Cervical Carotid Artery Research Articles

Intraluminal Thrombi in the Cervico-Cephalic Arteries

Background and Purpose- Intraluminal thrombus (ILT) is an uncommon finding among patients with ischemic stroke. We report clinical-imaging manifestations, treatment offered, and outcome among patients with ischemic stroke/transient ischemic attack and ILT in their cervico-cephalic arteries. Methods- Sixty-one of 3750 consecutive patients with acute ischemic stroke/transient ischemic attack (within 24 hours of onset) and ILT on initial arch-to-vertex computed tomography angiography from April 2015 through September 2017 constituted the prospective study cohort. Functional outcome was assessed using the modified Rankin Scale score with functional independence at discharge defined as modified Rankin Scale score ≤2. Results- Prevalence of ILT on computed tomography angiography was 1.6% (95% CI, 1.2%-2.1%). Median age was 67 years (interquartile range, 56-73), and 40 subjects (65%) were male. The initial clinical presentation included transient ischemic attack in 12 (20%) and stroke in 49 patients (80%); most strokes (76%) were mild (National Institutes of Health Stroke Scale ≤5). The most common ILT location was cervical carotid or vertebral artery (n=48 [79%]) followed by intracranial (n=11 [18%]) and tandem lesions (n=2 [3%]). The most common initial treatment strategy was combination antithrombotics (heparin with single antiplatelet agent) among 57 patients (93%). Follow-up computed tomography angiography (n=59), after a median 6 days (interquartile range 4-10 days), revealed thrombus resolution in 44 patients (75% [completely in 27%]). Twenty four of 30 patients (80%) with >50% residual carotid stenosis underwent carotid revascularization (endarterectomy in 15 and stenting in 9 patients) without peri-procedural complications a median of 9 days after symptom onset. In-hospital stroke recurrence occurred in 4 patients (6.6%). Functional independence was achieved in 46 patients (75%) at discharge. Conclusions- Patients presenting with acute stroke/transient ischemic attack with ILT on baseline imaging have a favorable clinical course in hospital with low stroke recurrence, high rate of thrombus resolution, and good functional outcome when treated with combination antithrombotic therapy.

Cumulative incidence of restenosis in the endovascular treatment of extracranial carotid artery stenosis: a meta-analysis

ObjectiveTo assess the cumulative incidence of restenosis and stroke after stenting for cervical carotid artery stenosis.MethodsWe reviewed PubMed, ScienceDirect, and Scopus and included all studies reporting restenosis after stenting. The...

Validation of a basic neurosonology laboratory for detecting cervical carotid artery stenosis

IntroductionMost of the cases of ischaemic stroke in our setting are of atherothrombotic origin. Detecting intracranial and cervical carotid artery stenosis in patients with ischaemic stroke is therefore essential. Ultrasonography has become the tool of choice for diagnosing carotid artery stenosis because it is both readily accessible and reliable. However, use of this technique must be validated in each laboratory. The purpose of this study is to validate Doppler ultrasound in our laboratory as a means of detecting severe carotid artery stenosis. Patients and methodsWe conducted an observational descriptive study to evaluate diagnostic tests. The results from transcranial and cervical carotid Doppler ultrasound scans conducted by neurologists were compared to those from carotid duplex scans performed by radiologists in patients diagnosed with stroke. Arteriography was considered the gold standard (MR angiography, CT angiography, or conventional arteriography). ResultsOur sample included 228 patients. Transcranial and cervical carotid Doppler ultrasound showed a sensitivity of 95% and specificity of 100% for detection of carotid artery stenosis >70%, whereas carotid duplex displayed a sensitivity of 87% and a specificity of 94%. Transcranial carotid Doppler ultrasound achieved a sensitivity of 78% and a specificity of 98% for detection of intracranial stenosis. ConclusionsDoppler ultrasound in our neurosonology laboratory was found to be a useful diagnostic tool for detecting cervical carotid artery stenosis and demonstrated superiority to carotid duplex despite the lack of B-mode. Furthermore, this technique was found to be useful for detecting intracranial stenosis.

Analysis of the ROADSTER pivotal and extended-access cohorts shows excellent 1-year durability of transcarotid stenting with dynamic flow reversal

ObjectiveWe report the 1-year outcomes of the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial. This trial introduced a novel transcarotid neuroprotection system (NPS), the ENROUTE transcarotid NPS (Silk Road Medical Inc, Sunnyvale, Calif). Postoperative results demonstrated that the use of the ENROUTE transcarotid NPS is safe and effective. The aim of this study was to evaluate the safety of transcarotid artery revascularization (TCAR) and to present the 1-year outcomes. MethodsThis study is a prospective, single-arm clinical trial. Current enrollment occurs in 14 centers. Primary end points were incidence rates of ipsilateral stroke at 1 year after TCAR. Occurrence of stroke was ascertained by an independent Clinical Events Committee. Patients with anatomic or medical high-risk factors for carotid endarterectomy (CEA) were eligible to be enrolled in the ROADSTER trial. ResultsOverall, 165 patients were included in the long-term follow-up (112 of 141 patients from the pivotal phase and 53 of 78 patients from the extended access). Mean age was 73.9 years (range, 42.1-91.3 years). Patients aged 75 years and older were 43.3% of the cohort. The majority of patients were white (92.7%) and male (75.2%). Most patients were asymptomatic (79.9%). Anatomic risk factors were distributed as follows: contralateral carotid artery occlusion (11.0%), tandem stenosis of >70% (1.8%), high cervical carotid artery stenosis (25.0%), restenosis after CEA (25.6%), bilateral stenosis requiring treatment (4.3%), and hostile neck (14.6%). Medical high-risk criteria included two-vessel coronary artery disease (14.0%) and severe left ventricular dysfunction with ejection fraction <30% (1.8%). In general, 43.3% of patients had at least one anatomic high-risk factor, whereas 29.9% of patients had medical high-risk factors. Both subsets of factors were present simultaneously in 26.8% of the cohort. At 1-year follow-up, ipsilateral stroke incidence rate was 0.6%, and seven patients (4.2%) died. None of the deaths were neurologic in origin. ConclusionsTCAR with dynamic flow reversal had previously shown favorable 30-day perioperative outcomes. This excellent performance seems to extend to 1 year after TCAR as illustrated in this analysis. The promising results from the ROADSTER trial likely stem from the novel cerebral protection provided through the ENROUTE transcarotid NPS in comparison to distal embolic protection devices as well as the transcarotid approach's circumventing diseased aortic arch manipulation and minimizing embolization. TCAR offers a safe and durable revascularization option for patients who are deemed to be at high risk for CEA.

Carotid artery calcification score and its association with cognitive impairment.

PurposeTo retrospectively investigate the possible association between carotid artery calcification score (CS) and cognitive impairment in carotid artery stenosis (CAS) patients.Patients and methodsCarotid artery was measured in 102 patients with cervical carotid arteries using Color Doppler ultrasound, multi-detector row spiral CT angiography and MRI scanning. Correlation analysis between CSs obtained by MD CT and cognitive scores was performed, and the correlation between CSs and vascular stenosis degree and MRI-measured plaque histological (lipid-rich necrotic nucleus [LRNC], intraplaque hemorrhage and fibrous cap surface rupture) and morphological parameters (lumen area [LA], wall area [WA], total area of blood vessels [TVA], plaque burden [PB]) was analyzed. Follow-up review analysis was conducted on 38 postoperative patients.ResultsSignificant negative correlation was discovered between CS value and cognitive scores in CAS patients (R=−0.359, P<0.001), which did not exist in postoperative patients (P=0.348); CS value also showed significant correlation with WA (R=0.521, P=0.042), TVA (R=0.215, P=0.017) and PB (R=0.237, P=0.003) and had a certain predictive value for the occurrence probability of carotid plaque LRNC (P=0.029, AUC =0.780) in preoperative patients.ConclusionCarotid artery CSs have significant correlation with cognitive scores, which could be used as risk factor for early screening of cognitive impairment in CAS patients. The possible mechanism may be related to the calcification impact on the plaque burden.

Non-bifurcating Cervical Carotid Artery を伴う 頚動脈狭窄にCAS を施行した1 例

Non-bifurcating Cervical Carotid Artery を伴う 頚動脈狭窄にCAS を施行した1 例

Biomarker Profiling of Neurovascular Diseases in Patients with Stage 5 Chronic Kidney Disease.

Patients with stage 5 chronic kidney disease (CKD5D) have a higher risk of developing neurocognitive deficits. Stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerotic disease (ICAD) are causes of such deficits in CKD5D. Chronic inflammation from renal failure elevates risk for these diseases through oxidative stress and vascular dysfunction. The adverse impact on the carotid and intracranial vasculatures contributes to the multifactorial pathophysiology of stroke. Eleven plasma biomarker levels in patients with CKD5D (n = 97) and healthy controls (n = 17-50) were measured using sandwich enzyme-linked immunosorbent assay (ELISA) method. Of the 97 patients with CKD5D, 24 had CCAD, 19 had ICAD, and 23 had acute stroke. Elevations in NACHT, LRR, and PYD domains-containing protein 3 (NALP3) levels in patients with CKD5D (+)CCAD (1.80 ± 0.11 ng/mL) compared to patients with (−)CCAD (1.55 ± 0.08 ng/mL) were statistically significant (P = .0299). Differences in D-dimer levels were also found to be statistically significant (P = .0258) between CKD5D (+)stroke (1.83 ± 0.42 μg/mL) and (−)stroke (0.89 ± 0.13 μg/mL) groups. The ages of the (+) neurovascular disease groups were found to be significantly elevated compared to the (−) neurovascular disease groups (P = .0002 carotid AD; P < .0001 ICAD; P = .0157 stroke). D-dimer levels were positively correlated with age in CKD5D (P = .0375). With the possible exception of NALP3 for CCAD, profiling levels of specific biomarkers for risk stratification of neurovascular diseases in the CKD5D population warrants further investigation.

Recurrent embolic stroke caused by large cavernous carotid aneurysm: Stroke recurrence prevention with high-flow bypass followed by proximal occlusion

Intracranial aneurysms may cause embolic stroke. Medical or surgical management is selected on an individual basis, as the optimal treatment strategy has not been established. A 79-year-old woman with a large cavernous carotid aneurysm suffered repeated embolic stroke after enlargement and partial thrombosis of the aneurysm, in spite of antiplatelet therapy. Coil embolization of the primitive trigeminal artery and ligation of the internal carotid artery (ICA) at the cervical portion followed by high-flow bypass from the cervical external carotid artery to the middle cerebral artery were performed. The aneurysm was thrombosed, and prevention of further stroke was achieved. Acute enlargement and thrombosis of large or giant cavernous carotid aneurysm may cause repeated embolic stroke, and requires emergent exclusion of the aneurysm from circulation by proximal ICA occlusion together with distal revascularization before devastating embolic stroke occurs.

P.092 Eagles and Talons: A case of cervical artery dissection from Eagle syndrome and fibromuscular dysplasia

Background: Eagle syndrome (also known as stylohyoid syndrome) and fibromuscular dysplasia (FMD) are rare conditions that have both been shown to be associated with cervical artery dissections (CAD). Direct mechanical injury from a neighboring bony fragement can produce arterial dissections and is the proposed mechanism in Eagle syndrome. The etiology of FMD remains unclear, however, similar shearing stresses have been proposed. We present a case in which both of these conditions were present. Methods: Case report Results: A previously healthy 52 year old male presented with an acute left MCA syndrome with computer tomography angiography followed by convensional angiography confirming a complete occlusion of the left ICA at the carotid bifurcation with evidence of a dissection of the proximal cervical carotid artery. Luminal irregularities proximal to the dissection and also of the right ICA were in keeping with fibromuscular dysplasia. A carotid stent was placed and a thrombectomy was performed for a proximal left M2 occlusion. On further review of the CT, the patient had markedly elongated styloid processes bilaterally, meeting criteria for Eagle syndrome. Conclusions: Previous literature has not described these two conditions coexisiting. We question whether chronic mechanical stress from an elongated styloid process could lead to arteries having an irregular or beading appearance resembling fibromuscular dysplasia.

IP109. The Learning Curve of Transcarotid Artery Revascularization

Transcarotid artery revascularization (TCAR) is a relatively new procedure that involves access to the proximal cervical common carotid artery (CCA), cerebral blood flow reversal as neuroprotection, and stent delivery. The purpose of this study was to describe the learning curve of TCAR. A retrospective review of all patients sequentially undergoing TCAR at three institutions was ordered chronologically. Procedural time was defined as the time of skin incision to time of the final bandage placed on the neck wound. Flow reversal time was defined as the time when reverse flow was initiated (CCA clamped) until the reverse flow was terminated (CCA unclamped). Operative times were then grouped into bins of five and analyzed using one-way analysis of variance (ANOVA) with P < .05 considered statistically significant. Results from ANOVA led to comparison of cases 1 to 10 vs 11 to 50, accomplished using Wilcoxon signed rank test. Overall, 190 procedures were performed by 7 vascular surgeons at 3 institutions between 2013 and 2017. The mean procedural time for all cases was 68.9 ± 9.5 minutes (Fig). When the procedural time of cases 1 to 10 (mean, 74.8 ± 9.6 minutes) was compared with that of cases 11 to 50 (mean, 67.5 ± 9.0 minutes), a significant difference was noted (P = .014). ANOVA results between all bins of procedural times showed that the first 5 cases were statistically longer than cases 31 to 50. Mean flow reversal time was 9.7 ± 3.5 minutes. When flow reversal times were compared using ANOVA testing, cases 1 to 10 were statistically similar and all cases within 11 to 50 were also similar, but the two groups differed from each other (P < .001). For flow reversal time, the first 10 cases had mean reversal times of 14.5 ± 3.7 minutes compared with 8.6 ± 2.3 minutes for cases 11 to 50 (P < .001). Patients of cases 1 to 10 experienced postoperative stroke (2/68 [2.94%]) not significantly different from patients of later cases (1/122 [0.82%]; P = .292; Table). Similarly, postoperative mortality rates were similar in the <10 and >10 case groups (1.47% vs 1.64%; P = 1.00). All three strokes and two of the three deaths (both in cases 11-50) occurred in symptomatic patients, which represented 42% of the overall cohort. A learning curve does exist for the TCAR procedure, but it is relatively steep. After 10 cases, surgeons are able to reduce procedural times by 10% (74.8 to 67.5 minutes) and, more important, flow reversal times by an average of 40% (14.5 to 8.6 minutes). The critical steps in the TCAR procedure may be easily adopted by a broad group of vascular surgeons learning this technique.TablePostoperative outcomes for cases 0 to 10 vs cases >10Stroke, n/N (%)Death, n/N (%)Stroke and death combined, n/N (%)Cases 0-102/68 (2.94)1/68 (1.47)3/68 (4.41)Cases >101/122 (0.82)2/122 (1.64)3/122 (2.46)P = .2915P = 1.000P = .6684 Open table in a new tab

Symptomatic Post Endarterectomy Common Carotid Artery Pseudoaneurysm Treated with Combination of Flow Diverter Implantation and Carotid Stenting.

A 74-year-old male developed cervical carotid artery psuedoaneurysm 8 months after carotid endarterectomy. The patient was successfully managed with dual implantation of flow-diverter and conventional carotid stent. Flow-diverter was placed across the neck of pseudoaneurysm to provide flow diversion while carotid stent was implanted within the lumen of the expanded flow-diverter to approximate and hold the flow diverter proximal and distal to the pseudoaneurysm. Follow-up ultrasonography revealed complete resolution of the pseudoaneurysm.

Abstract No. 441 VIABAHN stent-graft placement for emergent/urgent cervical cerebrovascular artery disease: a single-center experience of 22 cases

To report our single-center experience of Viabahn stent-graft placement for acute bleeding or pseudoaneurysms of innominate, cervical carotid, or vertebral artery in emergent/urgent clinical conditions. A retrospective study was conducted between Jan 2003 and Sep 2017. A total of 22 patients (14 male, 8 female; age range 18–82 years, mean 55.8 years and median 56 years) were treated with 22 Viabahn stent grafts (9 carotid blow-out syndrome and 13 pseudoaneurysms with or without dissection: 4 innominate, 4 common carotid, 12 internal carotid, 1 both common and internal carotid, and 1 vertebral artery involvement). The stent-graft patency was evaluated by angiogram, contrast-enhanced CT, MRA, ultrasonography, or direct observation during surgery. The mean and median imaging follow-up periods were 740 and 193 days, respectively. Technical success was 100% (22/22). Dual antiplatelet agents were given in 20 patients either immediately before or after the deployment of the stent-grafts. No immediate procedure-related complications occurred. Two unstable patients with carotid blow-out syndrome died of severe systemic disturbance within 8 days, despite successful bleeding cessation by the procedure. Three patients underwent subsequent bypass surgery within 17 days for concern about infection. One stent-graft occlusion occurred 195 days after the procedure with unexpected cession of antiplatelet therapy. One significant hemorrhagic complication was observed and died 125 days after the procedure (esophagocutaneous fistula). Two patients were lost to follow-up. Among the remaining 13 patients, 11 patients demonstrated 6 months or longer stent-graft patency and 2 developed more than 50% stenosis. Viabahn stent-grafting may be safe and useful for the management of emergent/urgent arterial bleeding or pseudoaneurysms involving cervical cerebrovascular arteries.

Abstract TP411: Biomarker Profiling of Neurovascular Diseases in Patients With Stage 5 Chronic Kidney Disease

Introduction: Patients with stage 5 chronic kidney disease (CKD5D) have a higher risk for developing neurocognitive deficits. Stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerosis (ICAD), are causes of such deficits in CKD5D. Chronic inflammation from renal failure elevates risk for these diseases through oxidative stress and vascular dysfunction. The adverse impact on the carotid and intracranial vasculatures contributes to the multifactorial pathophysiology of stroke. Objective: Profile levels of inflammatory and hemostatic biomarkers in CKD5D plasma, and relate measurements to neurovascular diagnoses. Methods: Eleven plasma biomarker levels in CKD5D patients (n=97) and healthy controls (n=17-50) were measured using sandwich ELISA method. Of the 97 CKD5D patients, 24 had CCAD, 19 had ICAD, and 23 had acute stroke. Data were collected in Microsoft Excel, and analyzed using GraphPad Prism. Statistics were performed with Mann-Whitney t-tests, Kruskal-Wallis non-parametric ANOVA, and non-parametric Spearman correlations. Results: Every biomarker was elevated in CKD5D plasma, except for plasminogen activator inhibitor-1 (PAI-1; p=0.9764), compared to controls. Statistical significance was only found between CKD5D (+) and (-)CCAD inflammasomes (NALP3; p=0.0299), and between (+) and (-)stroke D-dimer (p=0.0258). Ages between each (+) and (-) disease groups were also significant (p=0.0002 CCAD; p&lt;0.0001 ICAD; p=0.0157 stroke). D-dimer was correlated with age in CKD5D (r=0.2115, p=0.0375). Discussion: Lack of difference in PAI-1 levels between CKD5D and controls could be due to anticoagulants. Elevated D-dimer levels in CKD5D stroke patients could be due to increased age instead of stroke. NALP3 is known to be connected to the stability of atherosclerotic plaques in CCAD. NALP3 elevates IL-1β and IL-18, which subsequently increases risk of CCAD and stroke. Lack of more significant differences in biomarker levels between (+) and (-) disease groups could due to the BBB, which might filter out the biomarkers of our study. Conclusion: Profiling biomarker levels of this study may not be useful in the risk stratification of neurovascular diseases in the CKD5D population, with the possible exception of NALP3 for CCAD.

Facial Trauma Care in the Austere Environment.

As the United States continues to increase its use of Special Operations Forces worldwide, treatment of craniomaxillofacial (CMF) trauma must be adapted to meet the needs of the warfighter. The remoteness of Special Operations can result in potentially longer times until definitive treatment may be reached. A significant portion of Servicemembers incur injury to the CMF region (42%). Severe CMF trauma can result in substantial hemorrhage and airway compromise. These can be immediately life threatening and must be addressed expeditiously. Numerous devices and techniques for airway management have been made available to the forward provider. A thorough review of nonsurgical and surgical airway management of the patient with facial injury for the forward provider and providers at receiving facilities is provided in this article. Techniques to address flail segments of the facial skeleton are critical in minimizing airway compromise in these patients. There are many methods to control hemorrhage from the head and neck region. Hemorrhage control is critical to ensure survival in the austere environment and allow for transport to a definitive care facility. Associated injuries to the cervical spine, globe, skull base, carotid artery, and brain must be carefully evaluated and addressed in these patients. Management of vision- threatening orbital compartment syndrome is critical in patients with CMF injuries. Because the head and neck region remains relatively vulnerable in the warfighter, combat CMF trauma will continue to occur. Forward providers will benefit from a review of the acute treatment of CMF traumatic injury. Properly triaging and treating facial injuries is necessary to afford the best chance of survival for patients with a devastating combat CMF injury.

Usefulness of Flat Detector Computed Tomography Perfusion for Neuroendovascular Therapies

Objective: Flat detector computed tomography perfusion (FD-CTP) imaging is a new modality that enables quick assessment of the cerebral perfusion in the angiography suite. We present three cases in which FD-CTP served to improve the precision of the therapeutic strategy during endovascular treatment.Case presentation: The first case was a 40-year-old woman with a ruptured blood blister-like aneurysm in the right internal carotid artery (ICA). After the evaluation for tolerance to ICA occlusion using FD-CTP, she was treated successfully with endovascular internal trapping of the ICA.The second case was an 89-year-man with a cerebral infarct in the left cerebrum due to severe stenosis of the left middle cerebral artery. After the angioplasty, we could confirm the therapeutic effect by using FD-CTP, which demonstrated the disappearance of hypoperfusion in the left cerebral hemisphere. The third case was an 88-year-old man with severe stenosis of the left cervical carotid artery. After dilatation of the stenotic lesion by using a small-diameter balloon, a FD-CTP image showed hyperemia in the left cerebral hemisphere, so we decided not to undergo further carotid artery stenting.Conclusion: FD-CTP was useful for determining the therapeutic strategy during endovascular treatment.

One-Year Results of the ROADSTER Multicenter Trial of Transcarotid Stenting With Dynamic Flow Reversal

The aim of this study was to report the 1-year outcomes of the transcarotid artery stenting (TCAR) with cerebral blood flow reversal (ROADSTER) multicenter trial and to evaluate the durability of TCAR. This trial introduced a novel transcarotid neuroprotection system (ENROUTE Transcarotid NPS; Silk Road Medical Inc, Sunnyvale, Calif). Overall 30-day stroke rate was 1.4%, which was the lowest reported in any clinical trial for carotid artery stenting. This study is a prospective, single-arm clinical trial. Enrollment occurred in 14 centers. Primary end points were incidence rates of ipsilateral stroke and death at 1 year after TCAR. Occurrence of stroke was ascertained by an independent clinical event committee. Overall, 219 patients were enrolled (pivotal phase, 141; extended access, 78 patients). Of those, 164 patients were included in the 1-year follow-up (16 had postoperative events, 3 died, 10 declined to participate, and 26 were lost to follow-up). Mean age was 73.9 years (range, 42.1-91.3 years). Patients aged 75 years and older were 43.3% of the cohort; 34.8% of patients were female, 92.7% were white, and 5.5% were African American. Most patients were asymptomatic (79.9%). Patients with anatomic risk factors were distributed as follows: contralateral carotid artery occlusion, 11.0%; tandem stenosis of >70%, 1.8%; high cervical carotid artery stenosis, 25.0%; restenosis after CEA, 25.6%; and bilateral stenosis requiring treatment, 4.3%. Hostile neck was the indication for TCAR in 14.6% of cases. Physiologic high-risk factors including two-vessel coronary artery disease were reported in 14.0% of the participants, and severe left ventricular dysfunction (left ventricular ejection fraction <30%) was reported in three (1.8%) patients. Overall, anatomic and physiologic high-risk factors were reported in 43.3% and 29.9% of patients, respectively. Both subsets of factors were present in 26.8% of the entire cohort. At 1-year follow-up, ipsilateral stroke incidence rate was 0.6%, and overall mortality rate was 3.7%. The 1-year risk of stroke found in this study is the lowest to date to be reported in any Food and Drug Administration-approved carotid stent (Fig). Transcarotid artery revascularization with dynamic flow reversal had previously shown favorable 30-day perioperative outcomes. This excellent performance seems to extend to 1 year after TCAR as illustrated in this analysis. The promising results from the ROADSTER trial might stem from the novel cerebral protection provided through the ENROUTE Transcarotid NPS in comparison to distal protection devices. The transcervical approach circumvents aortic arch manipulation that takes place through the transfemoral approach. TCAR offers a potentially safe alternative option for patients who are deemed to be at high risk for CEA.

Prevalence of extracranial carotid artery aneurysms in patients with an intracranial aneurysm.

Background and purposeAneurysms in various arterial beds have common risk- and genetic factors. Data on the correlation of extracranial carotid artery aneurysms (ECAA) with aneurysms in other vascular territories are lacking. We aimed to investigate the prevalence of ECAA in patients with an intracranial aneurysm (IA).MethodsWe used prospectively collected databases of consecutive patients registered at the University Medical Center Utrecht with an unruptured intracranial aneurysm (UIA) or aneurysmal Subarachnoid hemorrhage (SAH). The medical files of patients included in both databases were screened for availability of radiological reports, imaging of the brain and of the cervical carotid arteries. All available radiological images were then reviewed primarily for the presence of an ECAA and secondarily for an extradural/cavernous carotid or vertebral artery aneurysm. An ECAA was defined as a fusiform dilation ≥150% of the normal internal or common carotid artery or a saccular distention of any size.ResultsWe screened 4465 patient records (SAH database n = 3416, UIA database n = 1049), of which 2931 had radiological images of the carotid arteries available. An ECAA was identified in 12/638 patients (1.9%; 95% CI 1.1–3.3) with completely imaged carotid arteries and in 15/2293 patients (0.7%; 95% CI 0.4–1.1) with partially depicted carotid arteries. Seven out of 27 patients had an additional extradural (cavernous or vertebral artery) aneurysm.ConclusionsThis comprehensive study suggests a prevalence for ECAA of approximately 2% of patients with an IA. The rarity of the disease makes screening unnecessary so far. Future registry studies should study the factors associated with IA and ECAA to estimate the prevalence of ECAA in these young patients more accurately.

Concomitant unruptured intracranial aneurysms and ischemic cerebrovascular diseases: a surgical experience of 31 cases

Objective: To summarize the clinic experience of preventing cerebral ischemic events during perioperative period in patients which concomitant unruptured intracranial aneurysms and ischemic cerebrovascular diseases. Methods: The clinical materials of 31 consecutive patients with concomitant unruptured intracranial aneurysms and ischemic cerebrovascular diseases from April 2010 to April 2014 were retrospectively reviewed.A total of 35 aneurysms were detected, and all of them were unruptured aneurysms.Among them, 17 cases were located on the ipsilateral side of artery stenosis or occlusion, and 18 cases were detected in the contralateral side. Minimal invasive surgical approaches such as small pterional approach and lateral sub-frontal approach were adopted.The better management of perioperative blood pressure was performed. Intraoperative electroencephalogram and somatosensory evoked potential monitoring, indocyanine green video angiography and/or microvascular Doppler ultrasonography were regularly used to guarantee the safety of the surgery. The follow-up by digital subtraction angiography or computed tomography angiography were made. Results: All of 35 aneurysms were clipped. Major infarction occurred in one patient with posterior communicating artery aneurysm concomitant with common cervical carotid artery stenosis.Large bone flap was resected and dural-matter were got enlarged to tolerate the edema period.Paralysis and aphasia accompanied at discharge.Minor infarction in posterior limb of internal capsule occurred in one patient.Twenty-nine patients were favorable with Glasgow Outcome Scale (GOS) score 5 at discharge, one patient with minor neurological defect (GOS 4), and one patient with severe neurological defect (GOS 3). The follow-up period was 6 to 40 months.Four patients were lost.The modified Rankin scale (MRS) of last follow-up were 0-1 in 25 patients, 2 in one patient and 3 in one patient.Third months after operation, 3 cases were performed carotid artery stenosis, 1 patients were performed carotid endarterectomy. Conclusion: Reinforcing the management of perioperative blood pressure, adjusting the perioperative blood coagulation function, and combine application of intraoperative monitoring technology can effectively prevent the occurrence of cerebral ischemia.

Severe ischemic stroke due to progression of cervical carotid artery dissection

Severe ischemic stroke due to progression of cervical carotid artery dissection

Surgical Treatment of Cervical Carotid Artery Aneurysm

Cervical carotid aneurysms are rare, and surgical treatment should be planned for each patient. The authors report 9 cases of cervical carotid aneurysm in 9 patients(mean age, 53.7 years;5 men)who were treated surgically between 2005 and 2014. The aneurysm was located in the internal carotid artery in 6 patients, the common carotid artery in 2 patients, and the carotid bifurcation in 1 patient. Four aneurysms were recurrences after a previous endovascular intervention(parent artery coil embolization, covered stent placement, or stent with coil embolization). The mean interval between the endovascular therapy and the onset of the present illness was 6 years. All the patients presented a mass effect at the neck, including lower cranial nerve dysfunction in 1 patient. Two patients presented with ischemic events presumably due to thromboembolism from the target aneurysms. Surgical treatments included local vascular reconstruction procedures in 6 patients(interposition vein or artificial graft bypass in 5 patients and in situ bypass in 1 patient). Four aneurysms were then resected. Two patients with rich collateral blood flow were treated with ligation of the parent artery proximal to the aneurysm. Surgical complications included embolic stroke and cranial nerve dysfunction in 2 patients, respectively, both presumably due to surgical manipulation. The modified Rankin scale(mRS)score at discharge was 0 in 5 patients, 1 in 1 patient, 2 in 2 patients, and 6 in 1 patient(vascular tumor). Surgical treatment of cervical carotid aneurysms seems a reasonable treatment of choice, but lower nerve dysfunction and embolism from the aneurysm should be avoided.