Retropharyngeal abscess due to Fusobacterium necrophorum complicated by progressive internal carotid artery stenosis and multiple cranial nerve palsies

BACKGROUND

A case of retropharyngeal abscess complicated by both artery and nerve injury has rarely been reported.

METHODS

A 36-year-old woman suddenly presented with right eye visual loss, dilated pupil, reduced direct light reflex, ptosis and ocular motility disorder on the side of inflammation progression, and was diagnosed with retropharyngeal abscess due to Fusobacterium necrophorum. The patient was treated only with antibiotics and, no further surgery was necessary but tracheotomy. Four months later, MRA showed right ICA occlusion and left ICA stenosis. MRI revealed continuous spread of inflammation due to the abscess from the retropharyngeal to the intracranial space.

RESULTS

These severe complications would be attributed to an endothelial damage to the arterial wall and an ischemic neuropathy caused by inflammation and thrombogenesis due to Fusobacterium necrophorum.

CONCLUSIONS

This case should provide a better understanding of the mechanism of vascular and cranial nerve injury due to retropharyngeal infections, and highlights the need for early antibiotic therapy and repeated vascular evaluation.

Internal Carotid Artery Stenosis and Ipsilateral Subretinal Drusenoid Deposits

Purpose

Subretinal drusenoid deposits (SDDs) in age-related macular degeneration (AMD) are strongly associated with vasculopathies such as myocardial infarction and ischemic stroke. This study evaluates ischemic stroke subjects for SDDs to determine whether ocular hypoperfusion from internal carotid artery (ICA) stenosis is associated with ipsilateral SDDs.

Methods

A cross-sectional study at Mount Sinai Hospital recruited 39 subjects with ischemic stroke (aged 52-90; 18 women, 21 men); 28 completed all study procedures. Computed tomography (CT) of the head and neck evaluated 54/56 ICAs for stenosis criteria: none (n = 33), mild (n = 12), moderate (n = 3), severe (n = 3), and complete (n = 3). Spectral-domain optical coherence tomography (SD-OCT) scans were read to consensus by two masked graders for soft drusen, SDDs and choroidal thickness (CTh; choroidal thinning = CTh < 250 µm). Univariate testing was done with Fisher's exact test. Multivariate logistic regression models tested age, gender, and ICA stenosis as covariates.

Results

Moderate or more ICA stenosis (≥50%-69%) was significantly associated with ipsilateral choroidal thinning (P = 0.021) and ipsilateral SDDs (P = 0.005); the latter were present distal to six of nine stenosed ICAs versus five of 33 normal ICAs. Mild ICA stenosis (≥1%-49%) was not significantly associated with ipsilateral SDDs. Multivariate regression found that older age (P = 0.015) and moderate or more ICA stenosis (P = 0.011) remained significant independent risks for ipsilateral SDDs.

Conclusions

At least moderate ICA stenosis (≥50%-69%) is strongly associated with ipsilateral SDDs and choroidal thinning, supporting downstream ophthalmic artery and choroidal hypoperfusion from ICA stenosis as the mechanism for SDD formation. SDDs may thus serve as sensitive biomarkers for ischemic stroke and other vascular diseases.

Transcarotid Artery Revascularization (TCAR): The Best Surgical Intervention Option in an Unusual Presentation of Carotid Dissection in a 37-Year-Old Pregnant Female

Carotid artery dissection (CAD) is a condition that compromises blood flow and leads to serious complications such as a stroke or cerebrovascular accident (CVA). This case report demonstrates an unusual case of right internal carotid artery dissection, stenosis of >70%, and an intraluminal thrombus. The patient presented to the emergency department with complaints of right-sided neck pain and severe headache status-post a complicated pregnancy. A computed tomography (CT) angiogram of the right carotid was conducted and showed a right internal carotid artery dissection with 70% luminal stenosis and thrombosis. Carotid endarterectomy (CEA), transfemoral carotid angioplasty with stenting (CAS), or transcarotid artery revascularization (TCAR) were all surgical intervention options that were explored. Risks and benefits were compared between the three surgical intervention options, and transcarotid artery revascularization was deemed the best surgical option in this patient's case.

[Advisability of carotid endarterectomy in asymptomatic patients]

OBJECTIVE

To determine the optimal treatment strategy for patients with asymptomatic carotid stenosis.

MATERIAL AND METHODS

The authors reviewed clinical guidelines for the management of patients with asymptomatic carotid stenosis 60-99%, as well as medical studies and meta-analyses comparing carotid endarterectomy and optimal drug therapy in asymptomatic patients between 1993 and 2023.

RESULTS

The choice of treatment strategy for patients with asymptomatic carotid artery stenosis is still a controversial issue. There were several large randomized clinical trials comparing carotid endarterectomy with optimal medical therapy in asymptomatic patients at the end of the 20th century. However, drug therapy has undergone significant changes calling into question the relevance of previous results. This review highlights the evolution of management of patients with asymptomatic carotid stenosis and also presents modern approaches to the treatment of these patients.

CONCLUSION

Patients younger 75 years old gain an advantage from carotid endarterectomy with small perioperative risk compared to optimal drug therapy and yearly risk of cerebral embolism. Patients with asymptomatic carotid stenosis 80-99% are candidates for carotid endarterectomy due to higher risk of acute cerebrovascular accident at least until more data are available. The choice of the best tactics for a particular patient should be made individually depending on own experience and patient's adherence to therapy and lifestyle correction. The results of the ACTRIS (2025) and CREST-2 (2026) studies are expected to clarify this issue.

Indications and Outcome of Carotid Endarterectomy (CEA): A Single Centre Experience

Background Stroke is a prevalent ailment that impacts a substantial number of individuals globally, resulting in both physical impairment and mortality. One of its major causes is carotid artery stenosis. The symptoms and degree of stenosis are key indications for carotid endarterectomy (CEA). In this study, we highlight the indications and outcomes of carotid endarterectomy in our center. Methods This is a descriptive, retrospective, observational study. Data of patients who underwent CEA at Glan Clwyd Hospital from January 2018 to January 2023 was retrieved. The study sample consisted of patients diagnosed with symptomatic carotid artery stenosis who had CEA at Glan Clwyd Hospital. The data was analyzed using statistical software SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Results A total of 150 patients were enrolled in the study. A majority of the patients were male, accounting for 69.3% (n = 104), and had a mean age of 71.1 ± 9.9 standard deviation. A majority of the patients were smokers (48.7%) and had additional medical conditions, including hypertension (34%), ischemic heart disease (17.3%), chronic obstructive pulmonary disease (73.3%), and diabetes (46.7%). Nevertheless, the remaining comorbidities were less common. The outcome of the CEA among the patients was cardiac event 3.3% (n = 5); transient ischemic attack (TIA) 3.3% (n = 5); stroke 0.6% (n = 1); hemorrhage 2.6% (n = 4); surgical site infection 2% (n = 3); perioperative mortality 1.3% (n = 2); and cranial nerve injury 1.3% (n = 2). However, no complications were reported in most of the patients, 85.6% (n = 128). Conclusion An endarterectomy is quite advantageous for treating symptomatic stenosis. The findings can be applied to patients who are physically suitable for surgery. The efficacy of endarterectomy is contingent upon not only the severity of carotid stenosis but also various other parameters, such as the time elapsed between the presenting event and the surgical intervention, as well as the patient's overall medical condition. However, the CEA is the gold standard in surgical management for symptomatic carotid disease.

Stronger influence of systemic than local hemodynamic-vascular factors on resting-state BOLD functional connectivity

Correlated fluctuations in the blood oxygenation level dependent (BOLD) signal of resting-state functional MRI (i.e., BOLD-functional connectivity, BOLD-FC) reflect a spectrum of neuronal and non-neuronal processes. In particular, there are multiple hemodynamic-vascular influences on BOLD-FC on both systemic (e.g., perfusion delay) and local levels (e.g., neurovascular coupling). While the influence of individual factors has been studied extensively, combined and comparative studies of systemic and local hemodynamic-vascular factors on BOLD-FC are scarce, notably in humans. We employed a multi-modal MRI approach to investigate and compare distinct hemodynamic-vascular processes and their impact on homotopic BOLD-FC in healthy controls and patients with unilateral asymptomatic internal carotid artery stenosis (ICAS). Asymptomatic ICAS is a cerebrovascular disorder, in which neuronal functioning is largely preserved but hemodynamic-vascular processes are impaired, mostly on the side of stenosis. Investigated indicators for local hemodynamic-vascular processes comprise capillary transit time heterogeneity (CTH) and cerebral blood volume (CBV) from dynamic susceptibility contrast (DSC) MRI, and cerebral blood flow (CBF) from pseudo-continuous arterial spin labeling (pCASL). Indicators for systemic processes are time-to-peak (TTP) from DSC MRI and BOLD lags from functional MRI. For each of these parameters, their influence on BOLD-FC was estimated by a comprehensive linear mixed model. Equally across groups, we found that individual mean BOLD-FC, local (CTH, CBV, and CBF) and systemic (TTP and BOLD lag) hemodynamic-vascular factors together explain 40.7% of BOLD-FC variance, with 20% of BOLD-FC variance explained by hemodynamic-vascular factors, with an about two-times larger contribution of systemic versus local factors. We conclude that regional differences in blood supply, i.e., systemic perfusion delays, exert a stronger influence on BOLD-FC than impairments in local neurovascular coupling.

Alternative Proximal Protection Method during Carotid Artery Stenting Using Combined Transbrachial and Transradial Artery Approaches

Herein, we report a case of carotid artery stenting with proximal flow protection for severe stenosis of the left internal carotid artery using transbrachial and transradial artery approaches. Because an abdominal aortic aneurysm was present, we avoided the transfemoral approach. The procedure was successfully performed with a combination of an 8-Fr balloon guide catheter and microballoon catheter on separate axes. No complications such as pseudoaneurysm, thrombosis, or dissection were observed at the puncture site. The patient was discharged without complications and showed good outcomes at 3 months. This technique may offer a useful alternative for patients with severe stenosis who cannot be treated using a femoral artery approach.

Recurrent Lymphocytic Hypophysitis Presenting as Internal Carotid Artery Stenosis and Oculomotor Nerve Palsy

A 75-year-old woman presented with nausea and vomiting. Magnetic resonance imaging (MRI) revealed that she had a pituitary mass. A biopsy revealed lymphocytic hypophysitis (LYH). Symptoms were improved by hormone replacement therapy. Although she was asymptomatic, follow-up MRI revealed an increase in the size of the mass. Intravenous methylprednisolone (IVMP) reduced the size of the mass; however, right ophthalmalgia and oculomotor nerve palsy developed. MRI showed that the pituitary mass had enlarged to the right oculomotor nerve in the cavernous sinus and to the right internal carotid artery (ICA), causing stenosis of the ICA. After IVMP administration, the symptoms dramatically improved, but ICA stenosis persisted.

Late In-Stent Thrombosis After Carotid Artery Stenting for Symptomatic Internal Carotid Artery Stenosis in a Patient With JAK2 V617F-Positive Essential Thrombocythemia: An Illustrative Case Report

Essential thrombocythemia (ET) is a myeloproliferative disorder complicated by thrombosis in 13% of cases. The Janus kinase 2 (JAK2) V617Fmutation is present in 60% of ET cases, and it has recently been reported that the mutation itself is a significant contributor to ischemic stroke. Here, we present an illustrative case of late in-stent thrombosis following carotid artery stenting (CAS) in a patient with ET and the JAK2 V617F mutation presenting with symptomatic internal carotid artery (ICA) stenosis. An 80-year-old man with a history of JAK2 V617F-positive ET suffered from left upper motor weakness and numbness. Magnetic resonance imaging/magnetic resonance angiography revealed multiple acute cerebral infarctions scattered in the right frontal and parietal lobes and right ICA stenosis. Despite continued antiplatelet therapy, plaque size did not decrease. CAS was performed one month later; however, five months after the procedure, in-stent thrombus growth was observed, leading to severe stenosis despite administering antiplatelet or anticoagulant drugs. The thrombus was eventually resolved with increased doses of hydroxyurea and aspirin administration. In conclusion, controlling platelets and inflammation with hydroxyurea and aspirin may help improve the condition in case of rapid thrombosis due to the JAK2 V617F mutation, unlike other thromboses. This case highlights the importance of careful follow-up after CAS.

External carotid artery to ophthalmic artery flow associated with internal carotid artery stenosis

PURPOSE

One of the most devastating complications of facial filler injection is sudden ischemic blindness. However, its mechanisms and predisposing factors are poorly understood. The purpose of this study was to investigate the prevalence of external carotid artery (ECA) to ophthalmic artery (OA) anterograde flow in patients with internal carotid artery (ICA) stenosis and in a control population without carotid disease.

METHODS

In this cross-sectional cohort study, two groups of patients who underwent catheter cerebral angiography over a 5-year period were identified: patients with symptomatic ICA stenosis and a control group of patients with refractory epistaxis undergoing embolization. Angiograms were reviewed by an interventional neuroradiologist. The primary outcome measure was the presence of ECA to OA flow, defined as choroidal blush before filling of the circle of Willis. Secondary outcome measures included the percentage and location of ICA stenosis and ECA anastomotic branches involved.

RESULTS

The study included 149 patients with ICA stenosis and 69 control patients. ECA to OA flow was more prevalent in patients with ICA stenosis (34.9%) compared to controls (2.9%) (p < .001). Logistic regression demonstrated that for each 10% increase in ICA stenosis over 70%, there was 2.8 times increased risk of ECA to OA flow (p < .001).

CONCLUSIONS

ECA to ICA anterograde flow can be demonstrated in approximately 3% of control patients and in over 1/3 of patients with symptomatic carotid stenosis. This provides a plausible pathway for small filler particles to pass with blood flow from the facial to the ophthalmic circulation.

Retinal Microvascular Changes in Internal Carotid Artery Stenosis

Purpose: We aimed to analyze retinal microvascular parameters, measured by optical coherence tomography angiography in patients with internal carotid artery stenosis compared to healthy individuals. Materials and Methods: A total of 41 eyes from 30 patients who had varying degrees of carotid stenosis, and 42 eyes from 42 healthy controls, were enrolled in this study. Depending on the degree of stenosis evaluated by Doppler ultrasonographic imaging, the patient group was further subclassified into mild, moderate, and severe carotid artery stenosis. Superficial and deep capillary plexus vessel densities, radial peripapillary capillary vessel density, foveal avascular zone, and flow densities in the choriocapillaris and outer retina were evaluated by optical coherence tomography angiography. Results: The superficial and deep capillary plexus vessel densities were significantly reduced among the groups, only sparing the foveal region. The mean superficial plexus vessel density was 45.67 ± 4.65 and 50.09 ± 4.05 for the patient and control group, respectively (p = 0.000). The mean deep capillary plexus density was 46.33% ± 7.31% and 53.27% ± 6.31% for the patient and control group, respectively (p = 0.000). The mean superficial and deep capillary vessel densities in the foveal region did not show any statistical difference between the patient and control groups (p = 0.333 for the superficial and p = 0.195 for the deep plexus vessel density). Radial peripapillary capillary vessel density was decreased in the patient group (p = 0.004). The foveal avascular zone area was wider in the patient group but this difference did not show a significant difference (p = 0.385). Conclusions: Retinal microvascular changes are a prominent outcome of internal carotid disease, and even mild stenosis can lead to alterations in the retinal microvascular bed which could be detected by OCTA. By early detection of microvascular changes in the retina in this patient group, we might speculate the overall vascular condition.

Lesion patterns and mechanism analysis of acute contralateral ischemic stroke accompanying stenosis of unilateral extracranial internal carotid artery

BACKGROUND

Previous studies on unilateral internal carotid artery occlusive disease have focused on the mechanisms of ipsilateral hemispheric stroke, and contralateral stroke is considered to be an accidental phenomenon. Little is known about the relationship between severe stenosis (including occlusion) of the unilateral extracranial segment of the internal carotid artery and contralateral cerebral stroke, and the infarct patterns and pathogenesis require further study. The purpose of this study was to investigate the clinical characteristics and pathogenesis of contralateral acute stroke with unilateral extracranial internal carotid artery stenosis (including occlusion).

METHODS

Thirty-four patients were enrolled in this study, and all patients underwent routine clinical evaluation, including medical history, physical examination, laboratory tests, and various imaging evaluations. The morphological characteristics of diffusion-weighted magnetic resonance imaging were applied to determine infarct patterns. The etiological classification was confirmed according to the TOAST classification.

RESULTS

There were six distinctive lesion patterns: small subcortical infarcts (six patients), large subcortical infarcts (one patient), diffuse infarcts (eight patients), multiple anterior circulation infarcts (eight patients), multiple posterior circulation infarcts (two patients), and multiple anterior and posterior circulation infarcts (nine patients).

CONCLUSION

Diffuse and multiple infarcts were the most common topographic patterns in ischemic stroke contralateral to internal carotid artery stenosis or occlusion. Hemodynamic impairment of the contralateral hemisphere due to hypoperfusion and blood theft is regarded as the basis of stroke occurrence. Low ischemic tolerance and embolism are the main causes of acute ischemic stroke.

Percutaneous Transluminal Angioplasty and Stenting for Progressive Intracranial Carotid Artery Stenosis Secondary to Invasive Sphenoid Sinus Aspergillosis: A Case Report

We report a case of invasive sphenoid sinus aspergillosis with progressive internal carotid artery (ICA) stenosis and contralateral carotid occlusion that was successfully treated with percutaneous transluminal angioplasty and stenting (PTAS). A 70-year-old man presented with right-sided visual disturbance, ptosis, and left hemiparesis. Magnetic resonance imaging of the head revealed a space-occupying lesion within the sphenoid sinus with infiltration of the bilateral cavernous sinuses, right ICA occlusion, and multiple watershed cerebral infarcts involving the right cerebral hemisphere. The patient was diagnosed with invasive sinus aspergillosis based on transnasal biopsy findings. Despite intensive antifungal therapy using voriconazole, rapidly progressive aspergillosis led to a new stenotic lesion in the left ICA, which increased the risk of bilateral cerebral hypoperfusion. We performed successful PTAS to prevent critical ischemic events. Finally, aspergillosis was controlled with voriconazole treatment, and the patient was discharged. He showed a favorable outcome, with a patent left ICA observed at a 3-year follow-up. PTAS may be feasible in patients with ICA stenosis and invasive sinus aspergillosis.

The clinical safety of generic and brand clopidogrel in patients undergoing carotid endarterectomy: a randomized controlled trial

Although some recent studies have found that original and generic clopidogrel brands are acceptable and have the same pharmacokinetic and pharmacodynamic properties, there is insufficient evidence to compare the clinical effectiveness and safety of brand and generic clopidogrel. The current study aims to evaluate the clinical safety of brand and generic clopidogrel by comparing clinical outcomes in patients undergoing carotid endarterectomy (CEA).

Method

This was a single centre, parallel-arm, phase III, open-label, and randomized group sequential trial. It was conducted to compare the clinical safety of a brand and three generic clopidogrel forms in patients who have undergone CEA. All enrolled subjects were treated perioperatively with dual antiplatelet (aspirin and clopidogrel). The involved participants were assigned randomly into four groups based on the type of clopidogrel. Safety parameters were measured, including haematoma, blood draining from drainage, mouth deviation, tongue deviation, and stroke. SPSS software was used to perform the data analysis.

Results

The trial included 80 patients in total (20 patients per group). Thirty-one (38.8%) patients were male. The mean age of patients was 65.6 years (49-79). Eighteen (22.5%) patients had a history of previous coronary intervention, and seventeen (21.3%) had symptomatic carotid artery stenosis. Overall, Plavix or Piax combined with aspirin were linked to better clinical safety than the other two generic clopidogrel, as the amount of bleeding was nearly two times lower in patients treated with Plavix or Piax (270±92.39 and 271.5±80.60, respectively) compared to PlavigrelAwa or Plavineer (505.7±169.1 and 496.5±174.6, respectively) (P≤0.001).

Conclusion

The findings of the current study showed diversity in clinical safety of different clopidogrel formulations that were provided perioperatively in CEA patients.

A Rare Case of Moyamoya Disease in a Patient With Sickle Cell Disease

Moyamoya disease (MMD) is an infrequent progressive cerebral pathology that primarily affects the branches of the internal carotid artery, resulting in stenosis of the internal carotid artery and subsequent development of multiple collateral vessels. As the disease advances, it manifests through various clinical presentations, including stroke and seizures. Prevalence rates indicate a higher incidence among individuals of Eastern Asian descent, while it is notably less common among African Americans. This case report describes the clinical presentation of a 32-year-old African-American female with a past medical history of sickle cell disease and stroke, who sought medical attention at our institution due to a deterioration in left-sided weakness and left wrist drop. Although the patient had been diagnosed with MMD at an early age, no previous medical records were available. Diagnostic evaluation utilizing brain imaging techniques confirmed the presence of MMD, exhibiting minute collaterals that had replaced the middle cerebral artery.

Internal carotid artery stenosis: hemodynamics in the ipsilateral ACA affects CT angiography manifestations

Objective

This study aimed to evaluate whether CT angiography (CTA) manifestations in anterior cerebral artery a1 segment (A1) were related to the hemodynamics in patients with internal carotid artery stenosis (ICAS).

Methods

A total of 97 cases were selected. The degree of ICAS and symmetry of A1 were evaluated by CTA examination. Hemodynamic indexes were detected by transcranial Doppler (TCD). The differences in CTA presentations of A1 and hemodynamics between the vessels on the stenotic and contralateral sides were analyzed according to the different degrees of stenosis. The degree of ICAS according to the different manifestations of A1 and the hemodynamics of A1's adjacent vessels were also analyzed.

Results

In the case of unilateral ICAS, the difference in Vm of A1 between the stenotic and the contralateral side was the most significant relative to the stenosis degree. When unilateral ICAS was ≥70%, the presentation of A1 on the stenotic side was more slender or non-visualized compared to that on the contralateral side, while in cases with unilateral stenosis <70% or bilateral stenosis with a similar degree of stenosis, A1 were mainly symmetrical. When A1 on the side of ICAS was slender or non-visualized, the Vm of A1 was significantly slower than that on the contralateral side (P < 0.001).

Conclusion

The CTA manifestations of A1 on the side of ICAS embodied the overall changes of the intracranial hemodynamics after ICAS. A combination of TCD and CTA examination of A1 can assist in judging the location and degree of ICAS.

Leukocyte Count Predicts Carotid Artery Stenosis in Men with Ischemic Stroke: Sub Study of the Preventive Antibiotics in Stroke Study (PASS)

Background: Inflammation is important in the development of atherosclerosis. Research suggested sex-dependent differences for the value of inflammatory markers for risk stratification of stroke patients with internal carotid artery stenosis (ICAS). We investigated whether leukocytes and thrombocytes were associated with ≥50% ICAS in acute stroke and whether this was sex-dependent. Patients included in the Preventive Antibiotics in Stroke Study (PASS) were used. PASS is a randomized controlled trial that randomized between four days of preventive ceftriaxone intravenously or standard stroke care alone. It investigated whether ceftriaxone could improve functional outcome at three months after stroke. Methods: Patients included in PASS were evaluated for the predictive value of leukocytes and thrombocytes for ICAS. Ischemic stroke and TIA patients were selected out of PASS patients. Logistic regression analysis was performed adjusting for NIHSS and other covariates. Results: 2550 patients were included in PASS. 1413 of 2550 patients (55%) were evaluated in this sub study. Female patients showed a mean of 8.55 × 10⁹/L for leukocytes and 259 × 10⁹/L for thrombocytes. Men showed a mean of 8.29 × 10⁹/L for leukocytes and 224 × 10⁹/L for thrombocytes. Multivariate logistic regression analysis showed that leukocytes were independently associated with ICAS ≥ 50% in male patients (OR 1.094, p = 0.008), but not in female patients (OR 1.041, p = 0.360). Thrombocytes were not associated with ICAS. Conclusions: We conclude that blood leukocyte count independently predicts ICAS in men after acute stroke, but not in women. Clinical Trial unique identifier: ISRCTN66140176.

Stenting for elderly patients with internal carotid artery stenosis: analysis of clinical efficacy

OBJECTIVE

This retrospective study aimed to investigate the clinical efficacy and safety of carotid artery stenting (CAS) in elderly patients with internal carotid artery stenosis (ICS).

METHODS

Ninety elderly ICS patients admitted between January 2019 - July 2021 were selected and divided into a control group and a research group according to different treatment method. The 42 cases in the control group were received carotid endarterectomy and the 48 cases in the research group were treated with CAS. The effects of the two intervention methods on the National Institutes of Health Stroke Scale (NIHSS) score, complication rate, oxidative stress, inflammatory cytokines and cognitive function were observed and evaluated.

RESULTS

Compared to baseline (before treatment), the research group showed significantly reduced scores of NIHSS and activities of daily living, appreciably decreased levels of malonaldehyde, interleukin-6 and high-sensitivity C-reactive-protein, but increased superoxide dismutase, Rapid Verbal Retrieve score and Digit Span Test score after treatment. Also, the same trends were found when comparing the above results with those of the control group after treatment. The two groups showed a comparable complication rate.

CONCLUSIONS

The above data indicate a definite clinical efficacy and a favorable safety profile of CAS for ICS in the elderly. CAS can effectively reduce the oxidative stress and inflammatory cytokines of patients and enhance their cognitive function.

Buddy Catheter Technique: A Method of Guiding the Mo.Ma Ultra into a Left Common Carotid Artery That Branches off the Aortic Arch at a Steep Angle

Objective

The Mo.Ma Ultra is an embolic protection device used in carotid artery stenting (CAS). In cases of left internal carotid artery stenosis (ICS) in which the common carotid artery (CCA) branches off the aortic arch at a steep angle, insertion of the Mo.Ma Ultra into the CCA is sometimes difficult. We introduce a "buddy catheter technique" that helps guide the Mo.Ma Ultra into the CCA, with an additional 4 Fr catheter into the external carotid artery.

Case Presentation

An 84-year-old man with left ICS whose CCA also branched off the aortic arch at a steep angle also underwent CAS. The "buddy catheter technique" was used, and the Mo.Ma Ultra was inserted smoothly. The buddy catheter technique displaces the left CCA upward. Displacement straightens the vessels anatomically, and the ledge effect can be prevented by aligning the course of the vessels with the wire. Nevertheless, this technique requires bilateral femoral puncture, and so, complications can occur.

Conclusion

The buddy catheter technique may be considered in cases in which the left CCA branches off the aortic arch at a steep angle.

Combination of High-Density Lipoprotein Cholesterol and Lipoprotein(a) as a Predictor of Collateral Circulation in Patients With Severe Unilateral Internal Carotid Artery Stenosis or Occlusion

BACKGROUND AND PURPOSE

Collateral circulation is considered an important factor affecting the risk of stroke, but the factors that affect collateral circulation remain unclear. This study was performed to identify the factors associated with collateral circulation, especially blood lipids.

METHODS

The study involved patients who had undergone digital subtraction angiography and were confirmed as having severe unilateral stenosis or occlusion of the internal carotid artery (ICA). We classified the collateral circulation status of each patient as good (Grade 3 or 4) or poor (Grade 0, 1, or 2) according to the grading system of the American Society of Interventional and Therapeutic Neuroradiology/American Society of Interventional Radiology. We collected data on patients' characteristics and identified the factors that affect collateral circulation.

RESULTS

This study included 212 patients. The multivariate logistic regression analysis showed that the high-density lipoprotein cholesterol (HDL-C) concentration and a complete anterior half of the circle of Willis were independent protective factors for good collateral circulation, whereas elevated lipoprotein(a) [Lp(a)] and serum creatinine concentrations were independent risk factors for good collateral circulation. The area under the receiver operating characteristics curve (AUC) was 0.68 (95% confidence interval [CI], 0.61-0.76) for HDL-C and 0.69 (95% CI, 0.62-0.76) for Lp(a). A binary logistic regression model analysis of the joint factor of HDL-C and Lp(a) yielded an AUC of 0.77 (95% CI, 0.71-0.84).

CONCLUSIONS

In patients with severe unilateral ICA stenosis or occlusion, the combination of HDL-C and Lp(a) is a useful predictor of collateral circulation.

Posterior fossa transient ischemic attack in the setting of bilateral persistent hypoglossal arteries: A case report and literature review

RATIONALE

Persistent hypoglossal artery (PHA) is the second rare abnormal anastomosis of the internal carotid and vertebrobasilar arteries, and bilateral persistent hypoglossal arteries in particular have rarely been reported. This is the first case of bilateral persistent hypoglossal arteries presenting with posterior fossa transient ischemic attack (TIA).

PATIENT CONCERNS

We reported a 54-year old female with posterior fossa TIA due to the coexisting bilateral persistent hypoglossal arteries and left internal carotid artery stenosis.

DIAGNOSIS

The patient was diagnosed with posterior fossa TIA, bilateral persistent hypoglossal arteries and left internal carotid artery stenosis.

INTERVENTIONS

The patient was given aspirin 100 mg/qd and advised to avoid excessive neck movement.

OUTCOMES

Symptoms of intermittent subjective dizziness accompanied by nausea were relieved.

LESSONS

Although requires no special treatment, PHA could be accompanied by hypoplasia of vertebral arteries and posterior communicating arteries and becomes the main blood supply pathway for the posterior circulation. Accurate identification and evaluation of PHA is important of ensuring the safety of carotid interventions and identifying specific types of stroke.

Anastomoses (Superficial Cervical Ansa) Between the Cervical Plexus and Peripheral Facial Nerve Branches: Implications for Regional Anesthesia in Carotid Endarterectomies - Anatomical Study

Purpose

Sensory innervation in the carotid triangle involves the cervical plexus, cranial nerves, and the sympathetic trunk. This innervation also applies to skin incision, including various anatomical structures with potentially different innervation, such as the skin (dermatomes), the platysma (myotomes), and the superficial layer of the cervical fascia (fasciotomes), as well as retromandibular retractor insertion (co-innervation: V, VII). The aim of this anatomical study was to develop an injection technique for carotid endarterectomies to additionally block anastomoses between the transverse cervical nerve (TCN), the cervical branch VII (CB VII), and the marginal mandibular branch VII (MMB VII). These anastomoses are also termed superficial cervical ansa (SCA).

Materials and Methods

Preparations (n=16) were performed on unembalmed donor cadavers (n=8). Subplatysmal injections (each using 5 mL of Alcian blue) were performed cranially within the carotid triangle between the anterior margin of the sternocleidomastoid muscle and the submandibular gland.

Results

Anastomoses between the TCN, CB VII, and MMB VII were stained in all preparations (n=16).

Conclusion

This anatomical study presents an ultrasound-guided subplatysmal SCA block to optimize, in addition to a cervical plexus block, the quality of anesthesia for carotid endarterectomies.

A case of carotid endarterectomy assisted with a three-way junction shunting tube for the internal carotid artery stenosis involving a persistent primitive hypoglossal artery

Only several cases of internal carotid artery (ICA) stenosis involving the persistent primitive hypoglossal artery (PPHA) have been treated with carotid endarterectomy (CEA) because of its extreme rarity. CEA was performed for an 87-year-old female with severe stenosis of the right ICA–PPHA bifurcation requiring shunting from CCA to both PPHA and ICA. We initially attempted to insert two intraluminal balloon shunts into the CCA, as previously reported. However, we found this procedure technically impossible to achieve. An improvised three-way junction tube was inserted distally into PPHA and ICA and proximally into CCA, securing blood flow during CEA. Unfortunately, the patient suffered post-operative ischemic brain lesions due to the prolonged ischemic time during our initial unsuccessful shunt attempt. A three-way junction shunting tube could be an effective shunt technique during an anatomically complicated CEA.

Psychological Determinants of Attitude to Surgery in Internal Carotid Artery Stenosis Patients

The basic way to prevent cerebral stroke in symptomatic 70–99% stenosis of internal carotid artery (ICA) is an open or endovascular surgical procedure. Psychological research done so far among ICA stenosis patients focused on cognitive functioning changes. The objective was to assess attitude to surgery in relation to self-efficacy, life quality perception, and health locus of control in ICA stenosis patients. Materials and Methods: The study involved 53 asymptomatic ICA stenosis patients, aged from 53 to 81. Four scales were applied: Generalized Self-Efficacy Scale (GSES); Satisfaction With Life Scale (SWLS); Multidimensional Health Locus of Control Scale (MHLC); and a simple scale to examine the attitude to surgery, where “−10” stands for the maximally negative attitude, “0”—neutral, and “+10”—maximally positive. The obtained results were put to statistical analysis. Results: It was found that women and men assessed their attitude to the surgery as positive (M = 7.92; SD = 3.094), though the men estimated it slightly higher (M = 8.03; SD = 3.02) than the women (M = 7.67; SD = 3.37). The mean value of self-efficacy was high (M = 32.53; SD = 6.231), and slightly higher for the men (M = 32.79; SD = 5.576) compared to the women (M = 31.87; SD = 7.836). The patients generally tended to manifest the external personal health locus of control (M = 28.62; SD = 3.17). The runner-up was internal health locus of control (M = 26.02; SD = 3.775), and the next one—external impersonal aspect (chance/luck) (M = 23.57; SD = 4.457). The mean assessment of the patients’ own life quality proved to be above average (M = 23.60) but varied (SD = 5.95). The women perceived the quality of their lives as better (M = 24.33; SD = 6.422) than the men (M = 23.32; SD = 5.818). Very strong positive correlations were found between self-efficacy and life quality assessment (p < 0.001) and between the internal and external personal aspects of health locus of control (p < 0.007) in the women, and positive correlations were found between the attitude to surgery and internal health locus of control (p < 0.021) in the men. Conclusions: When breaking the news of a need to have a surgical intervention due to ICA stenosis, the physician should strongly refer to the value of human life and health. The message should arise from external (in the case of women) or internal (in the case of men) motivation to undergo surgery, and enhance the patient’s conviction that the disease should be considered a challenge which must be taken to reverse their unfavorable situation and improve life quality.

Retinal vessel oxygen saturation in patients with unilateral internal carotid artery stenosis: a pilot study

PURPOSE

To investigate the retinal vessel oxygen saturation in patients with internal carotid artery stenosis (ICAS).

METHODS

This is a cross-sectional study. Sixteen patients with unilateral moderate or worse ICAS (≥50%) and no fundus diseases were included in the study. Sixteen gender- and age-matched healthy subjects were selected as controls. The mean oxygen saturation and vessel diameters of the retinal arterioles and venules were obtained using a dual-wavelength spectrophotometric retinal oximeter.

RESULTS

In the eye of the stenotic side, the retinal vessel oxygen saturation was 100.14 ± 10.27% in the arterioles and 56.50 ± 10.79% in the venules, and the arteriovenous (A-V) difference was 43.63 ± 7.71%. In the eye of the contralateral side, the oxygen saturation was 96.55 ± 7.50% in the arterioles and 57.42 ± 9.84% in the venules, and the A-V difference was 39.39 ± 6.33%. In healthy subjects, the oxygen saturation was 93.22 ± 5.98% in the arterioles and 56.57 ± 7.05% in the venules, and the A-V difference was 36.65 ± 7.33%. The arteriolar oxygen saturation in the stenotic side was higher than that in the contralateral side (p = 0.025) and that in the healthy subjects (p = 0.027), and the A-V difference in the stenotic side was significantly higher than that in the contralateral side (p = 0.009) and that in the healthy subjects (p = 0.013). The diameters of the arterioles in the stenotic side were smaller than those in the healthy subjects (p = 0.030).

CONCLUSIONS

Patients with ICAS had decreased retinal arteriole diameters and increased retinal vessel oxygen saturation in the arterioles and A-V differences, suggesting the presence of microcirculation disorder and hyperoxia in the retina.

Usefulness of 2D-Perfusion Analysis for the Assessment of Unilateral Cervical Internal Carotid Artery Stenosis

Objective

We investigated the usefulness of 2D-perfusion analysis for the evaluation of cerebral blood flow in unilateral cervical internal carotid artery stenosis.

Methods

We conducted a 2D-perfusion analysis during cerebral angiography and ¹²³I-iodoamphetamine (IMP) single photon emission computed tomography (SPECT) for unilateral cervical internal carotid artery stenosis without contralateral stenosis. The relationship between the ratio of the lesion side to the normal side in the parameters obtained by 2D-perfusion and the value calculated by stereotactic extraction estimation (SEE) analysis of SPECT was statistically examined.

Results

The ratios of the lesion side to the normal side regarding the peak arrival time (AT; time to peak [TTP]) of the contrast agent and the mean filling time (mean transit time [MTT]) of the contrast agent in 2D-perfusion significantly correlated with the area of Stage II and increase ratio (I.R) ≤30% in the SEE analysis (p = 0.002, 0.003).

Conclusion

2D-perfusion analysis can be used to estimate the extent of impaired cerebrovascular reserve (CVR) area in unilateral internal carotid artery stenosis.

[Minimally invasive carotid artery surgery]

OBJECTIVE

To determine the criteria for choosing a surgical approach and compare an effectiveness of carotid endarterectomy (CEAE) via 3 approaches.

MATERIAL AND METHODS

The study included 120 patients who underwent CEAE via 3 different approaches. Intraoperative skin marking included lower jaw angle, skin fold closest to common carotid artery bifurcation. Carotid artery bifurcation and borders of atherosclerotic plaque were visualized using ultrasound. An effectiveness of each access was evaluated in accordance with the following criteria: neurological complications, cosmetic effect and quality of life after 1 and 12 months. The patients were divided into 2 groups. Group I - 80 patients with CEAE with access through the natural skin fold (NSF); group II - 40 patients with CEAE using the classical longitudinal access. The 1st group was divided into 2 subgroups. Subgroup I A - 39 patients with CEAE using mini-access via NSF; subgroup I B - 41 patients with CEAE using extended access via NSF.

RESULTS

There were no strokes and transient ischemic attacks in a month after surgery in both groups. After 12 months, stroke occurred in 2 (%) patients of group II, cranial neuropathy - 8 (21%) patients in the same group. The best cosmic effect was achieved in subgroup I A after 1 and 12 months (37.1±6.7 scores). Mean score of physical health was 51.59±5.9 scores in subgroup I A, 46.03±7.53 scores - in subgroup I B, 38.84±5.28 scores - in group II. Index of mental health was 49.63±6.69, 45.68±5.6, and 48.59±7.29 scores, respectively.

CONCLUSION

Considering these data, we developed a personalized computer program ensuring fast choice of optimal surgical approach.

[Treatment of patients with a cerebral arterial aneurysm and stenosis of the internal carotid artery]

AIM

The purpose of this study was to analyse the world literature dedicated to the problem concerning treatment of a combination of internal carotid artery stenosis at the extracranial level and an arterial aneurysm of the brain, as well as to demonstrate own results of surgical treatment of patients presenting with this concomitant pathology of the carotid basin.

PATIENTS AND METHODS

From 2013 to 2019, a clinical course of combined pathology of the basin of the internal carotid artery (an intracranial aneurysm and stenosis of the internal carotid artery at the extracranial level) was revealed in 35 of 1638 examined patients. There were ten men and 25 women, with a mean age of 66±7 years. In all the 35 patients, intracranial aneurysms appeared to be asymptomatic and were revealed during diagnosis of an atherosclerotic lesion of the internal carotid artery. Fifteen (43%) of the 35 patients were operated on. A two-stage surgical approach was used in 2 patients with ipsilateral location of the cerebral aneurysm and stenosis of the internal carotid artery: the first stage consisted in clipping of the arterial aneurysm, with stage 2 being carotid endarterectomy. A vascular stage alone (carotid endarterectomy or stenting of the internal carotid artery) was carried out in 9 patients, with a neurosurgical stage alone (clipping of the aneurysm) in 4 patients.

RESULTS

The incidence of internal carotid artery stenosis with an arterial cerebral aneurysm, according to our findings, amounted to 2.1%. In the group of surgical treatment, in 1 case (6.7%) after stenting of the symptomatic stenosis of the internal carotid artery a female patient with an ipsilateral asymptomatic aneurysm of the middle cerebral artery intraoperatively developed 'minor' ischaemic stroke. Neither perioperative aneurysmal ruptures nor lethal outcomes were observed in the group of patients subjected to surgical interventions.

CONCLUSION

An individual tactical approach to patients presenting with a combination of a cerebral aneurysm and internal carotid artery stenosis at the extracranial level made it possible at this stage of the work to avoid both intracranial haemorrhagic complications and lethal outcomes. The frequency of perioperative ischaemic cerebral events amounted to 6.7%. Further collection of the clinical material is needed to work out an optimal surgical policy in a combined lesion of the extra- and intracranial basin of the internal carotid artery.

Time Course in Ocular Blood Flow and Pulse Waveform in a Case of Ocular Ischemic Syndrome with Intraocular Pressure Fluctuation

We report on a 70-year-old Japanese man with complaints of worsening left visual acuity who was diagnosed with ocular ischemic syndrome (OIS) associated with internal carotid artery (ICA) stenosis. A gonioscopy examination showed rubeosis iridis and elevated intraocular pressure (IOP) in the left eye (50 mmHg) at the baseline visit. The optic nerve head (ONH) and choroidal blood flow measured by laser speckle flowgraphy (LSFG) was impaired in the left eye compared with that in the right eye. Additionally, the blowout score (BOS), which indicates the variation of the mean blur rate (MBR) during systolic and diastolic periods, was decreased in the left eye. After treatment with an injection of bevacizumab and administration of Rho-associated kinase-inhibitor ripasudil eye drops, both ocular blood flow and BOS in each vascular bed gradually increased along with IOP reduction. The visual acuity also improved. The current case demonstrated increased blood flow and decreased fluctuation of blood flow in the ONH and choroid before and after the treatment in OIS with rubeosis iridis. The LSFG technique is useful to non-invasively assess the ocular circulation and pulse waveform in OIS.

Association between Enlarged Perivascular Spaces and Internal Carotid Artery Stenosis: A Study in Patients Diagnosed by Digital Subtraction Angiography

OBJECTIVE

An enlarged perivascular space (EPVS) is an imaging marker of cerebral small vessel disease, and its relationship with large artery disease is elusive. We investigated the EPVS in patients with internal carotid artery stenosis (ICAS) with the use of digital subtraction angiography (DSA) and tested the relationship between the degree of EPVS and the degree of ICAS; as well as the relationship between the degree of EPVS and white matter hyperintensity (WMH).

METHOD

A total of 202 patients with or without ICAS diagnosed by DSA were enrolled. The maximal ICAS rates, the degrees of EPVS and WMH were measured. The patients' clinical characteristics and laboratory parameters were recorded. Univariable analysis and multivariable regression were used to test their correlations. In a unilateral stenosis subgroup, the EPVSs in the ipsilateral hemisphere of stenosis and in the contralateral hemisphere were compared.

RESULTS

According to univariable analysis, there were significant differences in age (P = .000), Hg1bc (P = .035) and folic acid (P = .008) among the subgroups based on the degrees of EPVS in the basal ganglia (BG). Age (P = .000) and the level of fibrinogen (P = .018) differed statistically among the subgroups based on the degrees of EPVS in the white matter (WM). The correlation between the degrees of WM-EPVS and the ICAS levels was tested with a gamma test: G = .280, P = .001. The ordinal multivariable regression model showed that age was independently associated with both BG-EPVSs and WM-EPVSs. A current smoker status was also independently associated with WM-EPVSs. ICAS level was associated with the severity of WM-EPVSs after adjusting for other risk factors. The degree of BG-EPVS was not correlated with the degree of stenosis. (P = .101). In 59 patients with unilateral ICAS, as tested by the Wilcoxon signed ranks test, the WM-EPVS scores in the ipsilateral hemisphere of stenosis were higher than those in the contralateral hemisphere. (P = .004), but there was no difference in BG-EPVSs (P = .070). Both BG-EPVSs and WM-EPVSs were independently correlated with WMH.

CONCLUSIONS

BG-EPVSs and WM-EPVSs have different risk factors. WM-EPVSs but not BG-EPVSs are correlated with ICAS.

Multiparametric 3D Contrast-Enhanced Ultrasound to Assess Internal Carotid Artery Stenosis: A Pilot Study

BACKGROUND AND PURPOSE

Extracranial internal carotid artery stenoses (ICASs) may greatly differ with respect to morphological and hemodynamical aspects. The aim of this pilot study was to evaluate the use of multiparametric 3-dimensional (3D) contrast-enhanced ultrasound (3D-CEUS) to comprehensively examine ICAS.

METHODS

Fifteen patients with moderate to severe ICAS were examined with multiparametric 3D-CEUS, power-mode 3D ultrasound (3DUS), color-coded duplex sonography (CDS), and digital subtraction angiography (DSA) (n = 9). Multiparametric 3D-CEUS comprised the assessment of the morphology and the stenotic degree of ICAS and the measurement of the ipsistenotic cerebral circulation time (CCT).

RESULTS

Multiparametric 3D-CEUS reliably visualized even complex aspects of ICAS such as ulcerated or heavily calcified plaques with high spatial resolution. When comparing the different methods to quantify ICAS, the intermethod agreement was good (ranging from poor to excellent) between 3D-CEUS and CDS, moderate (ranging from poor to good) between 3D-CEUS and DSA, and poor (ranging from poor to good) between CDS and DSA. The CCT was significantly longer in patients with ICAS than in healthy subjects (8.2 ± 1.5 seconds vs. 6.5 ± 1.3 seconds, P = .026).

CONCLUSION

In this pilot study, bedside multiparametric 3D-CEUS provided reliable estimations of different morphological and hemodynamical aspects of ICAS, thus ideally complementing CDS.

Are Cerebral White Matter Lesions Related to the Presence of Bilateral Internal Carotid Artery Stenosis or to the Length of Stenosis Among Patients With Ischemic Cerebrovascular Events?

Background and purpose: Previous studies delivered contradicting results regarding the relation between the presence of an internal carotid artery stenosis (ICAS) and the occurence of white matter lesions (WMLs). We hypothesize that special characteristics related to the ICAS might be related to the WMLs. We examined the relation between the presence of bilateral ICAS, the degree and length of stenosis and ipsi-, contralateral as well as mean white matter lesion load (MWMLL). Methods: In a retrospective cohort, patients with ischemic stroke or transient ischemic attack (TIA) as well as ipsi- and/or contralateral ICAS were identified. The length and degree of ICAS, as well as plaque morphology (hypoechoic, mixed or echogenic), were assessed on ultrasound scans and, if available, the length was also measured on magnetic resonance angiography (MRA) scans, and/or digital subtraction angiography (DSA). The WMLs were assessed in 4 areas separately, (periventricular and deep WMLs on each hemispherer), using the Fazekas scale. The MWMLL was calculated as the mean of these four values. Results: 136 patients with 177 ICAS were identified. A significant correlation between age and MWMLL was observed (Spearman correlation coefficient, ρ = 0.41, p < 0.001). Before adjusting for other risk factors, a significantly positive relation was found between the presence of bilateral ICAS and MWMLL (p = 0.039). The length but not the degree of ICAS showed a very slight trend toward association with ipsilateral WMLs and with MWMLL. In an age-adjusted multivariate logistic regression with MWMLL ≥2 as the outcome measure, atrial fibrillation (OR 3.54, 95% CI 1.12-11.18, p = 0.03), female sex (OR 3.11, 95% CI 1.19-8.11, p = 0.02) and diabetes mellitus (OR 2.76, 95% CI 1.16-6.53, p = 0.02) were significantly related to WMLs, whereas the presence of bilateral stenosis showed a trend toward significance (OR 2.25, 95% CI 0.93-5.45, p = 0.074). No relation was found between plaque morphology and MWMLL, periventricular, or deep WMLs. Conclusion: We have shown a slight correlation between the length of stenosis and the presence of WMLs which might be due to microembolisation originating from the carotid plaque. However, the presence of bilateral ICAS seems also to be related to WMLs which may point to common underlying vascular risk factors contributing to the occurrence of WML.

[A case of hemichorea caused by right internal carotid artery stenosis]

This is a case of a 71 years old man. Hemichorea appeared in the left half of his body in the middle of November, 2014. Minute hyperintense areas in the white matter near the posterior horn of the right lateral ventricle and in the right parasagittal frontal cortex was shown in MRI diffusion weighted image. Severe stenosis was seen in the right internal carotid artery, and reduction in cerebral blood flow of the right cerebral hemisphere including the basal ganglia was shown in single photon emission computed tomography (SPECT). After having carotid endarterectomy of the right internal carotid artery in January, 2015, hemichorea disappeared, and the cerebral blood flow of the right cerebral hemisphere improved. It is known that hemichorea is caused by the infarction of the basal ganglia. In recent years, some hemichorea cases are reported around East Asia caused by internal carotid artery stenosis with reduction in cerebral blood flow.

Ultrasound assessment of carotid arteries: Current concepts, methodologies, diagnostic criteria, and technological advancements

Following cardiac disease and cancer, stroke continues to be the third leading cause of death and disability due to chronic disease in the developed world. Appropriate screening tools are integral to early detection and prevention of major cardiovascular events. In a carotid artery, the presence of increased intima-media thickness, plaque, or stenosis is associated with increased risk of a transient ischemic attack or a stroke. Carotid artery ultrasound remains a long-standing and reliable tool in the current armamentarium of diagnostic modalities used to assess vascular morbidity at an early stage. The procedure has, over the last two decades, undergone considerable upgrades in technology, approach, and utility. This review examines in detail the current state and usage of this integrally important means of extracranial cerebrovascular assessment.

[Hibrid intervention for internal carotid artery stenosis and ipsilateral aneurysm of anterior communicating artery]

The presence of an ipsilateral aneurysm in stenosis of the internal carotid artery is determined by the findings of CT angiography in 1.8-3.2% of cases. The available literature has described a wide variety of treatment for this pathology: isolated or alternate, with a method of simultaneous endovascular treatment, i. e., carotid stenting and endovascular embolization of an aneurysm, currently gaining popularity. The major difficulties associated with therapeutic decision-making in this cohort of patients include stage-wise nature, temporal parameters, the need for removal of an intracranial aneurysm, and assessment of perioperative complications. A clinical case report presented herein is an example of a method of a hybrid approach, i. e., simultaneously performing carotid endarterectomy and endovascular embolization of an aneurysm. In certain cases (anatomical variants, structure of an atherosclerotic plaque, individual peculiarities), this approach is more justified than popularity-gaining simultaneous endovascular treatment.

Extracranial-intracranial bypass in medial sphenoid ridge meningioma associated with severe stenosis of the intracranial segments of the internal carotid artery: A case report

RATIONALE

Tumor resection and extracranial-intracranial bypass concerning medial sphenoid ridge meningioma associated with severe stenosis of the internal carotid artery (ICA) of intracranial segments has been rarely presented. Effective treatment as to the complex lesions may be complicated. Tumor resection and cerebrovascular protection should be both taken into consideration.

PATIENT CONCERNS

We presented one case of medial sphenoid ridge meningioma associated with severe stenosis of the internal carotid artery of intracranial segments. The patient suffered hyperthyroidism, mirror-image dextrocardia and congenital heart disease atrial septal defect simultaneously.

DIAGNOSES

Before the neurosurgical treatment , the colleagues of department of cardiac surgery, anesthesiology and respiratory medicine agreed on our plan of resecting the tumor following the comprehensive evaluation of basal clinical conditions in the patient. For reducing the bleeding intraoperatively, the interventional branch performed digital subtraction angiography(DSA) and found collateral anastomosis between the supplying vessels of left middle meningeal arteries and anterior choroid arteries. No preoperative interventional embolization was determined considering the risk of cerebral ischemia.

INTERVENTIONS

The following subtotal resection of medial sphenoid ridge meningioma and left extracranial-intracranial bypass were carried out. Additionally, ipsilateral decompressive craniectomy was done. Post-operative imaging Computed tomography (CT), Computed tomography angiography (CTA) and Transcranial Doppler (TCD) indicated subtotal resection of tumor and bypass patency.

OUTCOMES

The patient was discharged with the right limbs of muscle strength of grade IV. The muscle strength of the patient returned to grade V after 6 months of follow-up.

LESSONS

Comprehensive treatment of tumor resection and extracranial-intracranial bypass concerning medial sphenoid ridge meningioma associated with severe stenosis of the internal carotid artery of intracranial segments is effective.

Treatment Strategy Based on Plaque Vulnerability and the Treatment Risk Evaluation for Internal Carotid Artery Stenosis

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are not appropriate treatment procedure for internal carotid artery stenosis (ICAS) in some patients. The importance of plaque vulnerability and the treatment risk evaluation has been reported. We analyzed whether treatment selection contributes to the outcome. We retrospectively examined 121 patients who underwent CEA or CAS. Treatment was selected based on plaque vulnerability and the treatment risk evaluation. We selected CAS for patients with stable plaques and CEA for patients with unstable plaques, and considered the other treatment for high-risk patients. The patients were classified as the stable plaque (Stable: n = 42), the unstable plaque and CEA low risk (Unstable/Low: n = 30), and the CEA high-risk (Unstable/High: n = 49). Frequency of perioperative stroke, myocardial infarction, death, and systemic complications was examined. CEA and CAS were performed in 35 and 86 patients, respectively. One patient (2.9%) had a stroke in CEA and five patients (5.8%) in CAS (P = 0.50). Systemic complications were observed in two patients (5.7%) in CEA and six (7.1%) in CAS (P = 0.80). There were no differences in stroke (Stable; 2.4%, Unstable/Low; 3.2%, and Unstable/High; 8.2%) and systemic complications (Stable; 9.5%, Unstable/Low; 3.3%, and Unstable/High; 6.1%) among three groups (P = 0.44 and P = 0.59, respectively). The treatment selection based on plaque vulnerability and the treatment risk evaluation could provide good treatment outcome for high-risk patients. It is ideal to select an appropriate treatment for ICAS by one neurovascular team.

Circulating miRNA levels differ with respect to carotid plaque characteristics and symptom occurrence in patients with carotid artery stenosis and provide information on future cardiovascular events

Introduction

Circulating microRNAs (miRNAs) levels are potentially important biomarkers and therapeutic targets of cerebral ischemic event (CIE) in patients with internal carotid artery stenosis (ICAS).

Aim

This prospective study investigated associations between circulating miRNAs and symptomatic and asymptomatic ICAS, carotid plaque morphology and future cardiovascular events.

Material and methods

Circulating miRNAs (miR-1-3p, miR-16-5p, miR-34a-5p, miR-124-3p, miR-133a-3p, miR-133b, miR-134-5p, miR-208b-3p, miR-375 and miR-499-5p) were analyzed in 92 consecutive patients with significant ICAS referred for revascularization. Group I comprised 65 subjects (41 males, age 69.3 ±9.7 years) with a recent CIE. Group II comprised 27 patients (15 males, age 68.2 ±8.4 years) with asymptomatic ICAS. The ICAS degree and plaque morphology was assessed by ultrasonography. The incidences of cardiovascular death (CVD), myocardial infarction (MI) and recurrent CIE (CVD/MI/CIE) were recorded prospectively (mean: 38.7 ±3.8 months).

Results

Groups II and I differed significantly in levels of miR-124-3p (p = 0.036), miR-133a-3p (p = 0.043) and miR-134-5p (p = 0.02). Hypoechogenic, as compared to echogenic, plaques differed in levels of miR-124-3p (p = 0.038), miR-34a-5p (p = 0.006), miR-133b (p = 0.048), miR-134-5p (p = 0.045), and miR-375 (p = 0.016), while calcified plaques differed in miR-16-5p (p = 0.023). Ulcerated plaques showed higher levels of miR-1-3p (p = 0.04) and miR-16-5p (p = 0.003), while thrombotic plaques showed lower levels of miR-1-3p (p = 0.032). CVD/MI/CIE occurred in 14 (15.5%) out of 90 follow-up patients. Multivariate Cox and ROC analysis showed associations between miR-1-3p and CVD (AUC = 0.634; HR = 4.84; 95% CI: 1.62–14.5; p = 0.005), MI (AUC = 0.743; HR = 7.8; 95% CI: 2.01–30.0; p = 0.003), and CVD/MI/CIE (AUC = 0.560; HR = 4.6; 95% CI: 1.61–13.1; p = 0.004), while miR-133b was associated with recurrent CIE (AUC = 0.581; HR = 2.25; 95% CI: 1.01–5.02; p = 0.047).

Conclusions

A significant difference in levels of selected miRNAs is observed in symptomatic vs. asymptomatic ICAS. Plaque morphology and structure is associated with change of miRNA levels. The expression of miR-1-3p may be a potential prognostic factor for future cardiovascular events.

Three-Dimensional Echographic Evaluation of Carotid Artery Disease

The introduction of three-dimensional echography (3D echo) in vascular field is not recent, but it still remains a seldom-used technique because of the costs of ultrasound probe and the need of dedicated laboratories. Therefore, despite significant prognostic implications, the high diagnostic accuracy in plaque definition, and the relative ease of use, 3D echo in vascular field is a niche technique. The purpose of this review is mainly clinical and intends to demonstrate the potential strength of a 3D approach, including technical aspects, in order to present to clinicians and imagers the appealing aspects of a noninvasive and radiation-free methodology with relevant diagnostic and prognostic correlates in the assessment of carotid atherosclerosis. A comprehensive literature search (since 1990s to date) using the PubMed, MEDLINE, and Cochrane libraries databases has been conducted. Articles written in English have been assessed, including reviews, clinical trials, meta-analyses, and interventional/observational studies. Manual cross-referencing was also performed, and relevant references from selected articles were reviewed. The search was limited to studies conducted in humans. Search terms, retrieved also with PubMed Advanced search and AND/OR Boolean operators (mainly in title and abstract), included three-dimensional, echo, stroke/transient ischemic attack, predictors, carotid, imaging, and biomarkers.

Genetic Polymorphisms rs699947, rs1570360, and rs3025039 on the VEGF Gene Are Correlated with Extracranial Internal Carotid Artery Stenosis and Ischemic Stroke

Extracranial internal carotid artery (ECICA) stenosis is a modifiable risk factor of ischemic stroke. VEGF plays a crucial role in the maintenance of endothelial integrity and physiological function. This study was designed to assess the correlations of VEGF polymorphisms with ECICA stenosis in ischemic stroke and to explore the relationships between these polymorphisms and different biochemical parameters. This study included a total of 650 ischemic stroke patients, 232 with ECICA stenosis while 418 had no ECICA stenosis as assessed by magnetic resonance angiography. Three SNPs in the VEGF gene, rs699947, rs1570360, and rs3025039, were assessed by real-time PCR coupled with melting curve analysis. Serum samples were analyzed for biochemical parameters in an automated clinical chemistry analyzer in the Laboratory Medicine Department. The CA and CA+AA (A allele bearing) genotype frequencies of the rs699947 polymorphism (AOR=1.46 and 1.47, respectively) and the GA genotype frequency of the rs1570360 polymorphism (AOR=7.33) showed a significant association with ECICA stenosis. However, the haplotype frequencies of C-A-A, T-A-C, and T-A-A (rs302503-rs1570360-rs699947) were significantly different between patients who experienced stroke with and stroke without ECICA stenosis. We found that the total homocysteine (tHcy) levels of stroke patients with ECICA stenosis with rs1570360 and rs699947 SNPs were significantly different compared to the wild-type reference genotype. In conclusion, VEGF rs699947 and rs3025039 polymorphisms were associated with increased risk of stroke, while rs1570360 and rs699947 were associated with stroke and ECICA stenosis.

Silent ischemic lesion laterality in asymptomatic internal carotid artery stenosis relates to reduced cerebral vasoreactivity

BACKGROUND

We investigated the relationship between silent ischemic lesions, defined as hyperintense lesions on T2-weighted magnetic resonance imaging scans of brain white matter and cerebral hemodynamics (baseline cerebral blood flow and cerebral vasoreactivity).

METHODS

Between January 2007 and December 2012, 61 patients with asymptomatic internal carotid artery stenosis were evaluated for asymptomatic silent ischemic lesions, acute infarction, and cerebral hemodynamics. Patients were divided into 2 groups based on silent ischemic lesion distribution; the Symmetry group (n = 34) included patients who showed symmetrical distribution of lesions (or had no lesions), and the Asymmetry group (n = 27) included patients with a greater number of lesions in the ipsilateral than that in the contralateral hemisphere. The Asymmetry group was further divided into Internal (n = 15) and External (n = 12) types.

RESULTS

Two External-type patients (17%) showed spotty asymptomatic acute infarction in the ipsilateral hemisphere. There were no significant differences in patient characteristics, histopathological findings, vascular risk factors, or cerebral blood flow values between the groups. The mean cerebral vasoreactivity value in the ipsilateral hemisphere for the Internal type was 13.0 ± 15.2% (range: -11.4% to 41.6%), which was significantly lower than values of the contralateral hemisphere (36.7 ± 20.8%; range: 3.9% to 75.7%; P <.01) and ipsilateral hemispheres of the other groups (P <.01).

CONCLUSIONS

The finding that increased ipsilateral asymmetrical silent ischemic lesions correlated with cerebral vasoreactivity reduction may help predict the risk of cerebral infarction in patients with asymptomatic internal carotid artery stenosis.

Multiterritory Atherosclerosis and Carotid Intima-Media Thickness as Cardiovascular Risk Predictors After Percutaneous Angioplasty of Symptomatic Subclavian Artery Stenosis

OBJECTIVES

To identify independent predictors of cardiovascular events among patients with subclavian artery stenosis.

METHODS

Two hundred eighteen consecutive patients with subclavian artery stenosis referred to angioplasty were examined for coexistent coronary, renal, or lower extremity artery stenosis of 50% or greater. Initial carotid intima-media thickness and internal carotid artery (ICA) stenosis were assessed. Intima-media thickness was reassessed in 108 randomly chosen patients to evaluate the change over time. The incidence of cardiovascular death, myocardial infarction (MI), ischemic stroke, and symptomatic lesion progression was recorded.

RESULTS

The patients included 116 men and 102 women (mean age ± SD, 62.1 ± 8.4 years). Isolated subclavian artery stenosis and involvement of 1, 2, and 3 or 4 other territories with stenosis of 50% or greater were found in 46 (21.1%), 83 (38.1%), 55 (25.2%), and 34 (15.6%) patients, respectively. Internal carotid artery stenosis of 50% or greater (relative risk [RR], 1.54; 95% confidence interval [CI], 1.39-1.70; P < .001) and initial intima-media thickness (RR, 1.16; 95% CI, 1.05-1.28; P = .005) were identified as independent markers of multiterritory atherosclerosis. The optimal intima-media thickness cutoff for atherosclerosis extent was 1.3 mm (sensitivity, 75.6%; specificity, 76.1%). During follow-up of 57 ± 35 months, cardiovascular death, MI, and ischemic stroke occurred in 29 patients (13.3%). Those patients had significantly higher intima-media thickness progression (+0.199 ± 0.57 versus +0.008 ± 0.26 mm; P = .039) and more widespread initial atherosclerosis (mean territories, 1.8 ± 1.1 versus 1.3 ± 1.1; P = .042). Independent predictors of cardiovascular death, MI, ischemic stroke, and lesion progression were coronary artery disease (RR, 1.32; 95% CI, 1.10-1.58; P = .003) and intima-media thickness progression (RR, 1.22; 95% CI, 1.02-1.46; P = .033; sensitivity, 75.0%; specificity, 61.8%).

CONCLUSIONS

In patients with symptomatic subclavian artery stenosis, baseline carotid intima-media thickness and ICA stenosis of 50% or greater are associated with multiterritory atherosclerosis, whereas intima-media thickness progression is associated with the risk of cardiovascular events.

Percutaneous transluminal angioplasty in a patient with internal carotid artery stenosis following gamma knife radiosurgery for recurrent pituitary adenoma

BACKGROUND

Intracranial vascular complications following radiosurgery are extremely rare.

CASE DESCRIPTION

We report a case of stenosis in the internal carotid artery 5 years after gamma knife radiosurgery for a recurrent pituitary adenoma. Percutaneous transluminal angioplasty was performed successfully with anatomical and functional improvement.

CONCLUSION

These results suggested the importance of monitoring for arterial stenosis in the long-term follow-up. Moreover, this is the first case of endovascular treatment as an effective therapy for intracranial arterial stenosis due to radiotherapy.

Impact of Severe Extracranial ICA Stenosis on MRI Perfusion and Diffusion Parameters in Acute Ischemic Stroke

Purpose: The aim of this study was to investigate the impact of a coexisting internal carotid artery (ICA) stenosis on lesion volumes as well as diffusion and perfusion parameters in acute ischemic stroke resulting from middle cerebral artery (MCA) occlusion.

Material and methods: Magnetic resonance imaging data of 32 patients with MCA occlusion with or without additional ICA stenosis imaged within 4.5 h of symptom onset were analyzed. Both groups consisted of 16 patients. Acute diffusion lesions were semi-automatically segmented in apparent diffusion coefficient (ADC) MRI datasets. Perfusion maps of cerebral blood volume (CBV), cerebral blood flow, mean transit time and T_max were calculated using perfusion-weighted MRI datasets. Tissue-at-risk (TAR) volumes were generated by subtracting the ADC lesion from the hypoperfusion lesion defined by T_max >6 s. Median ADC and perfusion parameter values were extracted separately for the diffusion lesion and TAR and used for statistical analysis.

Results: No significant differences were found between the groups regarding the diffusion lesion and TAR volumes. Statistical analysis of diffusion and perfusion parameters revealed CBV as the only parameter with a significant difference (p = 0.009) contributing a small effect (η² = 0.11) to the group comparison with higher CBV values for the patient group with a coexisting ICA stenosis, while no significant effects were found for the other diffusion and perfusion parameters analyzed.

Conclusion: The results of this study suggest that a coexisting ICA stenosis does not have a strong effect on tissue status or perfusion parameters in acute stroke patients except for a moderate elevation of CBV. This may reflect improved collateral circulation or ischemic preconditioning in patients with a pre-existing proximal stenosis balancing impaired perfusion from the stenosis.

The effect of anatomic variations of circle of Willis on cerebral blood distribution during posture change from supination to standing: a model study

The anatomic variation of Circle of Willis (CoW) has great impact on its compensatory capacity during stroke and cerebral ischemia. In the present study, a series of lumped parameter models were developed and used to simulate the effect of postural changes on the cerebral blood flow in ICA stenosis patients with different anatomic variants of the CoW. The results showed that the asymmetric distribution of cerebral blood flow caused by stenosis was attenuated in standing position in complete and half-complete CoW. However, in incomplete CoW, the decrease in blood flow in the ipsilateral cerebral arteries caused by unilateral ICA stenosis was dramatic in both supine and standing positions, a likely result of inadequate collateral circulation within the CoW. In conclusion, the anatomic variation of CoW plays a significant role in maintaining the balance of cerebral blood supply in patients with ICA stenosis, especially during postural change.

Microvascular versus macrovascular cerebral vasomotor reactivity in patients with severe internal carotid artery stenosis or occlusion

RATIONALE AND OBJECTIVES

In patients with severe internal carotid artery steno-occlusive lesions (ISOL), impaired cerebrovascular reactivity (CVR) is predictive of future ischemic stroke (IS) or transient ischemic attack (TIA). Therefore, the evaluation of CVR in ISOL patients may be a means to evaluate the risk for IS/TIA and decide on an intervention. Our aim was (1) to explore the feasibility of concurrent near-infrared spectroscopy (NIRS-DOS), diffuse correlation spectroscopy, and transcranial Doppler for CVR assessment in ISOL patients, and (2) to compare macrovascular and microvascular CVR in ISOL patients and explore its potential for IS/TIA risk stratification.

MATERIALS AND METHODS

Twenty-seven ISOL patients were recruited. The changes in continuous microvascular and macrovascular hemodynamics upon acetazolamide injection were used to determine CVR.

RESULTS

Oxyhemoglobin (HbO2, by near-infrared spectroscopy), microvascular cerebral blood flow (CBF, by diffuse correlation spectroscopy) and CBF velocity (by transcranial Doppler) showed significant increases upon acetazolamide injection in all subjects (P < .03). Only macrovascular CVR (P = .024) and none of the microvascular measures were significantly dependent on the presence of ISOL. In addition, while CBF was significantly correlated with HbO2, neither of these microvascular measures correlated with macrovascular CBF velocity.

CONCLUSIONS

We demonstrated the simultaneous, continuous, and noninvasive evaluation of CVR at both the microvasculature and macrovasculature. We found that macrovascular CVR response depends on the presence of ISOL, whereas the microvascular CVR did not significantly depend on the ISOL presence, possibly due to the role of collaterals other than those of the circle of Willis. The concurrent microvascular and macrovascular CVR measurement in the ISOL patients might improve future IS/TIA risk assessment.