Interventional recanalization as a treatment of carotid stump syndrome caused by right internal carotid artery occlusion: A case report

Sudden unilateral eye pain with vision loss related to carotid stump syndrome; A case report and literature review

INTRODUCTION AND IMPORTANCE

Carotid stump syndrome (CSS) is a rare cause of recurrent ipsilateral cerebrovascular accidents (CVAs) resulting from completely occluded internal carotid artery (ICA). In this condition, hemodynamic and embolic risks are related to cerebral and retinal ischemic strokes.

PRESENTATION OF CASE

A 65-year-old gentleman with multiple comorbidities, presented to our hospital with a sudden painful unilateral vision loss of the right eye. Head CT was done upon arrival, showing no evidence of ischemic or hemorrhagic brain insult and multiple right frontoparietal old infarct lesions were detected. Central retinal artery occlusion diagnosis was confirmed by an ophthalmologist. CT angiogram of the brain and carotids was done and revealed an obliterated, thrombosed, and non-opacified right internal carotid artery from the carotid bifurcation up to intracranial petrous/foramen lacerum. After taking the patient's surgical consent, right carotid stump endarterectomy and ligation of the stump under general anesthesia was done and the postoperative period was uneventful.

CLINICAL DISCUSSION

CSS is an uncommon underlying etiology, causing recurrent stroke events. The clinical features of this syndrome include cerebral and ophthalmology symptoms. Diagnosis of CSS relies on imaging modalities. Internal carotid artery stump surgical excision through the ipsilateral ECA endarterectomy is the gold standard for CSS treatment.

CONCLUSION

Despite being a rare entity, CSS is a treatable cause of retinal embolic events TIAs. Therefore, it is important to raise awareness of such condition. The presented case demonstrates the diagnosis, management and prognosis of CSS.

Early Warning of Ischemic Stroke Based on Atherosclerosis Index Combined With Serum Markers

CONTEXT

Ischemic stroke (IS) is a serious public health problem worldwide, threatening human life and health. Atherosclerosis is the cause of stroke. At present, there are few selective indexes that can be used to evaluate atherosclerosis in the clinic; providers rely mainly on the atherosclerotic index (AI). Disturbance of lipid metabolism is considered to be a key event leading to IS.

OBJECTIVE

The purpose of this study was to discover potential biomarkers in the serum of atherosclerosis-induced IS, combined with the AI to provide early warning for the diagnosis of IS.

METHODS

In this study, we used nontargeted metabolomics based on ultra-high performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UPLC-Q/TOF-MS) to measure the changes in serum metabolites in a group of patients with IS. To verify the reproducibility of candidate biomarkers in the population, we expanded the sample size.

RESULTS

Five metabolites were identified, including sphingomyelin (18:0/14:0), 1-Methylpyrrolinium, PC (18:0/18:0), LysoPC (18:0/0:0), and PC (18: 2/18:2). The combination of these 5 metabolic markers has good diagnostic and predictive ability, and the change level of these metabolites is significantly related to IS. Our results also indicate that changes in glycerophospholipid metabolism may indicate an early risk of IS development.

CONCLUSION

These findings may contribute to the development of new diagnostic methods of potential biomarkers in serum combined with the AI, thereby providing early warning for the diagnosis of atherosclerosis-induced IS, and may provide a new insights for pathogenesis in IS.

A systematic review of endovascular treatment for chronic total occlusion of the internal carotid artery

The management of patients with symptomatic chronic total occlusion (CTO) of the internal carotid artery (ICA) is controversial. The aim of this systematic review was to investigate patient selection, technical success, early and late outcome of endovascular treatment for CTO of the ICA. PubMed/Medline and EMBASE databases were searched until January 2, 2020 for studies on endovascular treatment for CTO of the ICA. A descriptive analysis of demographic, clinical and anatomic data, endovascular technique, perioperative and late outcomes was performed. A total of 1,222 articles were screened, 8 retrospective or prospective cohort studies were reviewed; 276 patients, 18.9% females, mean age: 64.3 years, underwent attempt at endovascular treatment of 278 lesions. Two hundred and thirteen patients (77.2%) had neurological symptoms; the others had evidence of ipsilateral cerebral hypoperfusion. Two hundred and thirty-eight lesions (91.2%) were treated >30 days after diagnosis of occlusion. Technical success was 66.9%. Perioperative mortality was 1.64% (4/243), early stroke rate was 3.3%. Follow-up averaged 23.4 months (range, 0.25–84 months), late mortality was 1.89% (5/265), stroke rate was 3.4% (9/265). Stroke rate was similar after successful stenting (3.57%, 4/112) vs. failed stenting (3.61%, 2/61; P=1.00), stroke/death rates were also similar after successful stenting (5.36%, 6/112) than after failed stenting (3.28%, 2/61; P=0.71). Endovascular treatment of CTO of the ICA in eight cohort studies was safe and feasible with a technical success of 67% and a low rate of early and late neurological complications. Pooled data in this review failed to confirm the benefit of successful stenting on stroke and mortality, but some of the included studies suggest benefit and some also supported improvement in neurocognitive function after successful stenting. Prospective randomized trials to investigate the benefit of endovascular treatment in addition to best medical therapy for symptomatic CTO of the ICA are urgently needed.

Effect of Parecoxib on Hippocampus and Hypothalamic Orexin Neurons in Rats with Cerebral Infarction

Cerebral infarction has seriously threatened human life and health. Parecoxib is the first nonsteroidal analgesic for surgical analgesia. However, its effect on orexin neurons during cerebral infarction treatment is unclear. In this study, a rat model of cerebral infarction was established by suture method. The experiment was assigned into sham operation group, cerebral infarction model group (MCAO), high and low dose group of parecoxib. Western blotting and immunofluorescence staining was used to evaluate the activity of orexin neurons. The infarct size was evaluated by TTC staining. The apoptosis of neurons in hypothalamus and hippocampus was determined by AV-PI staining. TTC staining suggested that parecoxib treatment significantly reduced cerebral infarct size, increased orexin neuronal activity, and decreased neuronal apoptosis in hypothalamus and hippocampus, which were significantly different from sham-operated groups. This study demonstrates that parecoxib has a protective effect on cerebral infarction rats, which can inhibit the apoptosis of hypothalamic and hippocampal neurons through the orexin neuron pathway. It provides a theoretical basis for the protective effect of parecoxib, indicating that it might be a new target for the treatment of cerebral infarction.

Acute Hemispheric Stroke: Full Remission Following Surgical Thrombectomy

Introduction

Carotid occlusion because of embolisation or as a distal extension of thrombus formation in an ulcerated plaque can be the cause of a devastating stroke, caused by sudden occlusion of the internal carotid artery (ICA). Often, invasive treatments are not an option because of the limited time frame. In rare situations of acute stroke onset and admission to therapy within six hours however, aggressive recanalisation may be considered. This technical note demonstrates surgical transcatheter embolectomy of intra-extra cranial ICA by reducing inflow by placing a clamp on the common carotid artery (CCA) before puncture cranial to the clamp.

Patient and technique

A 67 year old man was admitted as an emergency seven hours after an acute hemispheric stroke with paraplegia of his left arm and full consciousness. An immediate duplex scan showed more than 90% stenosis of the carotid bifurcation with low echolucent plaque material extending proximally up to the intracranial ICA. CT angiography confirmed the stenosis and a sub-occlusive thrombosis of the ICA up to the M1 segment of the middle cerebral artery (MCA). Because the onset of clinical symptoms was more than six hours previously, the patient was not within the clinical window for endovascular therapy. Following interdisciplinary consensus, surgical over the wire thrombectomy with endarterectomy with complete removal of the thrombus and subsequent thrombo-endarterectomy of the carotid bifurcation and bovine patch plasty was performed. The patient was discharged with statin and antiplatelet treatment on the second post-operative day with full remission of symptoms.

Conclusions

Immediate surgical transcatheter recanalisation of acute intra-extracerebral ICA thrombus with inflow reduction can be a valid procedure to improve cerebral circulation, leading to full remission of stroke symptoms.