Cervical Carotid Artery Research Articles

Carotid Artery Stenting by Direct Punctures of Cervical Carotid Artery Stenoses Using an Exoscope in a Hybrid Operating Room: A Technical Report.

Carotid artery stenting (CAS) has been established as an effective surgical treatment for internalcarotid artery stenosis and/or common carotid artery stenosis (ICAS/CCAS). Typically, CAS is performed via a transfemoral, transbrachial, or transradial approach. However, direct puncture CAS (DP-CAS) is preferred in cases where conventional access routes are challenging, such as in the presence of cervical vascular tortuosity or thoracic aortic aneurysm. Since 2020, our institution has selectively adopted DP-CAS, utilizing 3D exoscopy through the ZEISS KINEVO 900 microscope (Carl Zeiss AG, Oberkochen, Germany) or the ORBEYE exoscope (Sony Olympus Medical Solutions Inc., Tokyo, Japan) for carotid artery surgical exposure and puncture under high magnification in a hybrid operating room. In the hybrid operating room, exoscopic and angiographic fluoroscopic monitors were positioned side by side, enabling the surgeon to simultaneously visualize both during the puncture procedure. In cases utilizing the ORBEYE exoscope, its compact design minimized interference with the fluoroscopic arm, thereby facilitating improved working angles during CAS. This technical report reveals the current status of DP-CAS at our institution and focuses on the effectiveness of DP-CAS using an exoscope based on our clinical experience.

Contemporary Management and Outcomes of Carotid Artery Dissection

Carotid artery dissection is a significant cause of stroke and the leading etiology of ischemic stroke in young and middle-aged individuals. The management of carotid artery dissection is continually evolving and varies based on the patient's clinical presentation. While carotid dissection is typically managed medically, endovascular intervention may be warranted in certain cases, and open surgical intervention is rarely employed.This qualitative review examines contemporary management strategies for cervical carotid artery dissection, highlighting three illustrative cases where endovascular intervention was utilized. We present one case of traumatic etiology with acute stroke symptoms, another traumatic case with progressing dissection and pseudoaneurysm evident on imaging, and a case of iatrogenic carotid dissection. Through these cases, we aim to elucidate the decision-making process and outcomes associated with endovascular treatment in the context of carotid artery dissection.

Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review.

Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt cerebrovascular injury (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.

Which is a more appropriate recipient for posterior circulation bypass surgery: V3 or V2? Differences in underlying disease and lesion sites between extracranial vertebral artery dissection and atherosclerotic changes. Illustrative cases.

Revascularization for extracranial vertebral artery dissection or vertebral artery atherosclerotic occlusive lesions caused by vertebrobasilar insufficiency or posterior circulation infarction is relatively rare. When bypassing the cervical external carotid artery (ECA) or common carotid artery (CCA) using a radial artery (RA) or saphenous vein (SV) graft, it is difficult to determine whether the recipient site should be the V2 or V3 portion. In case 1, cervical ECA-RA-V3 bypass was performed for bilateral extracranial vertebral artery dissection with the onset of ischemia, and cervical CCA-SV-V3 bypass was added 12 days later. Nine years after surgery, the bilateral vertebral artery dissection had improved, and the patient still had a patent bypass. In case 2, cervical ECA-RA-V2 bypass was performed for arteriosclerotic bilateral extracranial vertebral artery occlusion. The bypass was patent 5 years after surgery. The postoperative course was uneventful in both patients. The authors present cases of posterior fossa revascularization using the vertebral artery V3 and V2 portions via skull base surgery and note that it is important to consider each patient's individual characteristics when selecting the V3 or V2 portion.

Predictors of Good Functional Outcome in Patients with Tandem Occlusion After Revascularization Treatment: Single-Center Experience with 12-Month Follow-Up

The optimal management and procedural strategy for tandem occlusion (TO) in acute ischemic stroke are still unclear, as is the long-term outcome of these patients. The aim of this study was to evaluate predictors of good functional outcome in patients with TO through the analysis of demographics, clinical, and radiological data with a 1-year follow-up. We collected data on 100 patients with TO who underwent revascularization treatments in our comprehensive stroke center. We divided patients into 2 groups: those with good functional outcome, defined as a modified Rankin Scale 0-2, and those with poor functional outcome, defined as a modified Rankin Scale 3-6 at 3, 6, and 12-month follow-up. Moreover, we investigated which variables were able to influence mortality. At multivariate analysis, endovascular treatment with mechanical thrombectomy combined with emergent cervical carotid artery stenting was an independent predictor of good functional outcome at 6 and 12months (adjusted odds ratio [aOR] 4.3, confidence interval [CI] 1.49-12.31, P= 0.007) (aOR 3.5, CI 1.25-9.61, P= 0.017) and was associated with a lower rate of mortality at 3 and 6months follow-up (aOR 0.14, CI 0.04-0.57, P= 0.006 and aOR 0.296, CI 0.97-0.902, P= 0.032, respectively). Furthermore, smoking habit was associated with a better outcome at 3-month follow-up (aOR 10.7, CI 2.2-51.6, P= 0.003) but not at 6- and 12-month. Our research, conducted in a small sample size of patients with acute ischemic stroke due to TO of anterior circulation, found that acute stent placement seems to be safe, improving clinical outcome, and it is associated with low rate of mortality at long-term follow-up.

High brain natriuretic peptide levels are associated with vulnerable plaque in cervical carotid artery

High brain natriuretic peptide levels are associated with vulnerable plaque in cervical carotid artery

Cerebrovascular disease in patients with antiphospholipid antibody syndrome: a transcranial Doppler and magnetic resonance imaging study.

Transcranial Doppler (TCD) and brain MRI may be useful in evaluating patients with APS, helping to stratify the risk of cerebrovascular ischaemic events in this population. This study aimed to assess the frequency of brain MRI abnormalities in patients with primary antiphospholipid syndrome, secondary antiphospholipid syndrome and SLE and correlate to TCD findings. The study, conducted over four years at two autoimmune disease referral centres, included 22 primary antiphospholipid syndrome patients, 24 secondary antiphospholipid syndrome patients, 27 SLE patients without APS and 21 healthy controls. All participants underwent TCD to assess cerebral haemodynamics, detect microembolic signals and evaluate right-to-left shunts, followed by brain MRI and magnetic resonance angiography. MRI scans were reviewed for acute microembolism, localized cortical infarctions, border infarctions, lacunar infarctions, ischaemic lesions, white matter hyperintensity, micro and macro haemorrhages and arterial stenosis ≥50% of the cervical carotid artery, by two neuroradiologists blinded to the clinical data. Brain MRI findings were similar between the groups, except for lacunar infarction, more frequent in patients with secondary antiphospholipid syndrome (P = 0.022). Patients with intracranial stenosis detected by TCD had a higher frequency of territorial infarction (40% vs 7.5%, P = 0.02), lacunar (40% vs 11.3%, P = 0.075) and border zone infarcts (20% vs 1.9%, P = 0.034). Patients with intracranial stenosis presented a higher frequency of territorial, lacunar and border zone infarcts, suggesting that evaluating the intracranial vasculature should not be neglected in patients with APS and stroke.

Management of Carotid Cavernous Fistula: a Case Report of Carotid Cavernous Fistula (CCF)

Abstract
 Introduction : Carotid-cavernous fistula (CCF) is an abnormal connection between the carotid arterial system and the sinus cavernous. Abnormal vascular shunt allowed blood to flow either direct or indirect from the carotid artery into the sinus cavernous. The indications for treatment of CCF are increased ocular pressure, double vision, bruits, severe headache, and severe proptosis resulting in keratopathy due to exposed cornea. Management of CCF include conservative management, endovascular intervention, surgery, and radiology intervention.
 Case Illustration : A 61 years old female came to the hospital complained redness on both eyes since 6 months ago, the redness in these eyes unrelieved even they had been treated. The patient have history given three types of drugs but there was not improvement. physical examination shown proptosis, injection of episcleral, cloudy lens with LOCSS NC2NO2C1P1 on both eyes, other examination also shown bruit on both eyes, Laboratory results was in normal limit. Funduscopic examination shown tigroid appearance.
 Discussion : Arterialization of the conjunctival vessels is a characteristic feature of CCF, other than physical examination, patient was planned for CT angiography examination to find external causes of injury assessing ICH and ischemia. Patient got external manual compression of the ipsilateral cervical carotid artery for about 30 to 40 seconds four times per hour several times daily for 4-6 weeks.
 Conclusion : Although CCF initially can be mistaken for conjunctivitis or episcleritis. Methods of therapy for CCF include conservative management, endovascular intervention, surgery, and interventional radiology. CCF itself is generally not life threatening but requires treatment to prevent worsening of the eye

Abstract TMP67: Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy May Affect Large Cerebral Arteries

Introduction: CADASIL is the most common monogenic small-vessel disease (SVD) form. Large and small brain arteries are intimately related, but it is unclear whether people with CADASIL have changes in their large arteries as a result. We hypothesized that CADASIL patients have affected large arteries compared to controls. Methods: We conducted a comparative analysis by matching 37 CADASIL patients with 104 lacunar stroke patients from the NYP/ Columbia University Medical Center Stroke Registry Study matched by age +/-3 and sex. We measured the basilar and intracranial carotid artery diameters in both groups in T2 MRI images. We rated cervical artery tortuosity as 0 for no tortuosity, 1 for 45-90°, and 2 for >90°. We ran generalized linear models to compare cases and controls, adjusting for demographics and clinical variables. Results: Patients with CADASIL were less likely Hispanic\Latino (10.8% vs. 51.9%, p=<0.001), hypertensive (27% vs. 73.1%, p=<0.001), current smokers (5.4%vs. 22.1%, p=0.024), but more likely to have a prior stroke (56.8% vs. 24%, p=<0.001) than controls—Table 1. In the adjusted model, patients with CADASIL had larger basilar artery diameters (p=0.007) and a statistical trend for greater cervical carotid artery tortuosity—Table 2. Conclusions: Although traditionally considered an example of pure SVD, patients with CADASIL have a higher prevalence of cervical tortuosity and intracranial artery dilatation. Whether changes in large arteries result from small artery disease or part of the NOTCH3 mutation phenotype is uncertain. Further investigation is needed to determine if large artery involvement influences the clinical manifestations of CADASIL.

Endovascular reconstruction of high cervical and long-segment carotid artery dissections with Leo plus stent.

Endovascular reconstruction has emerged as a viable alternative for carotid artery dissections (CADs) that are unresponsive to antithrombotic therapy. However, high cervical and long-segment CADs pose challenges during endovascular treatment due to their distal location and tortuous anatomy. We presented our experiences using endovascular reconstruction with the Leo plus stent for this type of CAD. We conducted a retrospective review of patients with high cervical and long-segment CADs treated using the Leo plus stent. We analyzed patient demographics, clinical presentations, procedural features, complications, and follow-up outcomes. A total of 17 patients (mean age, 48.1years) with 17 CADs were identified. Seven of these dissections were accompanied by pseudoaneurysm. The mean length of the dissection was 5.7cm, and the mean degree of stenosis was 92.3%. A single Leo plus stent was deployed in 15 patients, while another Wallstent carotid stent was used in 2 cases. All stents were successfully positioned in their intended sites. The average degree of residual stenosis was 22.2%. There were no perioperative complications. With a median follow-up duration of 29months, no ischemic stroke events occurred. All but one Leo plus stent remained patent during follow-up, and all 7 pseudoaneurysms had disappeared at the last radiological assessment. Our experience in treating high cervical and long-segment CADs with the Leo plus stent demonstrates that this approach is practical, safe, and effective, as evidenced by long-term observations. The Leo Plus stent appears to be a suitable option for managing this type of CAD.

Two Cases of Thrombus Resolution Unrelated to Large Artery Atherosclerosis or Alteplase Use

Thrombus resolution is generally associated with a favorable prognosis. Patients with thrombus resolution often present with erythrocyte-rich thrombi, frequently associated with large artery atherosclerosis or alteplase use. This might explain the increased rate of cervical carotid artery occlusion and reduced incidence of atrial fibrillation in patients with thrombus resolution. However, recent reports have demonstrated that thrombus resolution can occur owing to several etiologies and various factors. We present two cases of thrombus resolution: one associated with internal carotid artery dissection and the other with a left atrial appendage thrombus. Notably, both were considered to be unrelated to large-artery atherosclerosis or alteplase use.

Abstract 234: Antithrombotic use in Emergent Cervical Carotid Artery Stenting in Thrombectomy

Introduction Current literature suggests a benefit in functional outcomes and reperfusion rates when carotid artery stenting (CAS) and mechanical thrombectomy (MT) are performed emergently. However, rates of symptomatic intracranial hemorrhages have been inconclusive. Antithrombotic protocols used in CAS and MT tend to be heterogenous among physicians. There is no standardized data on antithrombotic therapy use during CAS and MT procedures with less associated rates of symptomatic hemorrhagic transformation. We aimed to compare the efficacy and safety of antithrombotic use in patients requiring CAS and MT. Additionally, we sought to analyze clinical and mortality outcomes in CAS and MT retrospectively at our institution. Methods We searched for patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent‐retriever and/or aspiration devices in our institution between 2019‐2023. Clinicoangiographic and antithrombotic data were analyzed. Good clinical outcomes were a < 4 points of NIHSS at 24 hours, mRS (0‐3) at 90 days, and disposition to home or inpatient rehabilitation. Characteristics of hemorrhagic transformation (HT) according to the European Cooperative Acute Stroke Study (ECASS). Clinical, radiographic, and mortality outcomes were described. Results Twenty‐seven patients were treated. The mean age was 64 years, nine females: mean occlusion time 400 minutes, mean fluoro time 32 minutes. Fourteen patients received IV tissue‐type plasminogen (tPA) activator. The admission NIHSS score mean was 16. Stent placement was feasible in all cases. Thrombolysis in Cerebral Infarction score of 2B was achieved in 18 patients (66.7%); the rest had a TICI 3 score. Twelve patients had improved 4 NIHSS points between admission and 24 hours. Dual antiplatelet therapy with aspirin and clopidogrel was used in 15 patients before stenting. While six patients received aspirin and ticagrelor, and the rest received eptifibatide drip. Seven (26%) patients had symptomatic intracranial hemorrhages. Antithrombotic type of treatment had no significant association with bad outcomes (p‐value: 0.872), neither did IV tPA use (p‐value: 0.853). Fourteen patients had good clinical outcomes (mRS 0‐3) at discharge, while eight died. At 90 days follow‐up, the median mRS was 3. Conclusion Our analysis suggests no significant association between symptomatic hemorrhagic transformation with IV tPA or heterogenous antithrombotic use. Our retrospective study has several limitations, including sample size and heterogeneous pathology. Larger studies are needed to stratify symptomatic hemorrhages' high‐risk profile in CAS and MT.

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case.

Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature. A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient's blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0. This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

Common carotid artery dissection from sportive choking

Tandem occlusions of the anterior circulation refer to the simultaneous presence of a cervical carotid artery occlusion or high-grade stenosis and an ipsilateral large vessel occlusion involving the intracranial internal carotid artery, M1 or proximal M2 middle cerebral artery. Whilst carotid occlusion usually results from progressive atherosclerotic disease, in younger individuals it may arise secondary to a dissection for which there are multiple aetiologies, with trauma being an important cause in patients having a relevant history. We present a rare case of traumatic left common carotid artery dissection in a young professional Jiu-Jitsu fighter presenting with delayed stroke symptoms and angiographic findings of a tandem occlusion. This case was successfully managed with endovascular clot retrieval and antiplatelet medication.

Diagnosis and management of tandem occlusion in acute ischemic stroke

Approximately 20–30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.

Variation in Carotid Artery Stenosis Measurements Among Facilities Seeking Carotid Stenting Facility Accreditation.

Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. The median ORS was 90.0% (interquartile range, 80.0%-90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%-73.6%), with a median difference of 21.8% (interquartile range, 13.7%-34.4%), P<0.001. The median difference in ORS and RMS for asymptomatic versus symptomatic patients was not statistically different (24.6% versus 19.6%; P=0.406). The median difference between ORS and RMS for facilities granted initial accreditation was smaller compared with facilities whose accreditation was delayed (17.9% versus 25.5%, P=0.035). The intraclass correlation between ORS and RMS was 0.16, indicating poor agreement. If RMS measurements were used, 72% of symptomatic patients and 10% of asymptomatic patients in the population examined would meet the Centers for Medicare and Medicaid Services criteria for stent placement. Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization.

IMAGING ASSESSMENT OF INTRACRANIAL VESSELS AND BRAIN PARENCHYMA IN TAKAYASU ARTERITIS AND ITS RELATION WITH MACARONI SIGN IN CERVICAL CAROTID ARTERIES

Objectives - Aim of this study to evaluate the imaging ndings of intracranial vascular and parenchymal involvement in Takayasu arteritis and to correlate these ndings with Macaroni sign in cervical carotid arteries. Materials and Methods: This is a cross-sectional study with total of 19 study subjects. We have evaluated each patient by ultrasonography of cervical carotid vessels. Subsequently each patient underwent MRI brain and MRA of cerebral vessels. We have assessed correlation of Macaroni sign in cervical carotid arteries with intracranial vascular and parenchymal involvement. Result: our study shows Maximum number of patients (63%) belonged to the age group (25-35) years with female predominance. Neurological involvement in the form of history of stroke were present in 31.5% of cases. In our study 19 patients of Takayasu arteritis the neck vessel involvement in the form of macaroni sign, were very common approximately 63.2% of cases. In Macaroni sign the echogenicity of intimamedia thickness were hyperechoic in most of the cases. The maximum thickness of the involved arterial wall was 2.7mm (mean ± SD, 1.14±0.66mm). Two patients of Takayasu arteritis showed calcic plaque with signicant stenosis and one patient also had the reverse ow in vertebral artery. Macaroni sign is a strong predictor for the intracranial cerebral vessels involvement in Takayasu arteritis. Conclusion: CCA involvement and Macaroni sign are very common as compared to cervical part of ICA in Takayasu arteritis. Takayasu arteritis is an unusual etiology for neurological brain parenchymal vascular insult. Ultrasonography (USG) is a simple, portable, bedside, non-invasive, standard realtime, quite sensitive and superior imaging method to detect the early changes in the wall of the arteries, progression of disease and indirect predictor of brain parenchymal vascular insult.

Quantitative CTA vascular calcification, atherosclerosis burden, and stroke mechanism in patients with ischemic stroke

BackgroundVascular calcification is recognized as the advanced stage of atherosclerosis burden. We hypothesized that vascular calcium quantification in CT angiography (CTA) would be helpful to differentiate large artery atherosclerosis (LAA) from other stroke etiology in patients with ischemic stroke. MethodsWe studied 375 acute ischemic stroke patients (200 males, mean age 69.9 years) who underwent complete CTA images of the aortic arch, neck, and head. The automatic artery and calcification segmentation method measured calcification volumes in the intracranial internal carotid artery (ICA), cervical carotid artery, and aortic arch using deep-learning U-net model and region-grow algorithms. We investigated the correlations and patterns of vascular calcification in the different vessel beds among stroke etiology by age category (young: <65 years, intermediate: 65–74 years, older ≥75 years). ResultsNinety-five (25.3%) were diagnosed with LAA according to TOAST criteria. Median calcification volumes were higher by increasing the age category in each vessel bed. One-way ANOVA with Bonferroni correction showed calcification volumes in all vessel beds were significantly higher in LAA compared with other stroke subtypes in the younger subgroup. Calcification volumes were independently associated with LAA in intracranial ICA (OR; 2.89, 95% CI 1.56–5.34, P = .001), cervical carotid artery (OR; 3.40, 95% CI 1.94–5.94, P < .001) and aorta (OR; 1.69, 95%CI 1.01–2.80, P = .044) in younger subsets. By contrast, the intermediate and older subsets did not show a significant relationship between calcification volumes and stroke subtypes. ConclusionAtherosclerosis calcium volumes in major vessels were significantly higher in LAA compared to non-LAA stroke in younger age.

566 Role of STA-MCA Bypass in Recurrent Ischemic Stroke

INTRODUCTION: In the recurrent scenario of ischemic strokes, clinicians are faced with the options of switching to a new antiplatelet medication or using a combination of antiplatelet medications in the acute setting and for long-term secondary stroke prevention, balancing future protective benefits and increased hemorrhagic risks. METHODS: Patients presenting recurrent ischemic stroke that were surgically treated with STA-MCA bypass at our hospital between 2016 and 2021. Criteria inclusion were patients diagnosed with a minor ischemic stroke or TIA in MCA or ICA territory, submitted or not to thrombolysis, without indication for mechanical thrombectomy, presenting with hypoperfusion &gt; 10% in the affected vascular territory. Were excluded patients presenting malignant ischemic stroke &gt;1/3 of the MCA territory, cardiogenic causes, or atherosclerotic disease in cervical carotid arteries. RESULTS: STA-MCA bypass was performed in 10 patients presenting recurrent ischemic stroke. There were 6 males and 4 female patients with an age ranging from 40 to 75 years and a mean age of 59.6 (SD 10.59). Presented initial etiologies were ICA occlusion (40%), MCA occlusion (30%), TIA (10%), Moyamoya disease (10%), and Vertebral Artery occlusion (10%). Middle Cerebral Artery (MCA) was the most common site affected (90%), and the mean initial NIHSS was 11.1 (SD 4.57). 1 Day after surgery, the NIHSS average was 11.1 (SD 4.57), followed by 8.3 (SD 4.98), and 6.7 (SD 5.92) average on days 3 and 14, respectively. When comparing pre-op NIHSS and post-op NIHSS, a significant improvement after STA-MCA Bypass (p = 0.0085) was found. CONCLUSIONS: STA-MCA Bypass can be a feasible option in recurrent ischemic strokes and can be indicated in some cases.

Intraoperative Neuromonitoring of Hypoglossal Nerves Using Transcranial and Direct Electrical Stimulation During Extracranial Internal Carotid Artery Surgery.

We explored whether the electromyogram (EMG) and the motor evoked potential (MEP) are useful for monitoring the function of the hypoglossal nerve during surgery targeting the cervical segment of the internal carotid artery. The present study included 6 patients with internal carotid arterial stenosis (1 patient underwent bilateral surgeries) and 1 patient with a cervical carotid artery aneurysm. In 5 of the 8 procedures, the EMGs were recorded. We examined whether changes in the MEP and/or EMG were capable of predicting postoperative hypoglossal nerve deficits. None of the 6 patients who underwent a total of 7 carotid endarterectomy (CEA) procedures experienced postoperative hypoglossal nerve morbidity. In 2 of the 7 procedures, the MEP disappeared or decreased significantly during CEA. In all 4 cases in which the hypoglossal nerve was directly stimulated during CEA, stable and reproducible EMGs were obtained throughout the manipulation of the internal carotid artery. Hypoglossal nerve morbidity was observed in the one case that underwent aneurysm removal and end-to-end anastomosis of the internal carotid artery. In this case, while the MEP decreased significantly during the operation, the EMG showed true-positive results and false-negative results, depending on the stimulation site. The monitoring of hypoglossal nerve function using EMG appears to be accurate if an appropriate stimulation site is selected. Hypoglossal nerve monitoring using MEP can produce false-positive results. Combined monitoring using both MEP and EMG is recommended in cases where exposure of the hypoglossal nerve is expected to be technically difficult.