Bilateral Internal Carotid Artery Occlusion Research Articles

Non-routine thrombectomy in pediatric arterial ischemic stroke.

Unlike in adults, the indications and techniques for mechanical thrombectomy for arterial ischemic stroke (AIS) in children are not clearly established. The medical and interventional management of children with acute large vessel occlusion may entail the modification of the standardized management of this condition in adults. We present six cases of children who underwent non-routine thrombectomy for AIS. We retrospectively reviewed the records of children diagnosed with AIS between 2015 and 2023 and evaluated patient characteristics, procedural technical data, and final clinical outcomes. Procedures deviating from the current definition and indications for AIS treatment in adults as well as previously reported pediatric thrombectomy cases were defined as non-routine thrombectomy. Seven non-routine thrombectomy procedures in six children were included in the study. The National Institutes of Health Stroke Scale scores on admission ranged from 4 to 35; no procedure-related mortality or major neurologic morbidity occurred. One child died of causes related to the initial severe heart failure and stroke; otherwise, all the children had a modified Rankin scale score of 0 to 1 at follow-up. Unique clinical and procedural features in our case series included presentation with acute stent occlusion (two children), bilateral simultaneous internal carotid artery occlusions associated with a unilateral tandem middle cerebral artery (MCA) occlusion (one child), MCA occlusion caused by thromboembolism of the atrial myxoma (one child), and very distal (one child) or delayed thrombectomy (two children). Modifications to the standard medical and interventional algorithms may be required for mechanical thrombectomy in children. Referral centers specialized in pediatric neurology, pediatric anesthesia, and pediatric intervention are optimal for treating children using mechanical thrombectomy and for modifying the treatment, if required.

Acute concurrent bilateral internal carotid artery occlusion: a teaching clinical image

Acute bilateral internal carotid artery (ICA) occlusion is a rare stroke syndrome presenting with acute coma, and patients usually have preserved brainstem function on initial examination. In this clinical image, we report a case of acute concurrent bilateral ICA occlusion. Acute bilateral ICA occlusion is an unusual entity with a poor outcome. It can mimic metabolic encephalopathies and posterior circulation infarcts and can be differentiated by careful evaluation of brainstem functions.

Spontaneous development and involution of a de novo pseudoaneurysm at the superficial temporal artery-middle cerebral artery bypass anastomotic site in a patient with moyamoya disease: illustrative case.

De novo pseudoaneurysm formation is a rare complication of extracranial-intracranial bypass surgery. The authors report the case of a 28-year-old male who presented with new-onset right temporal and occipital ischemia who was found to have bilateral proximal internal carotid artery occlusion with collateral vasculature formation consistent with moyamoya disease. The patient underwent bilateral superficial temporal artery-middle cerebral artery bypasses. A de novo pseudoaneurysm was found at the left-sided bypass distal anastomotic site recipient vessel 1 month after the surgery. The pseudoaneurysm demonstrated a progressive reduction in size and eventual complete involution at 6 months after surgery. Limited literature reports extracranial-intracranial bypass-associated aneurysms treated primarily with either clipping or resection and reanastomosis. The authors demonstrate, for the first time, a progressively benign natural history course of an extracranial-intracranial bypass distal anastomotic site pseudoaneurysm.

Ultrasound Diagnosed Fetal Hydranencephaly in the Prenatal Period

Abstract Hydranencephaly is a rare congenital encephalopathy characterized by a near complete absence of the cerebral cortical mantle and basal ganglia, with consequent replacement by cerebrospinal fluid (CSF). Although hydranencephaly is an extremely rare congenital entity with an incidence <1/10,000 live births, there are no known gender or racial predilections. However, polyhydramnios is a recognized association. Brain infarction from bilateral internal carotid artery occlusion, fetal hypoxia, leukomalacia, and congenital infections have all been implicated as possible etiologies for this rare entity. Ultrasonography can be used for prenatal diagnosis of fetal hydranencephaly, assessment for possible associations, and to exclude the common differential diagnoses. The objective of this report is to present an extremely rare congenital encephalopathy diagnosed in utero in a pregnant patient at the third trimester using ultrasonography, to review pertinent literature about this condition, and to highlight the role of ultrasonography in making a diagnosis of hydranencephaly while excluding common differential diagnoses. This was a case of hydranencephaly diagnosed at the third trimester of gestation, precisely at 36 weeks (with a discrepancy in the sonographically estimated average fetal gestational age which was about 33 weeks) at the time of diagnosis in a Nigerian tertiary health facility. Sonography revealed a disproportionately large fetal cranium relative to other fetal parts, the absence of a large proportion of the cerebral cortical mantle, and its replacement with anechoic CSF. The falx cerebri was preserved. Hydranencephaly is a rare congenital entity. Its diagnosis can be unraveled in the prenatal period with the use of ultrasonography particularly in resource-poor centers in sub-Saharan Africa where advanced imaging modalities such as magnetic resonance imaging are not readily available.

Angiogenesis effect of udenafil in a caveolin-1 deficient moyamoya disease model: A pre-clinical animal study

Purpose: Although pathogenic mechanisms of moyamoya disease (MMD) remain unknown, recent studies suggest that it is a caveolae disease. This study evaluated the effect of udenafil, a phosphodiesterase-5 inhibitor, on angiogenesis in in vitro and in vivo MMD models.Methods: Angiogenesis and vessel maturation were assessed in in vitro models, caveolin- 1 (Cav-1) knockdown human umbilical vessel endothelial cells (HUVECs) and coronary artery smooth muscle cells (CASMCs), and in in vivo model of bilateral internal carotid artery occlusion (bICAo). Udenafil was administered (1,3,10, and 30 μM) in cell culture conditions, and functional studies (migration and tube formation assay) were performed and vessel maturation factors and cyclic guanosine monophosphate (cGMP) accumulation were measured.Results: Udenafil (3 and 10 mg/kg) was orally administered once daily for 4 weeks in bICAo rat model, and histological analysis for angiogenesis and vessel maturation was performed. Udenafil increased vessel formation in both Cav-1 knockdown HUVEC and bICAo models without increased migration/proliferation of HUVECs and CASMCs. Udenafil increased CD31+ vessel density and NG2/Col4+ mural cell density in bICAo models. Cav-1 knockdown inhibited accumulation of cGMP, and udenafil treatment restored cGMP levels in Cav-1 knockdown HUVEC models. Vessel maturation factors (angiopoietin- 1 and platelet-derived growth factor receptor-β) and angiogenic factors (endothelial nitric oxide synthase) were increased after treatment with udenafil in vitro.Conclusion: Our results indicate that udenafil reversed cellular levels of cGMP related to Cav-1 deficiency and induced angiogenesis and vessel maturation. Further studies are warranted to confirm the therapeutic effects of this strategy in MMD.

An unusual case of bilateral internal carotid artery occlusion—A case report

An unusual case of bilateral internal carotid artery occlusion—A case report

Downregulation of mitochondrial pyruvate carrier 2 aggravates neuronal injury in the cortex following cerebral ischemia in rat

Cerebral ischemia is one of the most common disabling and lethal diseases worldwide, but its underlying mechanisms remain unclear. Mitochondrial pyruvate carrier 2 (MPC2), a subunit of MPC complex, plays pivotal roles in coordinating glycolytic and mitochondrial activities. In the present study, the expression of MPC2 was significantly reduced in the ischemic cerebral cortex of rats at 24 h after bilateral internal carotid artery occlusion (BICAO), and in the cortical neurons after 1 h oxygen-glucose deprivation (OGD)/24 h reoxygenation treatment. After MPC2 gene knockdown, the number and expression of neurons were remarkably decreased in the ischemic cerebral cortex of BICAO rats and OGD-treated neurons. UK5099 significantly reduced the number, expression and viability of OGD-treated neurons, and resulted in a significant decrease in length of neurite. Using RNA-sequencing (RNA-seq) technique, we further identified MPC2-related differential genes in the ischemic cerebral cortex of BICAO rats. In conclusion, our results suggested that the decrease in MPC2 expression aggravated ischemic injury, and MPC2-related genes might be a novel therapeutic target for cerebral ischemia.

Intracranial Flow Volume Estimation in Patients with Internal Carotid Artery Occlusion.

(1) Background: Carotid artery occlusion (CAO) in population studies has a reported prevalence of about 6 per 100,000 people; however, the data may be underestimated. CAO carries a significant risk of stroke. Up to 15% of large artery infractions may be secondary to the CAO, and in 27–38% of patients, ischaemic stroke is a first presentation of the disease. The presence of sufficient and well-developed collateral circulation has a protective influence, being a good prognostic factor in patients with carotid artery disease, both chronic and acute. Understanding the mechanisms and role of collateral circulation may be very important in the risk stratification of such patients. (2) Materials and Methods: This study included 46 patients (mean age: 70.5 ± 6 years old; 15 female, mean age 68.5 ± 3.8 years old and 31 male, mean age 71.5 ± 6.7 years old) with unilateral or bilateral ICA occlusion. In all patients, a Doppler ultrasound (DUS) examination, measuring blood flow volume in the internal carotid artery (ICA), external carotid artery (ECA), and vertebral artery (VA), was performed. The cerebral blood flow (CBF) was compared to the previously reported CBF values in the healthy population >65 years old. (3) Results: In comparison with CBF values in the healthy population, three subgroups with CBF changes were identified among patients with ICA occlusion: patients with significant volumetric flow compensation (CBF higher than average + standard deviation for healthy population of the same age), patients with flow similar to the healthy population (average ± standard deviation), and patients without compensation (CBF lower than the average-standard deviation for healthy population). The percentage of patients with significant volumetric flow compensation tend to rise with increasing age, while a simultaneous decline was observed in the group without compensation. The percentage of patients with flow similar to the healthy population remained relatively unchanged. ICA played the most important role in volumetric flow compensation in patients with CAO; however, the relative increase in flow in the ICA was smaller than that in the ECA and VA. Compensatory increased flow was observed in about 50% of all patent extracranial arteries and was more frequently observed in ipsilateral vessels than in contralateral ones, in both the ECA and the VA. In patients with CAO, there was no decrease in CBF, ICA, ECA, and VA flow volume with increasing age. (4) Conclusions: Volumetric flow compensation may play an important predictive role in patients with CAO.

Ring finger protein 213 c.14576G>A mutation is not involved in internal carotid artery and middle cerebral artery dysplasia

The ring finger protein 213 (RNF213) susceptibility gene has been detected in more than 80% of Japanese and Korean patients with moyamoya disease (MMD), a bilateral internal carotid artery (ICA) occlusion. Furthermore, RNF213 has been detected in more than 20% of East Asians with atherosclerotic ICA stenosis. In this study, we evaluated the frequency of RNF213 mutations in congenital occlusive lesions of the ICA system. This case series was conducted jointly at four university hospitals. Patients with a family history of MMD, quasi-MMD, or related diseases were excluded. Ten patients were diagnosed with abnormal ICA or middle cerebral artery (MCA) angiogenesis. Patients with neurofibromatosis were excluded. Finally, nine patients with congenital vascular abnormalities were selected; of these, five had ICA deficiency and four had twig-like MCA. The RNF213 c.14576G > A mutation was absent in all patients. Therefore, the RNF213 c.14576G > A mutation may not be associated with ICA and MCA congenital dysplasia—rare vascular anomalies making it difficult to study a large number of cases. However, an accumulation of cases is required for accurate determination. The results of this study may help differentiate congenital vascular diseases from MMD.

Failed endovascular therapy for acute internal carotid artery occlusion from pituitary apoplexy: illustrative case

BACKGROUNDLarge pituitary adenomas can rarely cause compression of the cavernous internal carotid artery (ICA) due to chronic tumor compression or invasion. Here, the authors present a case of pituitary apoplexy causing acute bilateral ICA occlusion with resultant stroke. Our middle-aged patient presented with sudden vision loss and experienced rapid deterioration requiring intubation. Computed tomography (CT) angiography revealed a large pituitary mass causing severe stenosis of the bilateral ICAs. CT perfusion revealed a significant perfusion delay in the anterior circulation. The patient was taken for cerebral angiography, and balloon angioplasty was attempted with no improvement in arterial flow. Resection of the tumor was then performed, with successful restoration of blood flow. Despite restoration of luminal patency, the patient experienced bilateral ICA infarcts.OBSERVATIONSPituitary apoplexy can present as an acute stroke due to flow-limiting carotid compression. Balloon angioplasty is ineffective for the treatment of this type of compression. Surgical removal of the tumor restores the flow and luminal caliber of the ICA.LESSONSPituitary apoplexy can be a rare presentation of acute stroke and should be managed with immediate surgical decompression rather than attempted angioplasty in order to restore blood flow and prevent the development of cerebral ischemia.

3β‐Diol Attenuates COX‐2 Levels in a Neonatal In‐Vivo and In‐Vitro Ischemic Injury Rodent and Human Model

Studies using experimental stroke models demonstrate that neuroprotective agents which provide protection from secondary injury, including inflammation, result in improved outcome. Estrogen receptor β (ESR2) has the potential to be a novel therapeutic target in the treatment of ischemic stroke. Previous studies have shown that ESR2 activation elicits beneficial effects in the cerebrovasculature by promoting vasorelaxation and by attenuating pro‐inflammatory mediator production. We previously observed that activation of the androgen, 5α‐androstane‐3β,17β‐diol (3β‐diol), reduced pro‐inflammatory mediator production in adult human vascular smooth muscle cells and rodent cerebral arteries, and this response was ESR2 dependent. The current study was designed to determine if ERS2 is expressed in both a human pediatric brain endothelial cell model and juvenile rat stroke model and whether 3β‐diol will attenuate cyclooxygenase‐2 (COX‐2) expression following ischemic injury. Male rat pups (P10–15) underwent 15 minutes of bilateral internal carotid artery occlusion (BCAO) or sham surgery and 24‐hour reperfusion. At the onset of reperfusion, pups were injected with 3β‐diol i.p. (2.5mg/kg) or vehicle (1.2% EtOH and 98.8% PEG). Next, animals were heavily sedated and whole brain removed at 24 hours. In an in‐vitro model of ischemic stroke, male primary pediatric human microvascular endothelial cells (HBMEC; Cell Systems) were exposed to hypoxia plus glucose deprivation (HGD; 1% O2) or normoxia (21% O2) plus or minus 3β‐diol (10nM) or vehicle (0.0001% ethanol) for 3h at passage 7, using a humidified chamber (BioSpherix®) housed within a 5% CO2 incubator. Total protein was extracted from rat whole brain and human endothelial cells, assayed for protein content, and COX‐2 levels assessed using western analysis. RT‐PCR analysis was used to explore whether 3β‐diol alters expression of its target receptor, ERS2. We observed that ESR2 was basally expressed in the prepubescent brain and HBMECs, and expression was not altered following ischemic injury. Proinflammatory COX‐2 protein levels were increased in both whole brain and HBMEC homogenates from BCAO and HGD groups compared to sham and vehicle controls, and the selective ERS2 agonist, 3β‐diol, attenuated this response. In conclusion, these studies suggest that 3β‐diol may have a role in modulating ischemia‐induced COX‐2 during stroke. Since ERS2 is expressed in the whole brain and brain endothelial cells, and ERS2 levels are not decreased during ischemic injury, ERS2 may be a viable target for future stroke therapeutics in the pediatric population by attenuating inflammatory modulators during ischemic injury in the developing brain.Support or Funding InformationUniversity of Arizona Valley Research Partnership Grant VRP04 P1 (RJG), American Heart Association 19AIREA34480018 (RJG).

MYOCARDIAL INFARCTION FROM EXTERNAL COMPRESSION OF THE OSTIAL LEFT MAIN CORONARY ARTERY IN A PATIENT WITH MOYAMOYA DISEASE

Extracranial vascular disease in patients with Moyamoya disease is increasingly recognized, with a wide spectrum of observed coronary artery pathology. A 54-year-old female with a history of bilateral internal carotid artery occlusion and ischemic strokes due to Moyamoya disease, left external

Abstract TP475: Effect of Udenafil, a Phosphodiesterase-5 Inhibitor, on Angiogenesis in a Cav-1 Deficient Moyamoya Disease Model

Background: Although pathogenic mechanisms of moyamoya disease remain unknown, recent studies suggest that it is a caveolae disease. This study evaluated the effect of udenafil, a phosphodiesterase-5 inhibitor, on vessel maturation in in vitro and in vivo moyamoya disease models. Methods: Angiogenesis and vessel maturation were assessed in in vitro models, caveolin-1 (Cav-1) knockdown human umbilical vessel endothelial cells (HUVECs) and coronary artery smooth muscle cells (CASMCs), and in in vivo model of bilateral internal carotid artery occlusion (bICAo). Udenafil was administered (1,3,10 and 30 μM) in cell culture conditions, and functional studies (migration and tube formation assay) were performed and vessel maturation factors and cyclic guanosine monophosphate (cGMP) accumulation were measured. Udenafil (3 and 10 mg/kg) was orally administered once daily for 4 weeks in bICAo rat model, and histological analysis for angiogenesis and vessel maturation was performed. Results: Udenafil increased vessel formation in both Cav-1 knockdown HUVEC and bICAo models without increased migration/proliferation of HUVECs and CASMCs. Udenafil increased CD31+ vessel density and NG2/Col4+ mural cell density in bICAo models. Cav-1 knockdown inhibited accumulation of cGMP, and udenafil treatment restored cGMP levels in Cav-1 knockdown HUVEC models. Vessel maturation factors (angiopoietin-1 and platelet-derived growth factor receptor-β) and angiogenic factors (endothelial nitric oxide synthase) were increased after treatment with udenafil in vitro . Conclusion: Our results indicate that udenafil reversed cellular levels of cGMP related to Cav-1 deficiency and induced angiogenesis and vessel maturation. Further studies are warranted to confirm the therapeutic effects of this strategy in moyamoya disease.

Simultaneous bilateral internal carotid artery occlusion: A case report and review of literature

Simultaneous bilateral internal carotid artery occlusion: A case report and review of literature

Bilateral internal carotid artery occlusion with compensatory perfusion in a HIV-infected patient

HIV infection occlusive arteriopathies may result in neurological symptoms. We report a case of bilateral complete occlusion of the extracranial portions of the internal carotid arteries in a HIV+ve patient who presented with a syncopal episode due to intraventricular haemorrhage. Compensatory blood flow from the posterior cerebral circulation via the circle of Willis resulted in small telangiectatic vessels arising from the posterior cerebral circulation which probably accounted for this rare haemorrhagic complication of an occlusive arteriopathy.

Asymptomatic Bilateral Internal Carotid Artery Occlusion with Ring Finger Protein 213 Gene Polymorphism

Asymptomatic Bilateral Internal Carotid Artery Occlusion with Ring Finger Protein 213 Gene Polymorphism

Asymptomatic Bilateral Internal Carotid Artery Occlusion Associated with Stenosis of the Right External Carotid Artery: Case Report

Asymptomatic Bilateral Internal Carotid Artery Occlusion Associated with Stenosis of the Right External Carotid Artery: Case Report

A case of bilateral internal carotid artery complete occlusion

Complete bilateral intracranial internal carotid artery occlusion is a rare disease with grave prognosis. It may cause recurrent stroke and extensive disability. We discuss a case of 62-year-old man who presented with sudden onset right sided hemiplegia, and GCS 7/15. CT scan revealed acute ischemic infarct in left MCA territory with mass effect and compression over the left lateral and third ventricle. Cerebral angiography showed bilateral intracranial internal carotid artery and middle cerebral artery occlusion. We present the case in view of wide range of presentation which depends on collateral formation and lack of specific guidelines for management.

Side-to-Side and End-to-Side Double Anastomosis Using the Parietal-Branch of the Superficial Temporal Artery-A Novel Technique for Extracranial to Intracranial Bypass Surgery: 3-Dimensional Operative Video.

In this 3-dimensional video, we perform a side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery (STA) to provide flow augmentation in a symptomatic 59-yr-old male with bilateral internal carotid artery occlusion at the origin, and left M1 segment occlusion. The patient suffered multiple left hemispheric strokes despite maximal medical therapy and was found to have poor hemodynamic reserve in the left hemisphere during evaluation with regional and global blood oxygenation level-dependent functional magnetic resonance imaging with CO2-challenge as well as quantitative magnetic resonance angiography and noninvasive optimal vessel analysis pre- and post-acetazolamide challenge. Postoperatively, the patient did very well and his hemodynamic studies improved significantly. The importance of this technique relies on the fact that we are using a single donor vessel to perform 2 anastomoses, and carries the following advantages: (1) the frontal STA branch remains intact and therefore can still be used at a later time if further revascularization is needed; (2) wound complications related to devascularizing the scalp from harvesting both STA branches are reduced; (3) 2 vascular territories are augmented (frontal and temporal) while using a single donor; (4) we are maximizing donor potential and optimizing cut flow index (CFI; total bypass flow postanastomosis divided by bypass cut flow) by flow augmenting 2 separate vascular beds therefore increasing demand. To explain that fourth point further: if the STA donor is able to carry a maximum 100 mL/min when cut, and after performing the first anastomosis bypass flow is only 37 mL/min, CFI will be 37/100=0.37, reflecting low demand, a poor indicator of graft patency, as previously published.1,2 By adding a second anastomosis which demands an additional 60 mL/min from the same STA donor, CFI (60+37)/100 improves to 1. Institutional Review Board approval was obtained for the review of patient chart and video files. Informed consent was obtained directly from the patient via telephone regarding use of media for educational and publication purposes.

Ruptured Posterior Circulation Aneurysms with Bilateral Internal Carotid Artery Occlusion: Surgical Nuance.

Background:Craniotomy and surgical clipping is the standard modality of treatment in patients of cerebral aneurysms. However, the surgical clipping of aneurysm may pose serious difficulties in the case of a bilateral carotid artery occlusion. The endovascular treatment has shown promising results in this disease.Methods:A retrospective study of all patients of posterior circulation aneurysms in the background of carotid occlusive disease at our department was performed. The aim of this study was to describe the clinical, radiological characteristics, and the treatment of this rare entity.Results:Four patients were treated from January 2009 to October 2015. The mean age of our patients was 34 years with ages that ranged from 17 to 45 without any gender predominance. The mean period between onset of symptoms and diagnosis was 6 weeks. Angiographic localization of the disease was observed in all patients. All patients were treated by endovascular techniques. The postoperative course has been satisfactory with a complete neurological recovery in all patients.Conclusions:Rupture of posterior circulation aneurysms in the setting of bilateral internal carotid artery occlusion is extremely rare. Treatment is exclusively endovascular intervention. The functional outcome of ruptured posterior circulation aneurysms in setting of bilateral carotid occlusive disease is particularly favorable with good neurological recovery.