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
, John Moshe Gomori 4, Asaf Honig 3,5, Ronen R. Leker 3 and Hans Henkes 6
Round 1
Reviewer 1 Report
- The authors presented their experience with the implantation of flow diverter stents (FDSs) for the management of intern carotid artery (ICA) dissections in tortuous tonsillar loop segments.
- The paper is very interesting and novel.
- The Introduction is too short and needs to be expanded providing more information on the aim of the paper.
- Methods are accurate.
- Results are too superficial. Give more evidence of your findings.
- The discussion section should be improved comparing your findings with similar one of the current literature and with a more critical point of view.
- English should be revised for grammar and style.
- English should be revised for grammar and style.
Author Response
The Introduction was significantly enriched as per the reviewer's request.
Material and Methods was not revised.
Additional information has been provided in the Results section as per the reviewer's request.
No relevant recent clinical experience on the use of flow diverter stents in carotid dissection was found with the exception of a short study by Hilditch et al. That study is now described in the Discussion section.
Reviewer 2 Report
Dear Editor,
I read with interest the article by Cohen et al. regarding the use of Flow-Diverter Stents in the endovascular management of tonsillar loop-associated ICA dissection presenting with carotid occlusion/near-occlusion and major ischemic stroke. The author presents their preliminary experience on 16 patients.
The manuscript is well written and of interest.
The introduction covers very well the current state of knowledge and supports the study.
The Materials and Methods section is well structured and easy to read.
The results are very well presented.
The article is of interest and will bring new information for clinicians in the field.
I recommend publishing the article.
Author Response
We thank the reviewer for his review.
Reviewer 3 Report
The authors present their experience with the use of a very complex technique in the treatment of acute ICA occlusions due to artery dissection, mainly based on the application of flow diverter stents. They define in a very clear matter what have to be considered the weak points of the procedure, especially its overall length and technical demand and the fact that the immediate post-operative use of dual antiaggregation might put the same patients at risk of developing a symptomatic ICH, although they did not experience any in their series. They also consider the problems of an effective thrombectomy in presence of an expanded artery. Results are very well presented and the main limitation of the paper, which I strongly agree with, is the risk of a late thrombosis. This is a risk that everyone of the new endovascular procedures carries and the real question to me is: what happens if a stented artery closes again? You just leave it there? But this is a definitely a question that new technical devices to come might be able to solve.
Overall the paper is extremely well written and I do believe it deserve publication as it is.
Author Response
We thank the reviewer for his review.
Round 2
Reviewer 1 Report
amended manuscript is acceptable.
