Carotid Artery Dissection Research Articles

Stroke prevention by endovascular treatment of carotid and vertebral artery dissections

IntroductionEndovascular intervention for cervical carotid artery dissection (CAD) and vertebral artery dissection (VAD) may be indicated in specific circumstances.ObjectiveTo review our institutional experience with endovascular treatment of cervical dissections over...

Fate of Distal False Aneurysms Complicating Internal Carotid Artery Dissection: A Systematic Review

False aneurysm formation occurs in 13–49% of internal carotid artery dissections (ICADs). In light of the uncertainty regarding the clinical course, expansion rates and optimal treatment of post-ICAD false aneurysms, a systematic review of the literature was undertaken to establish the fate of the nonoperated distal ICA false aneurysm after ICAD. PubMed/MEDLINE, Embase, and Cochrane databases were systematically searched up to 13 August 2015 for studies reporting clinical outcomes and imaging surveillance in patients who were found to have developed a false aneurysm associated with ICAD, with specific emphasis on the fate of the nonoperated false aneurysm. Eight studies reported on the course/clinical outcome of ICAD-associated false aneurysms in 166 patients. Of these, five of 166 false aneurysms (3%) increased in size; 86 of 166 (52%) remained unchanged in diameter; 35 of 166 (21%) diminished in size; 32 of 166 (19%) resolved completely; three of 166 (2%) thrombosed; and five 166 (3%) were repaired surgically. Another four of 166 (2%) underwent late surgery (0.5–5.0 years later). During the course of surveillance, none of the nonoperated false aneurysms associated with spontaneous ICAD gave rise to any new neurological or compressive symptoms. In this systematic review, >95% of nonoperated false aneurysms affecting the distal internal carotid artery that developed after an ICAD did not increase in size and were not associated with any delayed neurological symptoms suggesting that conservative management and serial surveillance is the optimal mode of treatment. As nearly all studies suffered from serious bias, reporting standards for diagnosis and follow-up are needed in order to better define their natural history.

Cervical Artery Dissections: A Review

BackgroundCervical artery dissection (CeAD) is an infrequent, yet potentially devastating, cause of stroke. While uncommon, CeAD is important for emergency physicians to quickly diagnose and treat because of the potential for cerebral ischemia, stroke, blindness, or death. To our knowledge, no review articles in the emergency medicine literature have been published on CeAD. A literature search of MEDLINE/PubMed, Embase, and other major abstracts in the English language was performed for the following terms: cervical artery, vertebral artery, and carotid artery dissection. The search included all titles from January 1, 2010 to February 28, 2015 and other relevant articles. ObjectivesWe sought to review the epidemiology, pathophysiology, risk factors, and clinical presentation for extracranial CeAD in the adult population, explore recent research on diagnosing this disorder, evaluate the most current research on treatment options, and summarize the prognosis of CeAD. DiscussionCeAD is an uncommon but important cause of stroke in the young that is likely caused by multifactorial processes. The diagnosis should be considered in those with underlying risk factors, a remote history of minor trauma, and concerning signs and symptoms. The condition should be pursued via magnetic resonance imaging or computed tomography angiography. Treatment should be aimed at preventing additional complications, including recurrent stroke or transient ischemic attack, with antiplatelets, anticoagulants, or even endovascular or surgical therapy. ConclusionOverall, the prognosis of patients with CeAD is good, with relatively low death rates. However, the diagnosis should not be missed, because treatment may help prevent worsening or persistent ischemia, recurrent dissection, and death.

Traumatic Dissections of Bilateral Internal carotid Artery with Aneurysms Formation

Carotid artery dissection is an unusual complication of blunt neck trauma with high mortality and severe neurological deficits. Traumatic bilateral dissections and dissecting aneurysms are extremely rare. A 17‐year‐old male presented to our emergency department with sudden onset of right hemiparesis and aphasia. Initial computed tomography scan of head and neck showed no remarkable finding. On the second day, a magnetic resonance angiography of head and neck demonstrated bilateral extracranial internal carotid artery dissections. The diagnosis of traumatic carotid artery dissection for emergency physicians is difficult because of the absence or delayed onset in symptomatology. Magnetic resonance angiography is currently considered as an appropriate initial diagnostic tool for carotid artery injury. In clinical practice, early diagnosis by keeping a high index of suspicions is required by emergency physicians.

Fate of Distal False Aneurysms Complicating Internal Carotid Artery Dissection: A Systematic Review

Fate of Distal False Aneurysms Complicating Internal Carotid Artery Dissection: A Systematic Review

Vascular Tortuosity May Be Associated With Cervical Artery Dissection

Dissection is an increasingly recognized cause of ischemic stroke, which occurs spontaneously or after trauma, in relatively young patients. We hypothesized that there might be a predisposing factor weakening the vascular wall and that arterial tortuosity might be higher in patients with dissection. We consecutively enrolled cervical artery dissection (CerAD) patients who had undergone magnetic resonance angiography. Age- and sex-matched healthy subjects who underwent magnetic resonance angiography in a routine health examination were used as controls. The tortuosity was measured semiautomatically from the carotid artery and vertebral artery (VA) arteries. Tortuosity index was defined as: [(arc/chord)-1×100] in each arteries. Independent risk factors associated with CerAD were investigated using multivariable analysis. Subgroup analysis according to the dissected artery was performed. There were no differences in vascular risk factors between the 75 CerAD patients and the 75 controls. The tortuosity indexes of the contralesional VA (16.3±6.8 versus 12.1±4.5, respectively; P<0.001) and carotid artery (8.8±4.0 versus 7.3±2.9, respectively; P=0.01) were higher in patients with CerAD compared with those of control subjects. VA tortuosity (odds ratio, 1.175; P=0.001) was independently associated with the presence of CerAD. In subgroup analysis, VA tortuosity was significantly higher in 57 patients with VA dissection than in controls (P<0.001), and carotid artery tortuosity was marginally higher in 18 patients with carotid artery dissection (P=0.05). CerAD is associated with tortuous cervical arteries, which may implicate weakened cervical vascular structure in these patients.

Common carotid artery dissection caused by radiotherapy: A case report.

In the present study, a case of acute cerebral infarction with radiation-induced carotid artery dissection is reported. Carotid artery dissection is generally asymptomatic at the early stages. Due to the non-specific clinical manifestations of carotid artery dissection, a detailed inquiry of the past history of a patient has a critical role in making a diagnosis of radiation-induced common carotid artery dissection. Onset of acute ischemic stroke is the predominant manifestation, and for patients with a history of head-and-neck radiotherapy, dissection should be considered. The condition may progress rapidly, and result in a poor prognosis. Therefore, a correct early diagnosis and initiation of appropriate therapy may lead to rapid recovery, and influence the overall prognosis.

Determinants of stroke following percutaneous coronary intervention in acute myocardial infarction (from ORPKI Polish National Registry)

Both hemorrhagic and ischemic cerebrovascular events are rare but serious complications after acute myocardial infarction (MI) and coronary angiography/percutaneous coronary intervention (PCI). The most threatening one is intracranial hemorrhage related to antiplatelet and antithrombotic treatment of acute MI. In up to 10% of patients with acute MI ischemic stroke can result from embolisation of intraventricular or intraatrial thrombi [ [1] Kleczynski P. Dziewierz A. Rakowski T. et al. Cardioembolic acute myocardial infarction and stroke in a patient with persistent atrial fibrillation. Int. J. Cardiol. 2012; 161: e46-e47 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar ]. It may occur within the first 2 weeks, but also as early as in the first 24 h. On the contrary, ischemic stroke observed during or early after coronary angiography/PCI is frequently iatrogenic and may be caused by embolisation of atherosclerotic or thrombotic material from the ascending aorta, carotid artery dissection, or air embolism [ 2 Hamon M. Baron J.C. Viader F. Hamon M. Periprocedural stroke and cardiac catheterization. Circulation. 2008; 118: 678-683 Crossref PubMed Scopus (82) Google Scholar , 3 Cohen M.G. Ohman E.M. Should the benefit of transradial access still be questioned?. JACC. Cardiovasc. Interv. 2016; 9: 908-910 Crossref PubMed Scopus (4) Google Scholar ]. There are some ambiguous data from observational and randomized studies on the higher rate of stroke associated with the radial access [ 3 Cohen M.G. Ohman E.M. Should the benefit of transradial access still be questioned?. JACC. Cardiovasc. Interv. 2016; 9: 908-910 Crossref PubMed Scopus (4) Google Scholar , 5 Patel V.G. Brayton K.M. Kumbhani D.J. Banerjee S. Brilakis E.S. Meta-analysis of stroke after transradial versus transfemoral artery catheterization. Int. J. Cardiol. 2013; 168: 5234-5238 Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar ]. In addition, an increased risk of stroke was suggested for primary PCI with the use of thrombectomy devices [ 4 Kwok C.S. Kontopantelis E. Myint P.K. et al. Stroke following percutaneous coronary intervention: type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007–12. Eur. Heart J. 2015; 36: 1618-1628 Crossref PubMed Scopus (61) Google Scholar , 6 Jolly S.S. Cairns J.A. Yusuf S. et al. Stroke in the TOTAL trial: a randomized trial of routine thrombectomy vs. percutaneous coronary intervention alone in ST elevation myocardial infarction. Eur. Heart J. 2015; 36: 2364-2372 Crossref PubMed Scopus (82) Google Scholar , 7 Barkagan M. Steinvil A. Berchenko Y. et al. Impact of routine manual aspiration thrombectomy on outcomes of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction: a meta-analysis. Int. J. Cardiol. 2016; 204: 189-195 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ]. However, these findings were not confirmed by other studies. Thus, we sought to identify the predictors of periprocedural stroke in a large, unselected cohort of patients presenting with acute MI enrolled in the Polish National Registry of PCI (ORPKI) from 2014 to 2015.

Intravascular Ultrasound for Intracranial and Extracranial Carotid Artery Stent Placement

Intravascular ultrasound (IVUS) can provide valuable information regarding endoluminal morphology. We present the first description of IVUS-guided intracranial and extracranial carotid artery stent placement for arterial dissection. A 41-year-old female with a sudden-onset headache and blurred vision underwent a computed tomography (CT) angiogram imaging that revealed bilateral carotid artery dissections (BCAD) and a left vertebral artery dissection (VAD). Endovascular treatment (EVT) of a long segment right carotid artery dissection (CAD) was performed employing two Carotid WALLSTENT™ Monorails™ (8 x 36 mm, 10 x 31 mm) (Boston Scientific, Marlborough, MA). With the help of the IVUS, the distal stent was placed up to the petrous carotid artery, followed by the placement of the second stent in the immediate proximal location with some overlap that extended down to the carotid artery bulb. Intraoperative angiography and post-stenting IVUS revealed excellent stent placement with good resolution of the dissection and good luminal patency with pseudolumen obliteration. Stent use for intracranial circulation dissections will continue to be a favorable option given the decreased morbidity of endovascular therapy in this location. As endovascular surgeons become more facile with the use of IVUS, using it as a guide for stent placement and post-stenting confirmation will help them to ensure proper positioning and improved patency rates.

Transcranial Doppler as a Predictor of Ischemic Events in Carotid Artery Dissection.

We aim to evaluate clinical features and transcranial Doppler (TCD) elements, as predictors of the development of ischemic events (IEs) in patients suffering from spontaneous carotid arterial dissection without stroke (CCADW). Consecutive patients with CCADW, seen in Clínica Alemana de Santiago between April 2004 and January 2015, were evaluated clinically, and with TCD, microembolic signals (MES) monitoring and breath hold Index (BHI) test were performed. Forty-one patients with 45 CCADW were included. Mean age 41.9 years, 31 male, and 12 (29.1%) patients present with multiple CCADW. At the moment of TCD evaluation, 17 (41.4%) patients were being treated with antiplatelets and the rest under Heparin. TCD monitoring lasted in average 53.3 minutes and demonstrated at the moment of evaluation, MES in four carotid arteries (11.1%) of 3 patients and 13 (28.8%) abnormal BHI in 11 patients. Six IEs occurred in 3 patients, 3 strokes, and 3 transient ischemic attacks. In the univariate analysis correlating IE with clinical and ultrasonographic findings, the degree of carotid stenosis, the presence of multiple CAD, and the presence of MES plus abnormalities of BHI were significantly associated with the risk of an IE. Multivariable analysis showed that only the presence of MES plus abnormal BHI were significant (P < .001). MES and abnormal BHI were present in the 3 patients and in four arterial territories that had IE. TCD can identify a subgroup of patients with CCADW who are at high risk of IE.

355 Endovascular Management of Cervical Carotid and Vertebral Artery Dissection

Abstract Endovascular intervention for cervical carotid artery and vertebral artery dissections (CAD and VAD) may be indicated in specific circumstances. We reviewed a prospectively maintained database from January 1996 to January 2016 of extracranial dissections undergoing endovascular intervention. There were 116 patients, including 93 in the CAD cohort and 23 in the VAD cohort, with a mean age of 44.9 years (range 5-76) and mean postprocedure follow-up of 41.6 months (range 1-146). Interventions included stent placement (n = 104), coil occlusion of parent artery (n = 11), or stenting with contralateral vessel coil occlusion (n = 1). The 2 cohorts were well matched in age, sex, dissection etiology, and admission/follow-up modified Rankin Scale (mRS) (P = .362, .371, .175, .355, and .835, respectively). The CAD cohort was significantly more likely to undergo stent placement or have failed medical therapy (P 3) in the CAD cohort (P = .014). Six (9.0%) patients of spontaneous etiology also reported recent chiropractic manipulation. The permanent morbidity/mortality rate was 3.4%, including 2 deaths, with a stroke rate of only 0.9% over 4825 patient-years. At last follow-up, 31 of 93 (33.3%) CAD patients and 10 of 23 (43.5%) VAD patients disabled prior to intervention were nondisabled at last follow-up; no patients in either cohort were worsened. In a long-term experience, endovascular management of CAD and VAD is highly effective in specific indications, with an acceptable complication profile. CAD requiring intervention is more likely than VAD to have failed medical therapy, present with thromboembolic events and pseudoaneurysms, and undergo primary stent placement, whereas VAD is more likely to undergo treatment for traumatic occlusions with recanalization.

Relationship between dyslipidemia and vascular repair after cervical artery dissection

AbstractBackgroundIn some cases of cervical artery dissection, vascular repair subsequently occurs at the stenotic or occluded sites. The factors responsible for this type of vascular repair remain unknown, but some reports from in vitro and animal models suggest that it is related to lipid metabolism.AimIn the present study, we investigated the relationship between vascular repair and dyslipidemia in cervical artery dissection.MethodsPatients with internal carotid artery and vertebral artery dissection who were admitted between April 2012 and March 2015 were included. Vascular repair was evaluated using magnetic resonance angiography. All patients were treated conservatively using antihypertensive and antiplatelet drugs, and also with statins in the presence of dyslipidemia. In this study, we investigated the relationship between vascular repair and dyslipidemia in cervical artery dissection.ResultsVascular repair was observed in 34 out of 55 patients (61.8%, repair group). Total cholesterol (203 mg/dL in repair group vs 225 mg/dL in non‐repair group), low‐density lipoprotein cholesterol (119 mg/dL vs 140 mg/dL), low‐density lipoprotein cholesterol/high‐density lipoprotein cholesterol ratio (2.09 vs 2.74) and triglycerides (117 mg/dL vs 154 mg/dL) were significantly negatively correlated with vascular repair. However, statin use was not significantly related to this type of repair.ConclusionsWe showed a relationship between vascular repair after cervical artery dissection and dyslipidemia. As cervical artery dissection often occurs at a relatively young age, vascular repair and the management of dyslipidemia are important issues to consider for the prevention of arteriosclerotic cerebrovascular diseases in later life.

Stroke etiologic subtype may influence the rate of hyperdense middle cerebral artery sign disappearance after intravenous thrombolysis.

Disappearance of hyperdense middle cerebral artery sign (HMCAS) on non-contrast brain computed tomography (CT) scan is a reliable sign of arterial recanalization after intravenous (IV) thrombolysis for ischemic stroke. We aimed to assess whether stroke etiologic subtype may influence the rate of HMCAS disappearance and the clinical outcome after IV thrombolysis. We conducted a retrospective analysis of data prospectively collected from 1031 consecutive stroke patients treated with IV thrombolysis. Outcome measures were HMCAS disappearance on follow-up CT scan within 22-36h of IV thrombolysis, neurologic improvement (NIH Stroke Scale [NIHSS] ≤4 points from baseline or NIHSS score of 0) at 7days, and modified rankin scale (mRS) ≤1 at 3months. Of 256 patients with HMCAS on admission CT scan, 125 had a cardioembolic stroke, 67 a stroke due to large-artery atherosclerosis (LAA), 58 a stroke of undetermined etiology, and six a stroke secondary to carotid artery dissection. HMCAS disappearance occurred in 145 (56.6%) patients, neurologic improvement in 122 (55.0%) patients, and mRS ≤1 in 64 (32.8%) patients. Compared with cardioembolic stroke patients, patients with stroke due to LAA had lower odds ratios (OR) for HMCAS disappearance (OR 0.29, 95% CI 0.15-0.58, p<0.001), neurologic improvement (OR 0.42, 95% CI 0.22-0.82, p=0.011), and mRS ≤1 (OR 0.18, 95% CI 0.06-0.52, p=0.002). No significant differences in outcome measures were found between cardioembolic strokes and strokes of undetermined etiology. This study suggests that stroke due to LAA is associated with lower rates of HMCAS disappearance, neurologic improvement, and mRS ≤1 after IV thrombolysis, compared with cardioembolic stroke.

Internal Carotid Artery S-Shaped Curve as a Marker of Fibromuscular Dysplasia in Dissection-Related Acute Ischemic Stroke

Background and Purpose: Craniocervical fibromuscular dysplasia (FMD) is associated with dissections and with S-shaped curves in the internal carotid artery (ICA). We evaluated the occurrence of S-curves in patients presenting with acute strokes due to ICA steno-occlusive dissections. Methods: This was a retrospective review of the interventional databases of two academic tertiary-care institutions. The presence of ICA S-shaped curves, C-shaped curves, 360-degree loops, as well as classic FMD and atherosclerotic changes at the ICA bulb and curve/loop was determined. Cases of carotid dissections were compared with a control group (consecutive non-tandem anterior circulation strokes). Results: Twenty-four patients with carotid dissections were compared to 92 controls. Baseline characteristics and procedural variables were similar, with the exception of younger age, less frequent history of hypertension, diabetes, atrial fibrillation and stent retriever use in patients with dissections. The rates of mTICI2b-3 reperfusion, parenchymal hematoma, good outcome and mortality were similar amongst groups. The frequency of S-curves (any side without superimposed atherosclerosis) was 29% in the dissection group versus 7% in controls (p < 0.01). S-curves were typically mirror images within the dissection group (85% had bilateral occurrence). The frequency of C-shaped and 360-degree curves was similar between groups. FMD changes within the craniocervical arteries were statistically more common in dissection patients. Ten patients (41%) of the dissection group had S-curves or classic FMD changes. Multivariate analysis indicated that S-curves were independently associated with the presence of dissections. Conclusion: S-shaped ICA curves are predictably bilateral, highly associated with carotid dissections in patients with moderate to severe strokes, and may suggest an underlying presence of FMD.

Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach

BackgroundCarotid dissection (CD) may, in certain cases, lead to significant stenosis, occlusion, or pseudoaneurysm formation, causing embolic stroke or hemodynamic failure, despite medical therapy.ObjectiveTo evaluate the results of endovascular treatment...

Spontaneous carotid artery dissection in pregnancy

Abstract We report on a 35-year-old woman who presented at 36 weeks of gestation with headaches and arterial hypertension. She was discharged after ruling out pre-eclampsia. The next day she returned with worsening headaches and an onset of Horner’s syndrome. A magnetic resonance (MR) angiography showed extensive dissection of the right-sided internal carotid artery. Anticoagulation and antihypertensive therapies were initiated after delivery of the baby by caesarean. The patient recovered fully. Headache in pregnancy is not always due to pre-eclampsia. Carotid artery dissection (CAD) is a rare but severe cause of headache that typically presents with neck pain and focal neurologic symptoms. Once the diagnosis is established, an immediate treatment should be started in order to minimise damage, especially ischaemic lesions.

High-risk mechanism of injury: A new indication for screening for blunt cerebrovascular injury?

Blunt cerebrovascular injury is a rare but catastrophic injury. Screening for blunt cerebrovascular injury after high-impact mechanism remains ill-defined but several associated lesions have been identified as high risk for concomitant blunt cerebrovascular injury and are used to prompt further investigation for early identification and intervention. We describe a case of a large cerebral infarction caused by a high cervical internal carotid dissection after a motorcycle collision. Upon presentation, the patient had a Glasgow coma scale of 14 and an open pelvic fracture, which was immediately addressed in the operating room. His subsequent imaging revealed a nasal fracture, bilateral rib fractures, bilateral pubic rami fractures and left acetabular fracture without evidence of traumatic brain injury, cervical spine injury or extensive facial fractures. After 48 h, he displayed a depressed sensorium and an abnormal pupillary exam. He was diagnosed by computed tomography angiogram with a carotid dissection resulting in a large infarct of the right hemisphere with herniation requiring emergent craniectomy. This case suggests screening for blunt cerebrovascular injury beyond the current recommendations especially in patients with high-impact mechanism.

Carotid artery dissection and motor vehicle trauma: patient demographics, associated injuries and impact of treatment on cost and length of stay.

BackgroundBlunt carotid arterial injury (BCI) is a rare injury associated with motor vehicle collision (MVC). There are few population based analyses evaluating carotid injury associated with blunt trauma and their associated injuries as well as outcomes.MethodsThe Nationwide Inpatient Sample (NIS) 2003–2010 data was queried to identify patients after MVC who had documented BCI during their hospitalizations utilizing ICD-9-CM codes. Demographics, associated injuries, interventions performed, length of stay, and cost were evaluated.Results1,686,867 patients were estimated having sustained MVC; 1,168 BCI were estimated. No patients with BCI had open repair, 4.24 % had a carotid artery stent (CAS), and 95.76 % of patients had no operative intervention. Age groups associated with BCI were: 18–24 (27.8 %), 47–60 (22.3 %), 35–46 (20.6 %), 25–34 (19.1 %), >61 (10.2 %). Associated injuries included long bone fractures (28.5 %), stroke and intracranial hemorrhage (28.5 %), cranial injuries (25.6 %), thoracic injuries (23.6 %), cervical fractures (21.8 %), facial fractures (19.9 %), skull fractures (18.8 %), pelvic fractures (18.5 %), hepatic (13.3 %) and splenic (9.2 %) injuries. Complications included respiratory (44.2 %), bleeding (16.1 %), urinary tract infections (8.9 %), and sepsis (4.9 %). Overall mortality was 14.1 % without differences with regard to intervention (18.5 % vs. 13.9 %; P = 0.36). Stroke and intracranial hemorrhage was associated with a 2.7 times greater risk of mortality. Mean length of stay for patients with BCI undergoing stenting compared to no intervention were similar (13.1 days vs. 15.9 days) but had a greater mean cost ($83,030 vs. $63,200, p = 0.3).ConclusionBCI is a rare injury associated with MVC, most frequently reported in younger patients. Frequently associated injuries were long bone fractures, stroke and intracranial hemorrhage, thoracic injuries, and pelvic fractures which are likely associated with the force/mechanism of injury. The majority of patients were treated without intervention, but when CAS was utilized, it did not impact mortality and trended toward increased costs.

Malignant Middle Cerebral Artery Infarction Secondary to Traumatic Bilateral Internal Carotid Artery Dissection. A Case Report

Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.

Direct Carotid Exposure for Neuroendovascular Approaches.

Objective The transfemoral approach is a common route for catheterization of the supra-aortic vessels in neuroendovascular therapy. However, in some cases, the patient's anatomy prevents transfemoral catheterization or distal access to the carotid s. In such cases, direct carotid exposure (DCE) for neuroendovascular approaches may be used to treat cerebrovascular diseases. Methods We present 11 cases in which we were unable to perform the distal approach and DCE was the preferred neuroendovascular treatment procedure. Results DCE was performed on 11 patients with cerebral aneurysm (n = 8), carotid cavernous fistula (CCF) (n = 1), malignant brain tumor (n = 1), and carotid angioplasty and stenting (n = 1). Ten patients were female; one was male. Ages ranged from 63 to 87 years (mean: 71.36 years). Coil embolization was performed on patients with cerebral aneurysm and CCF. The patient with a malignant brain tumor underwent polyvinyl alcohol particle embolization. The only complication was a carotid artery dissection that occurred in one patient during stenting. Conclusion DCE for neuroendovascular approaches can be used as an alternative for patients with tortuous vasculature access in the femoral route. In such patients, a combination of neuroendovascular treatment and surgery in a hybrid operating room with angiography is preferred.