Bilateral carotid aneurysms secondary to radiation therapy

Takayasu's Arteritis with a Thrombosed Aneurysm on the Common Carotid Artery Causing Ischemic Stroke

Takayasu's arteritis is an inflammatory disease of unknown etiology that causes stenosis, occlusion, or dilatation of the aorta and its major branches, the pulmonary arteries, and the coronary arteries. The incidence of extracranial carotid artery aneurysm in patients with Takayasu's arteritis is reportedly 1.8-3.9%. We herein report a patient with Takayasu's arteritis who presented with transient left hemiplegia immediately after neck massage. Carotid ultrasonography revealed a thrombus within the fusiform aneurysm on the right common carotid artery. We speculated that fragmentation from the intra-aneurysmal thrombus was caused by neck massage.

Endovascular glue embolization of a radiation-induced lenticulostriate artery pseudoaneurysm in a pediatric patient with optic pathway glioma: Case report and review of literature

Radiation-associated vascular changes most commonly present in the form of stenosis, thrombosis and occlusion. However, development of intracranial aneurysms secondary to radiation is far less common and often manifests with rupture. These aneurysms are difficult to treat and associated with high morbidity and mortality when ruptured compared with saccular aneurysms unrelated to radiation treatment. Both surgical and endovascular options are available for treatment of these aneurysms. We present a young patient with a radiation-induced intracranial pseudoaneurysm arising from the lenticulostriate branch of the left middle cerebral artery (MCA); this developed 1 year 4 months after 59.4 Gy of focused radiation to the suprasellar pilomyxoid astrocytoma. The patient successfully underwent endovascular glue embolization of the aneurysm and occlusion of the lenticulostriate artery after unsuccessful trapping of the aneurysm and occlusion of the parent artery using coils. She developed transient hemiparesis of the right side following the procedure, which was managed conservatively. We performed a complete review of the literature dealing with the radiation-induced intracranial aneurysms, their presentation, treatment and outcome.

Carotid Artery Sacrifice and Reconstruction in the Setting of Advanced Head and Neck Cancer

Objective

To determine oncological and neuromorbidity outcomes in patients with advanced head and neck cancer (stage IVB) requiring sacrifice and reconstruction of the carotid artery.

Study Design

Case series with chart review.

Setting

Tertiary care referral center.

Subjects and Methods

Overall, 51 patients underwent carotid artery sacrifice during surgical treatment of the neck, in both the primary and salvage setting. All patients underwent autogenous in-line carotid artery bypass grafting with either saphenous vein or the deep femoral vein in conjunction with vascular surgery. In all, the study included 39 males and 12 female subjects, with age ranging from 39 to 82 (mean, 62.7).

Results

Two patients (3.9%) had a cerebral vascular accident in the immediate postoperative period. The remaining 49 patients (96%) had no neurologic sequela. Serial ultrasonic evaluation revealed 4 patients with intra-luminal thrombus within the site of reconstruction. Perioperative mortality occurred in a single patient. Disease-related mortality occurred in 9.8% (5) of patients, with an overall 2-year survival of 82%.

Conclusions

We presently report the largest series of surgical treatment for advanced head and neck cancer with carotid artery involvement. We document an overall 2-year survival of 82% in the setting of low perioperative neuromorbidity and mortality rates. We therefore consider carotid artery sacrifice and autogenous vein graft reconstruction in the absence of distant metastatic disease as a viable treatment option for what was once thought to be a palliative procedure.

Carotid Artery Aneurysms: Serbian Multicentric Study

This multicentric Serbian study presents the treatment of 91 extracranial carotid artery aneurysms in 76 patients (13 had bilateral lesions). There were 61 (80.3%) male and 15 (19.7%) female patients, with an average age of 61.4 years. The aneurysms were caused by atherosclerosis in 73 cases (80.2%), trauma in six (6.6%), previous carotid surgery in six (6.6%), tuberculosis in one (1.1%), and fibromuscular dysplasia in five (5.5%). The majority (61 cases or 67%) of the aneurysms involved the internal carotid artery, 29 (31.9%) the common carotid artery bifurcation, and one (1.1%) the external carotid artery. Forty-five (49.4%) aneurysms were fusiform, while 46 (50.6%) were saccular. Twenty-nine (31.9%) cases were totally asymptomatic at the time of diagnosis. The remainder presented with compression in 14 (15.4%) cases, stroke in 11 (12.1%) cases, transient ischemic attack in 33 (36.3%) cases, and rupture in four (4.4%) cases. In cases where the aneurysm involved the internal carotid artery, four surgical procedures were performed: aneurysmectomy with end-to-end anastomosis in 30 (33.0%) cases, aneurysmectomy with vein graft interposition in 20 (22.0%) cases, aneurysmectomy with anastomosis between external and internal carotid artery in eight (8.8%) cases, and aneurysmectomy followed by arterial ligature in three cases. One case of external carotid artery aneurysm also was treated by aneurysmectomy and ligature. Aneurysm replacement with Dacron graft was performed in 29 (31.9%) cases where common carotid artery bifurcation was involved. Two (2.2%) patients died after the operation due to a stroke. They had ruptured internal carotid artery aneurysm treated by aneurysmectomy and ligature. Including these, a total of five (5.5%) postoperative strokes occurred. In two (2.2%) cases, transient cranial nerve injuries were found. Excluding the five patients who were lost to follow-up, 69 other surviving patients were followed from 2 months to 12 years (mean 5 years and 3 months). In this period, there were no new neurological events and all reconstructed arteries were patent. Three patients died more than 5 years after the operation, due to myocardial infarction. Aneurysms of the extracranial carotid arteries are rare vascular lesions that produce a high incidence of unfavorable neurological sequelae. Because of their varied etiology, location, and extension, different vascular procedures have to be used during repair of extracranial carotid artery aneurysms. In all of these procedures, an aneurysmectomy with arterial reconstruction is necessary.

Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature

A 42-year-old female presented with subarachnoid hemorrhage (SAH), presumably from a radiation-induced anterior communicating artery aneurysm. Six years earlier, she had undergone radiation treatment for an optic glioma that was diagnosed based on imaging criteria. The aneurysm was successfully clipped, and the optic glioma was biopsied to verify the diagnosis histologically. Radiation-induced cerebral aneurysms often manifest with a fatal SAH. These aneurysms typically develop in the field of radiation and are diagnosed a mean of 8.52 years after radiation. Rarely, the aneurysm sac thromboses spontaneously. Clipping or coiling of the aneurysm can be an effective treatment.

Therapy with 188Re-Labeled Radiopharmaceuticals: An Overview of Promising Results from Initial Clinical Trials

The development of an in-house 188W/188Re-generator has greatly increased the use of 188Re for treating various diseases. 188Re is of widespread interest due to its attractive physical and chemical properties. Many new radiopharmaceuticals labeled with 188Re have been developed and are currently in clinical trials, such as: 188Re-labeled renal excreting agents like 188Re-mercaptoacetylglycylglycylglycine (MAG3) and 188Re-diethylenetriamine pentaacetic acid (DTPA) for prevention of coronary arterial restenosis; 188Re-labeled phosphonates such as 188Re-hydroxyethylidene diphosphonate (HEDP), 188Re-alendronate (ABP), and 188Re-ethylenediamine-N,N,N',N'-tetrakis(methylene phosphoric) acid (EDTMP) for palliation of metastatic bone pain; 188Re-labeled lipiodol such as 188Re-n-hexyldiaminedithiol (HDD)-lipiodol for treatment of liver cancer; and 188Re-labeled colloids and microspheres for treatment of diseases such as rheumatoid arthritis, peritoneal effusion, and other solid tumors. However, there is still a need to develop new 188Re-labeled radiopharmaceuticals that are more specific for target lesions such as cancer-specific monoclonal antibodies and peptides. The availability of 188Re from a generator at a reasonable cost may help increase not only the research activities but also the clinical applications of 188Re-labeled radiopharmaceuticals.

Relative risk of stroke in head and neck carcinoma patients treated with external cervical irradiation

OBJECTIVE

To determine the rate of cerebrovascular events (stroke) in patients irradiated to high doses for squamous cell carcinoma of the head and neck.

STUDY DESIGN

Retrospective chart review of 413 patients treated from 1987 to 2000 with squamous cell carcinoma of the head and neck was performed to determine the risk of stroke compared with the expected rate.

METHODS

Surgical, radiotherapeutic, radiological, and clinical or office records of 413 patients were analyzed, and data were collected regarding clinical risk factors for stroke, irradiation parameters, and follow-up on whether or not a stroke event occurred. The actuarial risk of stroke for this population was calculated and compared with expected risk from population-based data.

RESULTS

Of the 413 patients, 20 had strokes in follow-up, occurring between 2 and 146 months after radiotherapy. The 5-year actuarial rate of stroke was 12%, which corresponded to a relative risk of 2.09 ( P=.0007) compared with the population-based "expected" data. Median radiation therapy dose was 64 Gy; there was no correlation between radiation therapy dose and stroke risk. No correlation was identified between surgery near the carotids and stroke risk.

CONCLUSIONS

An association between high-dose cervical irradiation for squamous cell carcinoma of the head and neck and stroke is demonstrated. Although the relative risk is approximately doubled, the absolute risk is modest in comparison to the risk of cancer recurrence. Further study of this association and possible interventions is warranted.

Carotid reconstruction in patients operated for malignant head and neck neoplasia

CONTEXT

Patients with malignant head and neck neoplasia may present simultaneous involvement of large vessels due to the growth of the tumoral mass. The therapeutic options are chemotherapy, radiotherapy, surgery or combined treatments.

OBJECTIVE

To analyze the result of surgical treatment with carotid reconstruction in patients with advanced malignant head and neck neoplasia.

DESIGN

Prospective.

SETTING

Hospital do Câncer A.C. Camargo, São Paulo, Brazil.

PARTICIPANTS

Eleven patients operated because of advanced malignant head and neck neoplasia that was involving the internal and/or common carotid artery.

MAIN MEASUREMENTS

By means of clinical examination, outpatient follow-up and duplex scanning, we analyzed the patency of the carotid grafts, vascular and non-vascular complications, disease recurrence and survival of the patients.

RESULTS

Six patients (54.5%) did not present any type of complication. There was one vascular complication represented by an occlusion of the carotid graft with a cerebrovascular stroke in one hemisphere. Non-vascular complications occurred in five patients (45.5%). During the follow-up, eight patients died (72.7%), of whom seven had loco-regional tumor recurrence and one had pulmonary and hepatic metastases (at an average of 9 months after the operation). Seven of these patients presented functioning grafts. The three patients still alive have no tumor recurrence and their grafts are functioning (an average of 9 months has passed since the operation).

CONCLUSIONS

Patients with advanced malignant head and neck neoplasia involving the carotid artery that are treated surgically present a prognosis with reservations. When the internal and/or common carotid artery is resected en-bloc with the tumor, arterial reconstruction must be performed. The long saphenous vein is a suitable vascular substitute.

Extracranial carotid aneurysm in Takayasu's arteritis

Extracranial carotid aneurysm caused by Takayasu's arteritis is extremely rare. We have experienced six cases of extracranial carotid aneurysm among 106 cases of Takayasu's arteritis that were treated surgically in the past 50 years. We herein review these cases and discuss the surgical indications and postoperative course of this rare disease. We report original observations about extracranial carotid aneurysm in Takayasu's arteritis.

Prevention of intimal hyperplasia by single-dose pre-insertion external radiation in canine-vein interposition grafts

OBJECTIVES

to evaluate the efficacy of single-dose pre-insertion gamma radiation of vein grafts in the prevention of intimal hyperplasia.

METHODS

femoral artery interposition grafts with internal jugular vein were inserted in 12 mongrel dogs. The animals were randomly divided into two groups. Immediately before graft replacement, jugular veins were treated with a single dose of cobalt-60 radiation at 14 Gy or received no radiation (control group). Six weeks after graft insertion, the vein grafts were pressure-perfusion fixed and harvested for the histomorphometric analysis. Quantitative data on anastomotic stenosis were calculated from Gilman parameters after cross-sectional image analysis.

RESULTS

vein grafts treated with radiation demonstrated significantly decreased neointima formation compared with grafts in the control group. The mean Gilman parameter for the control group was 1.09 S.E.M. 0.34 mm and for the radiotherapy group was 0.65 S.E. M. 0.23 mm (p<0.05). All vein grafts in the radiotherapy group had a decreased amount of intimal and cellular infiltration.

CONCLUSION

single-dose external pre-insertion gamma radiation of vein grafts reduced the amount of intimal hyperplasia in this animal model.

Clinical applications of brachytherapy for the prevention of restenosis

Restenosis remains the bane of percutaneous coronary intervention. Local delivery of radiation, brachytherapy, is a promising therapy for the prevention of restenosis. Animal studies have suggested that brachytherapy may be an effective treatment for preventing restenosis. The type of radiation as well as the doses and delivery systems are currently under study; several clinical trials are underway. This paper reviews the biological basis, including animal studies, of intracoronary brachytherapy as well as the current data from clinical trials.

Carotid resection and replacement with autogenous arterial graft during operation for neck malignancy

Carotid artery resection as part of the management of advanced head and neck cancers remains controversial. Since 1991, 30 patients have undergone resection of the carotid artery with immediate reconstruction using superficial femoral artery as replacement conduit. There was one stroke/death. Forty-three percent developed neck wound problems but no grafts failed or hemorrhaged. Mean follow-up was 20 months (3-76) and mean life expectancy was 16 months from the time of surgery. Fifty-eight percent were free of local recurrence at the time of death. There was a 35% disease-free survival rate at 2 years. These results compare favorably with alternative therapy including carotid ligation or shaving tumor from the carotid artery. Given the importance of cerebral perfusion and local tumor control we offer superficial femoral artery as a durable conduit for immediate extracranial carotid reconstruction in the often hostile environment associated with cancer resection in the neck.

The role of panoramic radiography in determining an increased risk of cervical atheromas in patients treated with therapeutic irradiation

PURPOSE

Therapeutic irradiation of the neck is a common component of treatment for those with carcinoma of the oral cavity, pharynx, and larynx. Such irradiation, however, has been implicated as the cause of accelerated atherosclerosis of the cervical carotid artery and subsequent stroke. Panoramic radiography, previously shown to be capable of identifying carotid artery atherosclerosis in non-irradiated individuals, was used to assess the carotid vasculature of patients who had been treated for cancer with therapeutic irradiation.

METHODS

The panoramic radiographs of 33 male subjects who had received therapeutic irradiation (> or = 50 Gy) to the neck 30 or more months previously were assessed for the presence of calcified carotid artery atherosclerotic lesions. Age-matched controls, similarly liable for oropharyngeal malignancy and atherosclerosis by virtue of their medical and habitual risk factors (hypertension, smoking, obesity) were assessed in a like manner.

RESULTS

The panoramic radiographs of the irradiation-treated subjects (age range, 32 to 84 years; mean age, 66.1 years) showed that 21% (7 of 33 subjects) had calcified atherosclerotic lesions. The mean age of these seven subjects was 64.6 years; four had unilateral lesions and three had bilateral lesions. The radiographs of the control subjects showed that 4.7% (5 of 107 subjects) had calcified atherosclerotic lesions. The mean age of these five subjects was 67; three had unilateral lesions and two had bilateral lesions. The lesions seen in the two populations had similar morphologic appearances. The discrete radiopaque calcifications were located within the soft tissues of the neck, approximately 2.5 cm inferior-posterior to the angle of the mandible.

CONCLUSIONS

Subjects who had received therapeutic irradiation of the neck had a statistically higher risk (p = 0.007, according to Fisher's Exact Test) of the development of calcified carotid artery atherosclerotic lesions than age-matched, risk-matched, non-irradiated control subjects. These lesions can be detected on routine panoramic radiographs.

Extracranial carotid artery aneurysms following accidental injury: ten years experience

Extracranial carotid artery aneurysms secondary to accidental injury are rare. We have seen eight lesions of this type in the last 10 years. The aneurysm was produced by blunt trauma in four patients, penetrating shrapnel injury in two, stabbing and electrical injury in one each. The left side was involved in seven patients. The internal and common carotid artery were each involved in four patients and the lesion was unilocular in five. These lesions often produce non-specific symptoms and may mimic neoplastic or inflammatory masses: a mistaken diagnosis of tonsillar abscess in one patient resulted in incision and drainage before an intravenous digital subtraction angiogram (IV-DSA) correctly identified the abnormality. IV-DSA is ideal for pre-operative assessment of these patients. Awareness of these lesions is essential since definitive surgical repair is possible. All patients in the present study underwent successful surgical repair.

Arterial occlusive disease after radiotherapy: a report of fourteen cases

Fourteen cases of arterial occlusion or severe narrowing following radiotherapy are studied in order to assess the possible etiological role of such therapy in arterial lesion. Surgical results are also discussed in terms of long-term efficacy. The average time of occurrence after radiotherapy was 8 years post-radiotherapy. This series includes 7 supra-aortic trunk stenoses and 7 abdominal aorta trunk stenoses. The doses received in the volumes irradiated ranged from 47 to 70 Gy with standard fractionation. Association of atherosclerotic risk factors (smoking, hyperlipidemia, diabetes, high blood pressure) was present in 12 patients, but stenoses were usually confined to irradiated areas, and at times occurred in uncommon sites. Surgical management included 11 by-passes, 2 endarterectomies and one percutaneous transluminal angioplasty. All patients experienced immediate and satisfactory functional improvements. Three patients were re-operated on because of the re-occlusion of the by-pass (2 cases) and graft infection (1 case). On the whole, stenoses in previously irradiated areas showed no particular difficulties for surgical treatment. It was concluded that radiotherapy seems to be a definite risk factor for arterial occlusion or narrowing, especially in association with atherosclerotic risk factors.

Mycotic cervical carotid artery aneurysms: a case report and review of the literature

Mycotic cervical carotid artery aneurysms are rare. We report one case successfully treated by resection and reconstruction with a saphenous vein interposition graft. A review of the English world literature revealed 22 additional cases. Principles of management include appropriate and timely antibiotic use, resection of the aneurysm, debridement of all infected tissue, and restoration of arterial continuity with autogenous tissue through uninvolved tissue planes.

Radiation-induced chronic arterial injury

Acute arterial disruption associated with infection, previous irradiation, and the postoperative state is a well-described entity. The recognition of a chronic form of radiation-induced arterial injury presenting years after therapeutic doses of radiation is less well appreciated. This paper summarizes the vital data obtained by reviewing the literature concerning 162 cases of arterial injury associated with prior radiotherapy. The vessels involved include coronary arteries, the aorta, renal arteries, the extra- and intracranial circulation, the ilio-femoral system, and the upper extremity arteries. A review of the histologic findings, the studies regarding pathogenesis, and the morphology of the lesions found in these 162 patients suggests a disease distinct from the atherosclerotic process.

Bilateral false aneurysms after carotid endarterectomy

Aneurysms of the extracranial carotid artery are not common. Various etiological factors have been enumerated. A case with bilateral carotid aneurysms following endarterectomy is presented.

Aneurysms of the extracranial carotid artery. Twenty-one years' experience

Aneurysms of the extracranial carotid artery are an uncommon but potentially serious problem, usually due to rupture or thromboembolic events. Thirty-seven aneurysms of the extracranial carotid artery were seen in thirty-four patients from 1956 to 1977. The ages ranged from twenty-nine to ninety-two years, with an average of fifty-nine years. There were twenty-three males and eleven females. Nineteen (51 per cent) were false aneurysms, sixteen (44 per cent) atherosclerotic aneurysms, and two (5 per cent) posttraumatic aneurysms. All patients presented with evidence of a mass in the neck, and only five (15 per cent) had neurological symptoms related to the aneurysm. Surgery was performed on twenty-eight carotid aneurysms. Resection and patch angioplasty was employed for eighteen aneurysms, resection with graft replacement for six, and resection and ligation of the internal carotid artery for four. Postoperative neurologic deficits developed in three patients (11 per cent), and one of these died. There was one other operative death due to acute myocardial infarction (operative mortality, 7 per cent). Nonoperative treatment was employed when the patient had other associated high risk disease or a small asymptomatic aneurysm.