute ischemic stroke and tandem occlusion due to internal carotid artery dissection: A multicenter experience. Neuroradiol J 36:86\u0026ndash;93\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6738026/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6738026/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEndovascular treatment of large vessel occlusion (LVO) caused by carotid artery dissection (CAD) is challenging due to difficulties in identifying and navigating the true lumen. Entering through the false lumen can complicate the procedure, increasing the risk of distal embolization into patent arteries (such as anterior cerebral artery) and making it harder to reach the LVO.\u003c/p\u003e \u003cp\u003eWe report a case of CAD leading to middle cerebral artery (MCA) occlusion, successfully managed with mechanical thrombectomy using a balloon guide catheter. Proximal flow arrest in the dissected carotid artery enabled flow reversal and facilitated the apposition of the false lumen, thereby enhancing visualization and navigability of the true lumen (REFLECT technique). Once the guiding catheter was positioned within the distal healthy segment of the carotid artery, it was possible to revascularize the intracranial arterial circulation. Subsequently, carotid stents were deployed within the true lumen to reconstruct the dissected carotid artery.\u003c/p\u003e","manuscriptTitle":"Reverse flow enhancing catheterization of true lumen in carotid artery dissection: REFLECT technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 11:20:10","doi":"10.21203/rs.3.rs-6738026/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"29ad77d7-7176-44d7-b420-0c7304f9be26","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T07:12:21+00:00","versionOfRecord":{"articleIdentity":"rs-6738026","link":"https://doi.org/10.1007/s00234-025-03714-x","journal":{"identity":"neuroradiology","isVorOnly":false,"title":"Neuroradiology"},"publishedOn":"2025-07-18 16:05:00","publishedOnDateReadable":"July 18th, 2025"},"versionCreatedAt":"2025-06-09 11:20:10","video":"","vorDoi":"10.1007/s00234-025-03714-x","vorDoiUrl":"https://doi.org/10.1007/s00234-025-03714-x","workflowStages":[]},"version":"v1","identity":"rs-6738026","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6738026","identity":"rs-6738026","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}