Bilateral Internal Carotid Artery Stenosis Research Articles

Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Single-Center Experience.

Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) can be managed with staged (CEA before CABG), reverse staged (CABG before CEA) or synchronous treatment. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG. Between 2000 and 2020 a total of 185 patients with symptomatic triple-vessel or left main coronary artery disease associated with 70-99% asymptomatic or 50-99% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. Study endpoints were defined as mortality, stroke and myocardial infarction at 30days. Additionally, the composite endpoint of these events was investigated. At 30days, mortality, stroke and myocardial infarction rates were 5.9%, 8.1% (permanent [unresolved deficit at discharge] 5.4%) and 3.8%, respectively, and the composite endpoint was reached in 13.0% of patients. Patientssuffering from a stroke more frequently had a contralateral 70-99% ICA stenosis (60.0% vs. 17.3%; p < 0.001), peripheral artery disease (73.3% vs. 38.9%; p = 0.013) and prolonged cardiopulmonary bypass time (mean 119 ± 62min vs. 84 ± 29min; p = 0.012). Multivariate logistic regression analysis revealed the duration of cardiopulmonary bypass (odds ratio [OR] 1.024; 95% confidence interval [CI] 1.002-1.046; p = 0.034), a history of type 2 diabetes mellitus (OR 5.097; 95% CI 1.161-22.367; p = 0.031) and peripheral artery disease (OR 5.814; 95% CI 1.231-27.457; p = 0.026) as independent risk factors for reaching the composite endpoint. Patients undergoing synchronous CEA and CABG face an elevated risk of perioperative cardiovascular events, particularly an increased stroke risk in patients with symptomatic and bilateral ICA stenosis. Graphical Abstract available for this article.

Recurrent Bilateral Extracranial Internal Carotid Artery Stenosis.

Recurrent Bilateral Extracranial Internal Carotid Artery Stenosis.

Vessel Wall Magnetic Resonance Imaging of Bilateral Distal Internal Carotid Artery Stenosis in Intracranial Giant Cell Arteritis

Vessel Wall Magnetic Resonance Imaging of Bilateral Distal Internal Carotid Artery Stenosis in Intracranial Giant Cell Arteritis

A Novel Staged Revascularization Strategy for Bilateral Severe Internal Carotid Artery Stenosis at High Risk for Hyperperfusion Syndrome

Since bilateral severe internal carotid artery stenosis often is associated with severely decreased cerebrovascular reactivity (CVR) due to poor collateral blood flow, revascularization carries a high risk for development of hyperperfusion syndrome. In this study, we report a new staged strategy to prevent postoperative hyperperfusion syndrome in such patients. Bilateral severe cervical internal carotid artery stenosis patients with decreased CVR to 10% or less on one side were prospectively enrolled in this study. We first performed carotid artery stenting on the side with the milder CVR decrease (lower-risk side), aiming to improve hemodynamics associated with the severe CVR decrease on the greater-risk side. Then, carotid endarterectomy or carotid artery stenting was performed on the contralateral side after an interval of 4-8 weeks. In all 3 cases enrolled in this study, CVR on the greater-risk side improved to 10% or more 1 month after the first treatment. The ratio of regional cerebral blood flow on the contralateral greater-risk side was 114% 1 day after the second treatment, and HPS did not develop in any of the cases. Our treatment strategy, in which revascularization on the lower-risk side precedes that on the greater-risk side, is effective for the prevention of HPS in bilateral ICA stenosis patients.

Lemierre syndrome associated Cavernous Sinus Thrombosis and Development of Internal Carotid Artery Narrowing: A Case Report and Review of Literature (P2-5.005)

<h3>Objective:</h3> To report a case of Lemierre syndrome complicated by cavernous sinus thrombosis (CST) and bilateral internal carotid artery (ICA) stenosis without cerebral infarction in a young woman and summarize the literature on Lemierre syndrome with arterial involvement. <h3>Background:</h3> Lemierre syndrome is a complication of oropharyngeal infection characterized by thrombosis of the internal jugular vein (IJV) with septic thrombophlebitis followed by bacteremia and septic emboli dissemination to distal organs, but arterial involvement is extremely rare. <h3>Design/Methods:</h3> A 24-year-old previously healthy woman presented to the hospital with one week of progressive jaw pain and neck swelling after recent tooth extraction. Physical examination showed left ptosis without other neurologic deficits. Computer tomography (CT) of the neck found multiple anterior neck abscesses. The patient underwent emergent incision and drainage of abscess at the left lateral pharyngeal, left masticator, and bilateral sublingual space. Vascular imaging revealed findings of non-occlusive thrombus in the left IJV, bilateral cavernous sinus thrombosis (CST), and septic emboli in bilateral apical lungs, consistent with Lemierre syndrome. Neuroimaging showed no cerebral infarction even though a digital subtraction angiogram (DSA) demonstrated bilateral ICA severe stenosis (&gt;70%) in both extracranial and intracranial segments. Cultures of abscess samples proved positive for <i>Candida albicans</i> and <i>Streptococcus constellatus</i>. The patient received treatment with full-coverage antibiotics and anticoagulation therapy resulting in an excellent outcome. <h3>Results:</h3> A literature search yielded 29 cases of Lemierre syndrome with arterial complications, which manifested as ICA occlusion or stenosis, or mycotic aneurysm development. Despite variable clinical symptoms, most patients developed CST and were all treated with antibiotics. Anticoagulation therapy is controversial given scarce and inconsistent evidence. <h3>Conclusions:</h3> The presented case and literature review emphasize the variability of the clinical course of Lemierre syndrome. Septic CST can be a rare cause of ICA occlusion, stenosis, or pseudoaneurysms because of arteritis, and thus expedited workup is necessary. <b>Disclosure:</b> Dr. Zhou has nothing to disclose. Dr. Malik has nothing to disclose.

Using eZIS of SPECT to evaluate the therapeutic effect of carotid endarterectomy.

Stroke is an acute cerebrovascular disease with high morbidity and mortality. The main causes of ischemic stroke include carotid artery stenosis, and carotid endarterectomy (CEA) can be used to improve the blood flow of the lesion site. Regional cerebral blood flow (rCBF) can be decreased by using single photon emission computed tomography (SPECT). The Easy Z-Score imaging system (eZIS) can display the changes of rCBF as Z-Score. The purpose of this study was to determine whether eZIS of SPECT can be used to evaluate the therapeutic effect of CEA in the treatment of carotid artery stenosis. In this study, subjects were divided into the surgery group and the control group. The surgery group included seven patients with unilateral or bilateral internal carotid artery stenosis who received CEA treatment, and the control group included 11 patients who only received conventional drug treatment but did not receive surgery. Cerebral perfusion imaging (CPI) was collected twice before and after the corresponding treatment (within 6 months). rCBF of the lesion site was measured and Z-score was calculated before and after treatment by the eZIS technique. The postoperative Z-score of the surgery group was 0.54 ± 2.71 compared with that of the preoperative -1.34 ± 2.68 ( P  = 0.0034; t  = 4.687; df  = 6), while the z-score of the control group was -0.33 ± 2.58 compared with that of the pretreatment 1.84 ± 2.62 ( P  = 0.0010; t  = 4.618; df  = 10). CEA can effectively improve the blood flow in the lesion area of patients with carotid artery stenosis. eZIS of SPECT can be used to evaluate the therapeutic effect of CEA on carotid artery stenosis visually.

Teaching NeuroImage: Bilateral Internal Carotid Artery Stenosis Due to Aggressive Giant Cell Arteritis.

Teaching NeuroImage: Bilateral Internal Carotid Artery Stenosis Due to Aggressive Giant Cell Arteritis.

Carotid endarterectomy in Russia. What if current guidelines do not answer difficult questions?

This literature review covers the publications of Russian vascular surgeons in recent years and deals with debatable issues of carotid surgery, including: 1. What is the best technique for carotid endarterectomy (CEA)? 2. Why does restenosis of the internal carotid artery (ICA) develop and how to eliminate it? 3. How to operate on bilateral ICA stenosis? 4. Should carotid glomus be preserved? 5. Is CEA safe in the acute phase of cerebrovascular accident (CVA)? 6. Is CEA safe in elderly patients? 7. How to operate on patients with combined internal carotid and coronary artery involvement? The evidence presented in this publication makes it possible to draw the following conclusions: 1. When choosing a CEA technique, the classical technique with patch angioplasty should be avoided due to the high risk of ICA restenosis. 2. To eliminate ICA restenosis, carotid angioplasty with stenting (CAS) should be used. When performing primary CEA with ICA transposition over the hypoglossal nerve, reCEA can be used 3. In the absence of contraindications, bilateral ICA stenosis can be operated at the same time using CEA. 4. CEA with carotid glomus preservation is the operation of choice in the treatment of patients with hemodynamically significant ICA stenosis due to the elimination of the risks of postoperative hypertension and the formation of hemorrhagic transformation. 5. If there are indications for cerebral revascularization in the most acute period of stroke, CEA should be abandoned in favor of CAS. 6. In old age, CAS is the safest treatment strategy. 7. In the presence of a combined ICA and coronary involvement, the choice of treatment tactics should be carried out only by a multidisciplinary commission, taking into account the risk stratification of adverse cardiovascular events. 

Abstract 13392: 3D TEE Aids in Assessment of Embolic Stroke Due to Aortic Atherosclerotic Plaque

Case Presentation: A 69-year-old right-handed man presented with new left-sided weakness and recurrent ischemic strokes. His had history of coronary artery disease, diabetes mellitus, hypertension, dyslipidemia, chronic kidney disease stage 3, obstructive sleep apnea and obesity. Plasma low-density lipoprotein was 127 mg/dL. Brain MRI showed diffusion restriction in the left caudate head, left corona radiata, left anterior lentiform nucleus, and left periventricular white matter from acute to subacute infarction. CT angiogram showed diffuse atheromatous disease in the anterior and posterior circulation, bilateral mild cervical internal carotid artery stenosis, and calcifications in the aortic arch ( Figure 1 ). Transthoracic echocardiogram (TTE) showed mild generalized left ventricular hypokinesis (ejection fraction 45%) without thrombus. Transesophageal echocardiogram (TEE) showed complex mobile atherosclerotic plaques in the aortic arch ( Figure 2 ) after which Apixaban &amp; Clopidogrel were started and statins increased. At 1-year follow-up there was no recurrent stroke. Discussion: This case highlights the role of 3D TEE in the detection of complex aortic arch atherosclerotic plaque with mobile components as the etiology of recurrent embolic stroke. 2D TTE &amp; TEE and CT chest were unable to show mobile components in the aortic arch plaque. Many patients identified as having “cryptogenic stroke” after 2D TTE &amp; TEE may in fact have mobile aortic arch plaques which can only be delineated by 3D TEE, thus reducing the need for further workup and expediting appropriate treatment.

Fibromuscular dysplasia: a rare adult case with aortic arch coarctation and bilateral subclavian artery and internal carotid artery stenosis

Fibromuscular dysplasia: a rare adult case with aortic arch coarctation and bilateral subclavian artery and internal carotid artery stenosis

Genesis of Antibiotic Resistance (AR) LXXXV: Turbulence Modeling(TM) of Hemodynamics in Simplified Severe Sepsis Protocol‐2 (SSSP‐2)‐NCT01663701: Clinical Connotation of Monitoring ISP [BP(PP), MAP, CBF, ICP, CPPopt, Comatose GCS 3, and CCP] for Attenuation of IHM

Based on the theoretical inferences derived from industrial CFD modules: Flow‐3DÒ Hydro FD simulation Model 04; 05_sediment_transport FLOW‐3D HydroÒ, (Courtesy: Flow‐3D HydroÒ), The Beauty of Vortex Streets, May 5, 2021; Curve Fitting of Solution Data in COMSOL Multiphysics®, July 27, 2021 © 2021 BY COMSOL INC., https://earthobservatory.nasa.gov/images/90734/two‐views‐of‐von‐karman‐vortices (NASA). and hemodynamic data (SSSP‐2), here we present a plausible physiological basis for the benefit of monitoring ISP for attenuation 100% ihm in the usual care cohort of SSSP‐2 (PMID: 28973227). Hypothesis &amp; Rationale:Monitoring the ISP‐induced transient APG, eases the point of care clinical intervention for the recovery from GCS3 to homeostasis. Geometry: RBC, WBC, platelets, p47; Whole blood viscosity ~ 3 centipoise (cP) or ~0.003 Pascal second (Pa. s) p53; Blood velocity in the Human Blood Vessels: table 2.1 p63, Blood Vol. Distribution: Table 2.2, p64; Stress–Strain Curve, Fig 2.15 p 78; ISBN:9780128024089. Gov Eq: Segmental Cerebral Perfusion Pressure Equation for The Intracranial Compartment: SPP = Pd − ICP = FFR · CPP − Ge · (1 − FFR) · (ICP − Pe) (PMCID: PMC8032738; PMID: 33833266). Derivation &amp; Prospects:ISP has been shown to induce cerebral hypoperfusion in turn vasogenic edema altering contralateral/ipsilateral CBF due to increased blood flow through the anterior communicating artery (Acom). Case Report (PMCID: PMC7332508; PMID: 32637214): A 72‐year‐old male presented with the right‐sided hemiparesis and underwent MRI. MR imaging show an acute infarction of the left frontal lobe [Figure 1] and bilateral internal carotid artery (ICA) stenosis (NASCET: Rt: 90%, peak systolic velocity 425 cm/s and Lt: NASCET 70%, peak systolic velocity 212 cm/s). After 2 months, SPECT showed an decrease in CBF in the right cerebral hemisphere [Figure 2a]. INVOS‐4100 cerebral oximeter based determination of the effect of carotid clamping and shunting on oxygen saturation (rSO2) showed rSO2 readings were lower than ipsilateral rSO2 readings. SPECT showed a decrease in CBF around the infarction [Figure 2b]. SPECT indicated a contralateral increase in CBF [Figure 2b]. Tx, with free‐radical scavenger(Rx), showed an improvement in CBF, and laterality disappeared 2 weeks after CEA [Figure 2c and d]. The CBF of both sides equaled 2 weeks later [Figure 3]. Subsequent MR imaging with fluid‐attenuated inversion recovery (FLAIR) images showed a local high‐intensity lesion around a previous infarction in comparison with before CEA [Figure 4a and b]. FLAIR MR imaging 2 weeks after initial surgery confirmed the complete disappearance of the high‐intensity lesion [Figure 4c]. Taken together, the focal vasogenic edema induced neurologic impairment is shown to be alleviated by treating edema and cerebral ischemia while monitoring hemodynamic parameters. This model could be applied for the attenuation of fluid bolus augmented VKVS, collapsing of cerebral vessels leading to 100% ihm, in the usual care group in SSSP‐2 (PMID: 28973227).

Carotid Artery Stenosis and Ischemic Strokes in Patients with Giant Cell Arteritis: A Characteristic Pattern-Literature Review and Case Report.

Purpose  Ischemic stroke is a relatively rare complication of giant cell arteritis often accompanied by vessel stenosis. Our purpose was to compare the location of internal carotid artery stenosis in GCA patients by performing a literature review suggesting a specific and characteristic pattern. Methods  We performed a PubMed research including all articles and cited articles reporting cases and case series about giant cell arteritis patients with internal carotid artery stenosis and ischemic strokes. Results  In this case series 39 cases were included. We found a clear tendency of giant cell arteritis-related stenosis to be in the intracranial segments (35/39 (89.7%)). Only in 8/39 (20.5%) patients there was further involvement of extracranial segments. Many cases (27/39 [69.2%]) showed a bilateral involvement. Discussion  This literature review reveals a specific pattern of internal carotid artery involvement in patients with giant cell arteritis and ischemic strokes. To our knowledge this pattern has not been reported as a sign strongly pointing toward giant cell arteritis before. We have not found case reports mentioning other common types of vasculitis reporting this involvement pattern. Conclusion  Internal carotid artery stenosis and ischemic stroke is a rare complication in patients with giant cell arteritis. Considering the characteristic features of bilateral distal internal carotid artery stenosis giant cell arteritis should be suspected which potentially leads to an early diagnosis and immunotherapy.

Atypical Moyamoya Disease Associated with Midaortic Syndrome

AbstractWe report a case of a 4-year-old boy who presented with moyamoya disease associated with midaortic syndrome. He had been treated for severe persistent hypertension until he suffered multiple episodes of seizure and cerebral ischemic attack. Cerebral angiography showed bilateral terminal internal carotid artery stenosis. Angiographic survey showed severe stenosis of abdominal aorta and bilateral proximal renal arteries. This is a very rare report of moyamoya disease with midaortic syndrome.

MOYAMOYA DISEASE: A STORY OF MULTIPLE STROKES

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Moyamoya disease (MMD) is a specific cerebrovascular disease first described in 1957 by Japanese surgeons, characterized by stenosis or occlusion of the terminal portions of bilateral internal carotid arteries (ICA) with development of fragile small vessel collateral blood vessels. It may cause ischemic attacks or cerebral infarction, more frequent in children than adults. Incidence peaks in two different age groups: children who are approximately 5 years of age and adults in their mid 40's. Initial presentation is that of TIA or cerebral ischemia/hemorrhage. CASE PRESENTATION: 46-year-old female with history of hypertension initially presented with right sided tingling and numbness, CT head was negative, CTA head and neck significant for left ICA stenosis, she received tPA. Underwent full neurology work up including MRI no acute stroke or acute bleeding, MRA head and neck showed >80% narrowing of left ICA, etiology at that time was unknown. Followed by neurology clinic with imaging every 6 months; MRI Brain/MRA two years after initial presentation significant for left ICA supraclinoid occlusion and right supraclinoid moderate stenosis, left hemisphere supply via leptomeningeal collaterals from posterior cerebral artery (PCA) and anterior cerebral artery (ACA) consistent with MoyaMoya Disease. She subsequently had left superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis. Remained asymptomatic for two more years until gradual onset of forgetfulness and memory loss. Repeat imaging at that time demonstrated evolving ischemia of frontal region and high-grade stenosis of bilateral internal carotid arteries, she underwent an additional intracranial bypass. DISCUSSION: Moyamoya disease is a chronic, occlusive cerebrovascular disease involving bilateral stenosis of ICA or occlusion of the terminal portions of MCA and ACA. There are four types of MMD: ischemic, hemorrhagic, seizures, or "other;” hemorrhagic being more common in adults. Initial presentation consists of symptoms of TIA or stroke like symptoms including severe headaches, unilateral weakness, or memory changes. On angiography, characteristic stenosis or occlusion of bilateral terminal portion of ICAs as well as the moyamoya vessels are seen at the base of the brain. Cases with milder symptoms can be medically managed, while more severe symptomatic cases are treated with revascularization such as STA-MCA anastomosis. However, these procedures do not prevent progression of disease and patients may require multiple procedures to prevent ischemic episodes. CONCLUSIONS: Moyamoya disease is a chronic, occlusive cerebrovascular disease involving bilateral ICA, initial symptoms are those of TIA or stroke. Milder cases can be managed medically but more severe cases require surgical intervention, however, this does not slow down progression of disease. Reference #1: Burke, G., Burke, A., Sherma, A., Hurley, M., Batjer, H., Bendok, B (2009). Moyamoya Disease: A Summary. Journal of Neurosurgery. https://doi.org/10.3171/2009.1.FOCUS08310 Reference #2: Fukui M, Kono S, Sueishi K, Ikezaki K. Moyamoya disease. Neuropathology. 2000;20 Suppl:S61-S64. https://doi.org/10.1046/j.1440-1789.2000.00300.x Reference #3: Scott, M., Smith, E. (2009). Moyamoya Disease and Moyamoya Syndrome. The New England Journal of Medicine. 2009; 360: 1226-37. http://moya-moya.org/wp-content/uploads/2011/05/moya-moya.pdf DISCLOSURES: no disclosure on file for Victor Montalvan; No relevant relationships by Brandon Rogers, source=Web Response No relevant relationships by Jasmine Sekhon, source=Web Response

Gradient of luminal narrowing of internal carotid artery on atherosclerotic plaque as risk factor for cerebral ischemic damage

Aim. To study the clinical significance of the gradient of narrowing of arterial lumen (GNL) for atherosclerotic stenosis of the internal carotid artery (ICA) as a risk factor for ischemic brain damage.Material and methods. We proposed a new parameter of hemodynamic severity of ICA atherosclerotic stenosis — GNL. It calculated as ratio of the difference in the ICA cross section areas on the stenotic lesion and the near non-stenotic region to the distance between them: Snorm — Sstenosis)/Dnorm — stenosis, mm2 /mm. We examined 25 patients with advanced atherosclerosis and with uni(n=22) or bilateral (n=3) ICA stenosis &gt;50% according to European Carotid Surgery Trial, and 11 individuals without ICA stenosis. Each participant underwent magnetic resonance angiography (MRA) of the carotid arteries with reconstruction of the arteries from C6-C7 level to the parietal bones, and the GNL was calculated. The thickness of the baseline slice was 0,8-1 mm. Each subject also underwent cerebral magnetic resonance imaging (MRI) in T1-, T2-, PD-, flair-weighted protocols. Results. Patients were divided into groups: group 1 (n=12) — without ischemic injury in the ICA system, and group 2 (n=13)  — with MRI signs ischemic injury history. The groups did not differ in proportion of stenosis (74,9±4,25% and 77,8±3,8%, p&lt;0,05), ICA lumen area on the stenotic lesion (1,05±0,18 mm2 and 1,14±0,17 mm2 , p&lt;0,05) and the ICA diameter at the non-stenotic region (4,30±0,32 mm and 4,9±0,29 mm, p&lt;0,05). In control group, GNL was &lt;0,75 mm2 /mm. Groups 1 and 2 significantly differed (2,47±0,41 mm2 /mm and 4,60±0,51 mm2 /mm, p&lt;0,02). In group 2, 12 out of 13 patients had GNL &gt;3,35 mm2 /mm, and, in group 1, 9 out of 12 — less than 3,35 mm2 /mm. GNL did not correlate significantly with other parameters of ICA stenosis. Two patients with the highest GNL in each group (5,5 and 8,6 mm2 /mm) had a fatal ischemic stroke within six monthsConclusion. Firstly, proposed parameter of stenosis hemodynamic severity GNL is independent, informative and prognostically important indicator for carotid artery atherosclerotic lesion.

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.

Critical Stenosis of the Internal Carotid Artery: Variability in Vertebral Artery Diameters and Areas of Cerebral Chronic Infarction in Computed Tomography

We investigated unilateral and bilateral cervical internal carotid artery (ICA) stenosis according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST). We retrospectively investigated ICA stenosis on Head&Neck Computed Tomography Angiography (CTA); and their simultaneous brain computed tomography images were also evaluated. In unilateral ICA stenosis group (n=36), 17 of them had right ICA stenosis and 19 left ICA stenosis. In bilateral stenosis group, there were 24 patients. ICA stenosis was evaluated according to NASCET and ECST methods. We also evaluated vertebral artery dimension, plaque density and cerebral infarct (Cerebral kortex, white matter, basal ganglion-thalamus). Unilateral ICA stenosis according to the NASCET was 70.64% to 73.68% (right-left) and according to the ECTS was 65.52% to 71.15% (right-left). For bilateral stenosis, ICA stenosis according to the NASCET was 67.70 to 67.91 (right-left); according to the ECTS was 62.45% to 62.15% (right-left). Vertebral artery dimensions were 3.26 to 3.72 mm (right-left) in unilateral ICA stenosis; and 3.52 to 3.71 mm (right-left) in bilateral ICA stenosis. In bilateral stenosis group, mixt plaque; and in unilateral stenosis group, hard plaque was detected. In unilateral stenosis, white matter and basal ganglion-thalamus infarcts; in bilateral ICA stenosis, cerebral cortical infarct was detected. Left-vertebral artery diameter increased in higher L-ECTS ICA stenosis (unilateral) group. Increase in left vertebral artery diameter in unilateral L-ECTS ICA stenosis may be related to increase of the collateral flow by vertebral arteries to support brain blood-flow.

Neurological complications after cardiac surgery: a retrospective case-control study of risk factors and outcome

BackgroundTo evaluate incidence, risk factors, and outcomes of postoperative neurological complications in patients undergoing cardiac surgery.MethodsA total of 2121 patients underwent cardiac surgery between August, 2008 and December, 2013; 91/2121 (4.3%) underwent brain computed tomography (70/91, 77%) or magnetic resonance imaging (21/91, 23%) scan because of major stroke (37/2121, 1.7%) and a spectrum of transient neurological episodes as well as transient ischemic attacks and delirium /psychosis/seizures (54/2121, 2.5%). The mean age was 65.3 ± 12.1 years and 60 (65.9%) were male. Variables were compared among study- and matched-patients (n = 113) without neurological deficits.ResultsA total of 37/2121 (1.7%) patients had imaging evidence of stroke. Radiological examinations were done 5.72 ± 3.6 days after surgery. Patients with and without imaging evidence of stroke had longer intensive care unit length of stay (LOS) (13.8 ± 14.7 and 12.9 ± 15 days vs. 5.7 ± 12.1 days, respectively (p < 0.001) and hospital LOS (53 ± 72.8 and 35.5 ± 29.8 days vs. 18.4 ± 29.2 days, respectively (p < 0.001) than the control group. The hospital mortality of patients with and without imaging evidence of stroke was higher than the control group (7/37 patients [19%], and 12/54 patients [22%] vs. 4/115 patients [3%], respectively (p < 0.001). Multivariate analysis showed that bilateral internal carotid artery stenosis of any grade (p < .001), and re-do operations (p = .013) increased the risk of postoperative neurological complications.ConclusionsNeurological complications after cardiac surgery increase hospitalization and mortality even in patients without radiologic evidence of stroke. Bilateral internal carotid artery stenosis of any grade, suggesting a diffuse patient propensity toward atherosclerosis, and re-do operations increase the risk of postoperative neurological complications.

Unilateral moyamoya disease mimicking intracranial hemorrhage in a pediatric patient: Surgical treatment with encephalo-duro-myo-synangiosis in a progressive disease

Abstract Background Moyamoya disease (MMD) is characterized by progressive bilateral internal carotid artery stenosis and its distal branches. When angiographic findings are unilateral, the diagnosis is considered to be probable MMD. Surgery is recommended treatment of patients with deterioration caused by progressive cerebral ischemic events. Different techniques have been described, and the encephalo-duro-myo-synangiosis (EDMS) procedure is highly recommended for patients with rapid deterioration. A case of unilateral MMD mimicking intracranial hemorrhage in a pediatric patient is reported. Case description A 14-year-old girl was referred to our center due to a decreased level of consciousness. Physical examination revealed right-sided hemiparesis; however, a brain CT scan showed multiple hyperdense masses mimicking a hemorrhagic lesion. A brain MRI showed a large hypointensity in the temporoparietal, suggesting a vascular lesion. In all children that exhibit encephalitis, vascular events such as MMD should be considered. An emergency surgical EDMS procedure was performed, and the patient regained consciousness and exhibited no TIAs during the follow-up period. A postoperative brain MRI showed an improvement in brain vascularity. Conclusion After EDMS, a considerable degree of neurological recovery was observed in our patient with rare unilateral MMD mimicking intracranial hemorrhage. We found that the progression of clinical improvement after indirect revascularization in our case was due to EDMS. Surgical treatment with EDMS is reasonable for MMD because it allows for flexible revascularization that adequately addresses the requirement for new blood supply in the ischemic lesion. The EDMS procedure is followed by an observation period to preclude the possibility of the patient developing definite MMD.

Novel Susceptibility Loci for Moyamoya Disease Revealed by a Genome-Wide Association Study.

Moyamoya disease (MMD) is a rare cerebral vasculopathy characterized by bilateral internal carotid artery stenosis and often leads to stroke in children or young adults. Although familial inheritance is well recognized, the genetic basis of MMD remains poorly understood. A 2-stage genome-wide association study was conducted involving 1492 cases and 5084 controls. In the discovery stage, logistic regression was used to test associations, and imputation was conducted based on genotyped single-nucleotide polymorphisms (SNPs). In the validation stage, the top significant SNPs were again genotyped in an independent cohort. Fixed-effects inverse variance-weighted meta-analysis was used in the combined discovery and validation samples. Furthermore, association analysis was conducted in subgroups using patient clinical data. The study identified 10 novel risk loci with genome-wide significance (P<5×10-8) and confirmed a previously reported locus on 17q25. No significant SNP showed evidence of heterogeneity between the 2 stages. Cumulatively, these SNPs explained 14.76% of disease risk variance-a substantial proportion of the 39.02% of risk variance explained by all genome-wide genotyped SNPs. One SNP, rs9916351 in RNF213 (Pcombined=4.57×10-54; odds ratio, 1.96), showed a stronger genetic effect on early-onset than late-onset MMD (P=0.003). Two novel SNPs in genes regulating homocysteine metabolism, rs9651118 in MTHFR (Pcombined=2.49×10-19; odds ratio, 0.65) and rs117353193 in TCN2 (Pcombined=6.15×10-13; odds ratio, 1.43), were associated with high-serum homocysteine in MMD cases. Additionally, another SNP associated with MMD (rs2107595 in HDAC9; Pcombined=1.49×10-29; odds ratio, 1.64) was previously implicated in large-vessel disease. Tissue enrichment analysis showed that the genes of associated loci were highly expressed in the immune system (false discovery rate, <0.05). This study identifies several novel susceptibility genes for MMD. The association with homocysteine metabolism and the immune system enrichment of susceptibility gene expression suggest that therapeutic interventions targeting these pathways may be effective approaches for MMD treatment.