Carotid Artery System Research Articles

Diagnosis of variants of carotid-vertebasilar anastomoses on MR angiography

Objective To explore the feature of embryonic communication between the carotid and vertebro-basilar system using MRA of head and neck on MR. Methods The MRA images from 7 246 consecutive patients in Liaocheng People's hospital between June 2009 and December 2015 were retrospectively reviewed. The feature of embryonic communication between internal carotid, external carotid artery and vertebro-basilar system using MRA was analyzed by two doctors. Results Forty-four cases of embryonic communication between the carotid and vertebro-basilar system were found. Thirty-nine cases of primitive trigeminal artery (PTA) and primitive trigeminal artery variants (PTAV) were detected by MRA. The prevalence of both PTA and PTAV was 0.54% (PTA, 27 cases;PTAV, 12 cases). Twenty-three cases of PTA were lateral types;four cases were medial types. All PTA originated from C4 portion of internal carotid artery, of which 27 cases connected with the basilar artery and two cases connected with the superior cerebellar artery. The region of the BA proximal to the site of convergence with the PTA was hypoplastic in seven cases and completely absent in two cases. Three cases of primitive hypoglossal artery and 2 cases of primitive proatlantal artery were detected by MRA. The prevalence of primitive hypoglossal artery and primitive proatlantal artery was 0.04% and 0.03% respectively. Two cases of primitive hypoglossal artery were from the lateral internal carotid artery and one was from the external carotid artery. It's all on the right side. One case of primitive proatlantal artery was on the left which arises from the external carotid artery, one on the right which originated from the outer part of the internal carotid artery. Thirty-four cases were coexisted with other variants of head and neck vessels. All of the primitive hypoglossal arteries were coexisted with vertebral artery absence. One case of primitive proatlantal intersegmental artery was coexisted with vertebral artery dysplasia. Eighteen cases were associated with cerebral infarctions, and three cases with aneurysm. Conclusions MRA can accurately assess the variants of carotid-vertebasilar anastomoses and have diagnostic significance. Key words: Magnetic resonance imaging; Primitive trigeminal artery; Primitive hypoglossal artery; Primitive proatlantal intersegmental artery

An Eye with a Heartbeat: Carotid Cavernous Fistula–a Case Report

BackgroundA carotid cavernous fistula is a rare type of arteriovenous (AV) fistula due to an abnormal communication between the cavernous sinus and the carotid arterial system. Normal venous return to the cavernous sinus is impeded as high-pressure arterial blood enters the cavernous sinus. The classical triad of symptoms is characterized by pulsating exophthalmos, ocular bruit, and conjunctival chemosis. However, it is important to note that some patients do not exhibit this triad of symptoms. Case ReportA 49-year-old man presented to the Emergency Department (ED) with a chief complaint of “there is a heartbeat in my eye.” Pertinent history included an episode of trauma 2 months prior to his onset of unilateral vision loss. Computed tomography scan of the head obtained in the ED upon his initial injury was unrevealing. Despite no identifiable pathology, his pain had gradually worsened since ED discharge. On this occasion, an ocular bruit was appreciated over the affected eye, prompting further diagnostic testing. The patient was admitted for urgent cerebral angiography and definitive endovascular neurosurgical intervention to preserve his eyesight. We discuss the clinical presentation, pathophysiology, and diagnostic modalities important to the management of this rare and potentially devastating cause of vision loss. Why Should an Emergency Physician Be Aware of This?A carotid cavernous fistula is a rare and easily misdiagnosed cause of unilateral ocular pain in the ED. Further, it emphasizes the importance of a detailed clinical history and physical examination to make this diagnosis and save eyesight.

Anatomical Variability of the Posterior Communicating Artery.

Objective:Although posterior communicating artery (PCoA) is a smaller branch of the internal carotid artery, it gives the main contribution in the formation of circle of Willis (CW) by communicating with the internal carotid arterial system and the vertebro-basilar arterial system. The size of PCoA varies frequently. The present work aims to study the PCoA regarding its morphology, morphometry, and symmetry.Materials and Methods:This study was conducted on 170 human cadaveric brains. Brains were dissected carefully and delicately to expose all components of CW, especially PCoA. Morphological variations of PCoA were noted along with its morphometry and symmetry.Results:Morphological variations of PCoA were aplasia (3.52%), hypoplasia (25.29%), fenestration (0.58%), and persistent fetal pattern (16.47%). In the present study, we found the five different types of terminations of PCoA. Type I termination was the most common type, seen in 92.94% of cases, Type II termination was seen in 1.17%, Type III and Type IV terminations both were seen in 0.58%, and Type V was seen in 1.17%. The mean length of PCoA was 15.9 mm and 15.3 mm on the right and left sides, respectively. The mean diameter of PCoA was 2.1 mm and 1.9 mm on the right and left sides, respectively. Symmetry of PCoA was seen in 65.29% and asymmetric PCoA was seen in 34.70% of cases.Conclusion:The present study provides the complete description of PCoA regarding its morphology, symmetry, and morphometry. Awareness of these anatomical variations is important in neurovascular procedures.

The Face – A Vascular Perspective. A literature review

Vascular supply is key for maintenance of healthy tissue conditions but also with regard to healing following trauma or therapeutic interventions. The face is probably the most exposed part of the body and any changes of vascularity are readily visible (skin blanching, ecchymosis, hematoma, edema). With regard to the arterial supply, all vessels reaching the facial skin originate from the bilateral common carotid arteries. The ophthal­mic artery is considered the major arterial shunt between the internal and external carotid artery systems. Main arterial contributors to the face include the facial, transverse facial, and infraorbital arteries. In general, homonymous veins accompany the arteries, but there are some exceptions (inferior ophthalmic vein, retromandibular vein). Furthermore, the facial vein demonstrates a consistently more posterior course compared to the facial artery. Lymphatic vessels including lymph nodes play an important role for facial drainage.

The Face – A Vascular Perspective. A literature review

Vascular supply is key for maintenance of healthy tissue conditions but also with regard to healing following trauma or therapeutic interventions. The face is probably the most exposed part of the body and any changes of vascularity are readily visible (skin blanching, ecchymosis, hematoma, edema). With regard to the arterial supply, all vessels reaching the facial skin originate from the bilateral common carotid arteries. The ophthal­mic artery is considered the major arterial shunt between the internal and external carotid artery systems. Main arterial contributors to the face include the facial, transverse facial, and infraorbital arteries. In general, homonymous veins accompany the arteries, but there are some exceptions (inferior ophthalmic vein, retromandibular vein). Furthermore, the facial vein demonstrates a consistently more posterior course compared to the facial artery. Lymphatic vessels including lymph nodes play an important role for facial drainage.

Tratamiento de la fístula carótido-cavernosa

Introducción: Denominamos fístula carótido-cavernosa (FCC) a cualquier comunicación anómala entre la arteria carótida interna y el seno cavernoso generando un shunt arteriovenoso patológico. Métodos: Revisión retrospectiva, del servicio de Neurointervencionismo Uruguay “CEDIVA”, incluyendo 17 pacientes con FCC diagnosticados entre julio de 1998 hasta julio de 2013; valorando clínica, tratamiento realizado y resultados. Búsqueda bibliográfica de FCC en los últimos 10 años. Resultados: Edad promedio 48 años; 58% hombres y 42% mujeres. 76,4% tuvieron antecedente traumático, y 23,6% no tuvieron antecedente. Clínica más frecuente fue la ocular (94%). Todos los pacientes se hicieron arteriografía diagnóstica. De los 13 pacientes con antecedente traumático, todos fueron FCC directa. De los 4 pacientes sin antecedente traumático, 3 fueron FCC indirectas, y una fue FCC directa. El tratamiento en todos fue endovascular. La elección de la técnica a utilizar se basó en características de la FCC y el neurointervencionista encargado del procedimiento. A todos los pacientes se les realizó arteriografía de control a los 3 meses. Hubo mejoría clínica en 76,4% de los pacientes. Conclusiones: Es una entidad de gran importancia, siendo fundamental que el neurocirujano la conozca correctamente a fin de realizar un diagnóstico y tratamiento precoz para prevenir secuelas potencialmente graves.

Risk factors for the development of the ischemic stroke in the carotid arterial system in males and females

Introduction. Biologically determined differences between males and females and different levels of sex hormones determine some specific features of their ischemic stroke (IS). Clinical studies aimed at identifying risk factors for the development of IS in persons of different sexes are considered to be necessary for elaborating strategies to increase life expectancy and to improve quality of life. Objective : to study risk factors for the development of IS in the arteries of the carotid system in males and females. Materials and methods. Risk factors for the development of IS in the arteries of the carotid system were analyzed in 268 patients for the period from 2010 to 2017. Among the patients, there were 148 (55%) men and 120 (45%) women aged from 47 to 79 years. MRI of the brain, duplex scanning of the cerebral arteries, and transthoracic and transesophageal echocardiography were used to establish the diagnosis of the stroke subtype. Results. In the age group 47-79 years, females had more often cardioembolic and lacunar stroke, while males had predominantly atherothrombotic stroke and stroke with competing causes. Atrial fibrillation, diabetes mellitus, atherosclerotic cardiosclerosis, chronic heart failure, thyroid disease and excess body weight were also more common in females. In contrast, there were significantly more smokers and over-consumption of alcohol among males, and the same was true for small heart attacks and transient symptoms in the past history. Atherosclerosis of the extracranial part of the internal carotid artery (ICA) of high degree was found more often in males, while females with atherothrombotic stroke had significantly higher blood cholesterol level. The study of arterial hypertension (AH) revealed the following differences between groups: AH III degree (180/110 mm Hg or higher) was more often in females, and AH I degree (140-159 / 90-99 mm Hg) in males, while the proportion of patients with grade II AH (160-179 / 100-109 mm Hg) and patients without AH was approximately equal in the two groups. Conclusions. The risk factors for the development of IS in the arteries of the carotid system in men are atherosclerotic carotid stenosis, smoking and excessive alcohol consumption. Development of stroke in men is preceded by small infarcts with transient symptoms. The risk factors for the development of IS in the arteries of the carotid system in women are atrial fibrillation, diabetes mellitus, atherosclerotic cardiosclerosis, chronic heart failure, thyroid disease, and excess body weight. As in men, despite of significantly higher cholesterol levels, there are more pronounced atherosclerotic carotid stenosis and more frequent ISs, one may suggest the existence of an additional factor leading to stroke (alternatively, women may have some gender-specific protective factor).

Supraclinoid direct carotid-cavernous sinus fistula.

Carotid-cavernous fistulas (CCFs) are vascular shunts between the carotid arterial system with direct drainage into the cerebral venous system, mainly to the cavernous sinus. Direct CCF is a well-recognised complication following head trauma. Classically in direct or traumatic CCF, vessel wall tear occurs at the cavernous segment of the internal carotid artery, between the fixed and free segment. Tears at the supraclinoid segment are rare. We report a case of an internal carotid artery supraclinoid segment pseudoaneurysm, with a direct communication with the cavernous sinus, draining into the superior ophthalmic vein.

Diagnosis of arterial gas embolism in SCUBA diving: modification suggestion of autopsy techniques and experience in eight cases

The purpose of this study was to suggest modifications of autopsy techniques in order to improve post-mortem diagnosis of arterial gas embolism (AGE) based on multidisciplinary investigation of SCUBA diving fatalities. Five adult human cadavers from the voluntary donation program of the Human Anatomy Laboratory, and eight judicial autopsied bodies of SCUBA divers from the Forensic Pathology Service were assessed. Before performing any autopsies, we accessed the diving plan and the divers' profiles for each case. We then introduced a new dissection procedure that included identification, isolation, and manipulation of carotid, vertebral and thoracic arterial systems. The dissected vascular structures that allowed optimall isolation of the systemic arterial circulation were identified and ligated. In three of the eight judicial cases, we had a strongly suggestive history of arterial gas embolism following pulmonary barotrauma (PBt/AGE). In these cases, the additional arterial dissection allowed us to clearly diagnose AGE in one of them. The autopsy of the rest of the cases showed other causes of death such as asphyxia by drowning and heart attack. In all cases we were able to reject decompression sickness, and in some of them we showed the presence of artefacts secondary to decomposition and resuscitation maneuvers. These results allow us to suggest a specific autopsy technique divided into four steps, aimed at confirming or excluding some evidence of dysbaric disorders according to a re-enactment of the incident. We have demonstrated the presence of large volumes of intravascular air, which is typical of PBt/AGE.

Bilateral carotid-cavernous fistula presented with unilateral symptomatology

Introduction. Carotid-cavernous fistula presents an abnormal communication between carotid arterial system and the venous cavernous sinus. Due to anatomical characteristics of the sinus, the clinical picture is first manifested as ophthalmic problem. These fistulas are either of spontaneous or traumatic origin with different hemodynamics. They are usually on one side. However, bilateral carotidcavernous fistulas are rare and deserve special interest. Case report. We presented a 76-years-old female patient, who complained on diplopia and right eye protrusion and esotropia. Ophthalmological findings aroused suspicion of a right-side spontaneous carotid-cavernous fistula. Further non-invasive and invasive investigations confirmed our initial diagnosis. Unexpectedly, digital subtraction angiography revealed another fistula, on her left side. Both fistulas were of low flow and did not need therapy. Conclusion. Carotid- cavernous fistula represent certain diagnostic and therapeutic challenge. Although they are not indicated in a clinical picture, sometimes bilateral fistulas can be found during appropriate diagnostic procedures.

Variations of circle of Willis in human cadavers

Aims and Objective: The blood supply of brain is of great importance because of the metabolic demands of the nervous tissue. A significant anastomosis, the Circle of Willis exists between the carotid and vertebral arterial systems. An understanding of the distribution of the arteries is very important. As the neurological signs depends on the site of lesion. Material and Methods: The study was conducted on 45 adult brain specimens of both sexes in human cadavers. The collected specimens were preserved in 10% formalin. The Circle of Willis of each brain was dissected with care. Results: Variations of Circle of Willis in brain specimens includes – anomalous morphology, incomplete circle, and variable shape of Circle and variable length and external diameter of arteries of Circle of Willis. In the present study the terminal bifurcation of the basilar artery was found to be unequal in few cases. Conclusion: Various diseases of arteries of brain like cerebrovascular attack, aneurysm, haemorrhage etc. are related to the anatomic patterns of the Circle of Willis. The knowledge of which is of considerable help to neurosurgeons.

Comparative anatomy of the carotid artery system in the lion

Comparative anatomy of the carotid artery system in the lion

Carotid artery evaluation in ischemic stroke patients using Color Doppler imaging

Background: Stroke is a major cause of mortality, morbidity, & health care expenditure globally. Carotid artery stenosis accounts for approximately 85% of all strokes. There is great value of safe, noninvasive and low cost screening test; therefore Doppler ultrasound study of carotid system is an important modality. Duplex Sonography, combining high resolution imaging and Doppler spectrum analysis has proved to be popular, non invasive, accurate and cost effective means of assessing carotid artery disease. Objective: 1.To assess carotid arteries with the help of color Doppler and -B mode imaging in carotid artery disease. 2. To correlate cerebrovascular accidents with extra cranial carotid artery status. Methods: This study was carried out in patients who had symptoms and signs of strokes, or transient ischemic attacks at a tertiary teaching hospital from the period of January 2015 to June 2016. The study was carried out on 94 patients. A detailed clinical history was taken and clinical examination findings were recorded. Risk factors like hypertension, diabetes mellitus, smoking and ischemic heart disease were documented. CT scan examination of the brain was carried out in all the patients and the findings were noted. Results: In this study, 79% of the patients were males and only 21% were females. The highest number of stroke patients in our study was found in the age group of 50-59 years which was 28%. Around 17% of patients had right MCA territory infarct, 9% had Left MCA territory infarct. Lacunar infarcts were seen in 33% patients. About 3% patients had right ACA territory infarct, 2% patients had left ACA infarct, 2%patients had right cerebellar infarct & 5% patients have age related cerebral atrophy. Normal study of brain was found in 25 patients in this study, 63% of patients had plaque in the carotid system. 47% of patients had plaque on the right side, 41% patients had plaque on the left side and 12% patients had bilateral involvement. Conclusion: Color Doppler examination is an economic, safe, reproducible and less time consuming method of demonstrating the cause of cerebrovascular insufficiency in the extra cranial carotid artery system and will guide in instituting treatment modalities.

Current Status of Forensic Identification for Blunt Injuries of Internal Carotid Arterial System

Internal carotid arterial system is the main source of blood supply in brain. In forensic identification practice, blunt injures of internal carotid arterial system usually cause complications such as thrombus, aneurysm and arteriovenous fistula, etc. The deaths following delayed cerebral infarction or intracranial haemorrhage are not rare. At present, literature of deaths caused by blunt injuries of internal carotid arterial system mainly consist of case reports in China. This paper reviews related literature and case reports at home and abroad, and summarizes forensic medical features and identification method of the deaths caused by such injuries. The results show that blunt injures of internal carotid arterial system are related to the direct or indirect force on head and neck, which can result in exceed physiological range traction of head and neck, incision following basicranial fracture, etc. Such injuries are common in the cases as mechanical asphyxia, cervical manipulation, traffic accident and fall, etc. The artery should be examined carefully, and the relationship among injury, disease and death should be analysed correctly when no cause of infarction and hemorrhage was found in routine examination of such cases in forensic pratice. Because of the difficulty for exposing the artery completely in autopsy, angiography can be used to infer the location when necessary for improving the scientificity and reliability of the appraisal conclusion.

Doppler ultrasonography can be useful to determine the etiology of idiopathic sudden sensorineural hearing loss

ObjectiveThis study aims to evaluate clinical features of both carotid and vertebral arteries in the idiopathic sudden sensorineural hearing loss (ISSNHL) patients and healthy individuals to contribute additional knowledge on vascular compromise theory. MethodsThis study was designed as a retrospective case control study in a tertiary referral center. 55 patients for ISSNHL and 35 healthy participants (70 ears) are involved to the study. All of the patients were evaluated for the systemic disorders and excluded other possible causes (autoimmune diseases, acoustic schwannoma, drug toxicity, etc) of ISSNHL. The carotid and vertebral arteries were assessed with Doppler USG; in fact, the vascular diameter (VD), intima media thickness (IMT), peak systolic velocity (PSV), blood flow (BF) and resistive index (RI) were evaluated. Related parameters were compared with the control groups. ResultsIn carotid artery system; common carotid artery intima-media thickness (CC-IMT) (p<0.001), and internal carotid artery intima-media thickness (IC-IMT) (p<0.001) were found significantly increased. Otherwise; PSV, VD and BF were not differed significantly. In vertebral artery system; VD (<0.001), PSV (<0.002) and BF (<0.001) were decreased significantly but vertebral artery RI was statistically increased (<0.001). ConclusionIn our study, we found the carotid artery thickening on vascular wall. We also demonstrate the vascular compromise on vertebral arteries. The Doppler USG may lead to determine the etiology of ISSNHL and further investigations are needed to define the exact results.Level of evidence: III b

Seeing the difference—Painless progressive vision loss in a vasculopath

A 78-year-old Caucasian man with significant vascular disease reported sudden onset of worsened vision during a routine wound-care appointment for nonhealing necrotic leg ulcers. He described painless blurring of vision with grey scotomas in his right eye, his only well-seeing eye, after trauma to the left eye as a child. He presented with retinal ischemia, a cotton wool spot, and optic nerve swelling. Temporal artery biopsy showed myxoid degeneration and extensive calcium deposition, which also was present on imaging throughout his carotid and vertebral arterial system—the clinical picture of calciphylaxis.

Operative management of catastrophic bleeding in the head and neck

The otolaryngologist commonly performs several procedures in close proximity to the carotid and innominate arterial systems. In this article, we will discuss the management of catastrophic bleeding following adult tonsillectomy and tracheostomy, as well as the management of carotid blowout syndrome in head and neck cancer patients. Although the bleeding risk from tonsillectomy is considered very low, the acceptance of transoral robotic surgery as a treatment modality of oropharyngeal head and neck carcinomas makes the spectre of catastrophic oropharyngeal bleeding more real. Aggressive resection in this area can leave minimal parapharyngeal fat over the carotid artery and damage from manipulation of smaller vessels can lead to pseudoaneurysms. Tracheostomy also carries a very low but real risk of trachea-innominate artery fistula, which has devastating consequences. Finally, we will discuss how to identify head and neck cancer patients who are at risk for carotid blowout syndrome as well as appropriate interventions to manage this condition.

Bleeding after tonsillectomy

Oropharyngeal hemorrhage after tonsillectomy is one of the most common postprocedural ENT emergencies that require immediate attention. Management choices depend on the severity of bleeding, underlying platelet or coagulation disorders, and the patient’s maturity and age. Treatment range from simple observation to an emergent need to both secure the airway and stop the hemorrhage. The workup of the hemorrhagic patient will be discussed from the preoperative to postoperative time period. Surgical techniques in response to various acuity will be discussed to fully elucidate options to control the hemorrhage.

Influential factors and clinical significance of fluid-attenuated inversion recovery vascular hyperintensities in transient ischemic attacks of carotid arterial system.

Fluid-attenuated inversion recovery vascular hyperintensity (FVH) is often observed in conjunction with acute ischemic stroke (AIS) of the carotid system. Despite its bearing on patient care outcomes, factors influencing FVH and its clinical significance in patients with transient ischemic attacks (TIAs) of the carotid arterial system have yet to be evaluated. Consecutive inpatients (N=154) diagnosed with TIAs of the carotid system in a 2-year period (2012-2014) were enrolled in our study. Each had undergone magnetic resonance imaging (MRI) within 72h of symptom onset, followed by intracranial and extracranial vascular imaging. We investigated the frequency and nature of factors associated with FVH, also examining its clinical significance in the 30-day prognosis of TIA. Of the 154 patients enrolled (male, 92; mean age 63.0±11.9), FVH was confirmed in 61 patients (39.6%). In logistic regression analysis, intracranial large-artery disease (LAD) (OR=2.39, 95% CI 1.16-4.92; p=0.018) and prior stroke (OR=3.33, 95% CI 1.48-7.51; p=0.004) emerged as factors independently associated with FVH positivity. Ultimately, 25 patients (16.2%) progressed to AIS within a 30-day follow-up period. Logistic regression analysis indicated that contralateral FVH positivity (OR=5.98, 95% CI 1.81-19.76; p=0.003), atrial fibrillation (OR=7.05, 95% CI 1.33-37.40; p=0.022), and extracranial LAD (OR=4.12, 95% CI 1.26-13.41; p=0.019) were independently associated with AIS during the 30-day follow-up of TIAs in these patients. Intracranial LAD and previous stroke are independently associated with FVH in patients experiencing carotid system TIAs. If present, FVH may predict an oncoming AIS in the 30days following a TIA.

P326 The role of intraoperative neurophysiological monitoring in carotid endarterectomy (CEE)

To determine the role of somatosensory evoked potentials (SSEP) and transcranial dopplerography (TCDG) in assessment of TIA and IS; to find the relationship between the decrease in the amplitude of the N20 complex and the duration period in the same patients. 15 patients with decrease of flow velocity in the (ICA) stenosis > 60% were examined: 13 of them had symptomatic stenosis and 2 were asymptomatic. In all cases IOM was held with registration of SSEP (stimulation of n. medianus) and TCDG of the ACM with an assessment of retrograde blood flow (RBF). All patients underwent SSEP and RBF; TCDG was not possible in 3 patients. In 5 patients there were no significant changes in the RBF, TCDG and SSEP parameters during the probe with compression of ICA. According to the results of the compression ICA, they did not need any shunt. In 6 patients the parameters of RBF, TCDG and SSEP tests were significantly lower in comparison with normal values, but the increase in systemic blood pressure to 160–170/90 mmHg accompanied by an increase in N20 amplitude, of the RBF and decrease of flow velocity in the ICA the shunt assembly was also not performed. The duration period of the decrease in the N20 amplitude did not exceed 10 min in all patients. In 4 patients the shunt was installed because the decrease in RBF was more than 1/3 of the baseline (TCDG 50%. 1. In patients with CEE the decrease of TCDG and SSEP parameters can be used as a possible predictors of ischemic changes in carotid artery system. 2. The role of the reduction of RBF, TCDG and SSEP parameters and the duration period of the temporary reduction should be checked in a bigger cohort of patients with possible risk of brain ischemic event.