Cervical Internal Carotid Artery Research Articles

Internal carotid artery rupture during endovascular thrombectomy in patients with tandem occlusion: A two-case report.

Endovascular thrombectomy in patients with tandem occlusions can rarely result in the rupture of the internal carotid artery, leading to subarachnoid haemorrhage and death. However, this complication and its causes are rarely reported and discussed in the literature. We describe two cases of internal carotid artery rupture during endovascular thrombectomy in patients with tandem occlusion. It is hypothesised that the primary approach to the distal lesion, before recanalization, creates a blind alley that faces an intraluminal pressure increase upon manual contrast injection, surpassing the vessel's resistance and resulting in arterial wall rupture. To prevent this complication, approaches such as treating the proximal occlusion first, injecting the contrast through a microcatheter or retracting the endovascular support catheter proximally to the stenosis of the cervical internal carotid artery have been suggested and are discussed.

Distal normal vessel diameter might be associated with silent brain infarcts after stenting for symptomatic carotid stenosis

BackgroundCarotid artery stenting (CAS) has been the standard treatment for carotid stenosis because it is less invasive; however, the risk of periprocedural thromboembolism is high. We investigated the predictors for silent brain infarcts (SBIs), focusing on embolic protection in CAS. MethodsThis study was single-center retrospective study, and we obtained baseline demographics and clinical, laboratory, and periprocedural variables of patients who underwent CAS. Also, methods used for embolic protection (no EPD, distal EPD, or proximal balloon guiding catheter) during CAS were obtained. Distal normal vessel diameter was defined as the diameter of cervical internal carotid artery where the artery wall becomes parallel. Diffusion-weighted imaging was performed before and after procedure to detect SBIs. The primary outcome was stented territory SBIs, and the secondary outcomes were any territories SBIs and stented territory SBIs in cases with EPD. ResultsA total of 196 CAS procedures with mean age 69.1 ± 9.9 years were included. After CAS, stented territory SBIs occurred in 53 (27.0 %) cases and any territories SBIs in 60 (30.6 %) cases. Univariable analyses revealed that distal normal vessel diameter (odds ratio = 1.71, 95 % confidence interval = 1.20–2.43, P = 0.003) was associated with the occurrence of stented territory SBIs after CAS. After adjusting for potential variables, larger distal normal vessel diameter (1.61 [1.10–2.36], P = 0.014) increased the occurrence of SBIs after CAS. Consistent results were obtained when the outcome was any territories SBIs or stented territory SBIs in cases with EPD. ConclusionsDistal normal vessel diameter was a predictor for the occurrence of SBI after CAS. The passable pore size of EPDs may vary depending on vessel diameter, and may impact the occurrence of SBIs.

A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports

A Sudden Unilateral Visual Field Loss in a Recreational Tennis Player: Cervical Internal Carotid Artery Dissection Associated With Low-Impact Sports

Adventitia Layer-Focused Microsurgical Flow Reconstruction for Long-Segment Tubular Stenosis of the Cervical Segment (C1) Internal Carotid Artery: Clinical Valuable Experience in 20 Cases.

To evaluate the efficacy of perivascular sympathectomy in managing adventitia layer-related long-segment tubular stenosis of cervical segment (C1) internal carotid arteries (ICAs) in a cohort where conventional medical and endovascular interventions were not viable options, we retrospectively analyzed 20 patients (8 males, 12 females, aged 41-63 years) who underwent perivascular sympathectomy for long-segment (>5 cm) tubular cervical ICA stenosis (non-atherosclerotic, non-intima related, and nondolichoarteriopathic) between 2017 and 2023. The procedure aimed to alleviate symptoms such as hemiparesis, pulsatile tinnitus, and migraines associated with transient ischemic attacks (TIAs). Preoperative and postoperative symptoms were assessed, and patient follow-up was conducted by MR angiography and perfusion studies. Postoperatively, 10 out of 11 migraine sufferers (90.9%) reported complete cessation of symptoms, while one patient (9.09%) experienced reduction in frequency and intensity. In cases of tinnitus, six out of nine patients (66.6%) reported complete resolution, two (22.2%) had reduced symptoms, and one (11.1%) saw no change. Regarding motor function, all 12 patients (100%) with initial hemiparesis (30-40% loss of motor function) showed complete recovery postoperatively. There was no TIA attack among the patients after the procedure in the mean two-year follow-up. Perivascular sympathectomy has shown promising results in alleviating symptoms and preventing recurrent cerebrovascular events in long-segment tubular stenosis of cervical ICAs.

A technique for reconstruction of a giant extracranial internal carotid artery aneurysm: A technical note.

Surgery is effective for extracranial internal carotid artery (EICA) aneurysms. However, the risk of cranial nerve injury associated with surgical repair, such as graft-assisted resection and extracranial-intracranial bypass techniques, is relatively high. Here, we report two cases of surgical treatment for EICA aneurysms and describe the surgical techniques and strategies to avoid cranial nerve injury. Two patients presented to our facility with an increasing cervical pulsatile mass and no neurological symptoms. Angiography showed a large aneurysm in the cervical internal carotid artery. Surgical treatment was performed to prevent rupture of the aneurysm. In both patients, the aneurysm was strongly attached to the vagus nerve. The aneurysm and vagus nerve were carefully dissected using a low-power bipolar (20 Malis; 3 watts), leaving connective tissue on the vagus nerve side. The aneurysm was detached from the vagus nerve without injury. Based on intraoperative findings, one patient underwent clipping, and the other underwent aneurysmectomy and primary closure for aneurysm obliteration and angioplasty. Both patients were discharged without any cranial nerve dysfunction. The selection of a strategy based on intraoperative findings and low-power bipolar cutting is important for the treatment of extracranial carotid artery aneurysms to preserve cranial nerves.

A New Preoperative Simulation Using Magnetic Resonance Imaging Bone-Like Imaging with Zero-Echo-Time Sequence

This study aimed to evaluate the clinical usefulness of zero-echo time(ZTE)-based magnetic resonance imaging(MRI)in planning an optimal surgical approach and applying ZTE for anatomical guidance during transcranial surgery. P atients who underwent transcranial surgery and carotid endarterectomy and for whom ZTE-based MRI and magnetic resonance angiography(MRA)data were obtained, were analyzed by creating ZTE/MRA fusion images and 3D-ZTE-based MRI models. We examined whether these images and models could be substituted for computed tomography imaging during neurosurgical procedures. Furthermore, the clinical usability of the 3D-ZTE-based MRI model was evaluated by comparing it with actual surgical views. ZTE/MRA fusion images and 3D-ZTE-based MRI models clearly illustrated the cranial and intracranial morphology without radiation exposure or the use of an iodinated contrast medium. The models allowed the determination of the optimum surgical approach for cerebral aneurysms, brain tumors near the brain surface, and cervical internal carotid artery stenosis by visualizing the relationship between the lesions and adjacent bone structures. However, ZTE-based MRI did not provide useful information for surgery for skull base lesions, such as vestibular schwannoma, because bone structures of the skull base often include air components, which cause signal disturbances in MRI. ZTE sequences on MRI allowed distinct visualization of not only the bone but also the vital structures around the lesion. This technology is minimally invasive and useful for preoperative planning and guidance of the optimum approach during surgery in a subset of neurosurgical diseases.

Importance of cerebral angiography in the evaluation of delayed carotid stent thrombosis: a case report

BackgroundWhile noninvasive imaging is typically used during the initial assessment of carotid artery disease, digital subtraction angiography remains the gold standard for evaluating carotid stent thrombosis and stenosis (Krawisz in Cardiol Clin 39:539–549, 2021). This case highlights the importance of digital subtraction angiography for assessing carotid artery stent patency in place of non-invasive imaging.Case presentationWe present a 61-year-old African American male patient with a history of right cervical internal carotid artery dissection that was treated with carotid artery stenting and endovascular thrombectomy, who developed recurrent right hemispheric infarcts related to delayed carotid stent thrombosis. Digital subtraction angiography found multiple filling defects consistent with extensive in-stent thrombosis not clearly observed with magnetic resonance angiography. Etiology was likely secondary to chronic antiplatelet noncompliance. Therefore, the patient was treated medically with a heparin drip, and dual antiplatelet therapy (dAPT) was restarted. At 1-month follow-up the patient did not report new motor or sensory deficits.ConclusionIn the setting of delayed carotid stent thrombosis secondary to antiplatelet noncompliance, digital subtraction angiography may play an essential diagnostic role for early identification and determination of the most appropriate treatment.

Another cause of treatable dementia: rapid cognitive improvement after carotid endarterectomy. Illustrative case.

Revascularization techniques in cervical internal carotid artery (ICA) stenosis are indicated to prevent the onset or recurrence of ischemic events in the setting of atherosclerotic carotid artery disease. Recent reports, case series, and comparative studies have suggested that revascularization techniques may also improve cognitive outcome in both symptomatic and asymptomatic patients, thus raising the question of whether another surgically treatable dementia has presented itself. A 70-year-old right-handed female with a history of hypertension, diabetes, and bilateral silent cerebral infarcts was evaluated for progressive cognitive impairment over a 1-year period, which was associated with a severe left cervical ICA stenosis. Carotid endarterectomy (CEA) was indicated as a revascularization technique, and the patient showed significant neurocognitive improvement as early as one month postoperatively, consistent with blood flow restoration to the left hemisphere on control imaging. This case serves as a reminder that CEA may improve the cognitive outcome of patients previously impaired by uncomplicated severe cervical ICA atherosclerotic disease, which can be another cause of treatable dementia. Further prospective studies may help to assess this potential benefit.

Impact of Day 1 carotid patency on outcome in dissection-related tandem occlusions treated with mechanical thrombectomy

The clinical benefit of mechanical thrombectomy(MT) for stroke patients with tandem occlusion is similar to that of isolated intracranial occlusions. However, the management of cervical internal carotid artery(ICA) occlusion during the MT, particularly in the setting of carotid dissection, remains controversial. We aimed to investigate the clinical impact of cervical ICA patency at day 1 on 3-month functional outcome. We collected data from the Endovascular Treatment in Ischemic Stroke, a prospective national registry in 30 French centers performing MT between January 2015 and January 2022. Inclusion criteria were consecutive tandem occlusions related to cervical ICA dissection treated with MT. Tandem occlusions of other etiology, isolated cervical ICA occlusions without intracranial thrombus and patients without day-1 ICA imaging were excluded. Primary endpoint was the 3-month functional outcome. Secondary endpoints included intracranial hemorrhage(ICH), excellent outcome, mortality and early neurological improvement. A sensitivity analysis was performed in patients with intracranial favorable recanalization after MT. During the study period, 137 patients were included of which 89(65%) presented ICA patency at day 1. The odds of favorable outcome did not significantly differ between patients with patent and occluded ICA at day 1(68.7 vs 59.1%;aOR=1.30;95%CI 0.56-3.00,p=0.54). Excellent outcome, early neurological improvement, mortality and ICH were also comparable between groups. Sensitivity analysis showed similar results. ICA patency at day 1 in patients with tandem occlusions related to dissection did not seem to influence functional outcome. Endovascular recanalization of the cervical ICA including stenting might not be systematically required in this setting.

Stenting for Traumatic Pseudoaneurysms of the Cervical Internal Carotid Artery: Case Report and Systematic Review

The optimal stenting approach for traumatic pseudoaneurysms (PSA) of the extracranial internal carotid artery (ICA) remains underinvestigated. We present a case of a traumatic pseudoaneurysm of the extracranial ICA managed with stenting and review of prior published similar cases. The systematic review followed PRISMA-S guidelines and included studies that investigated traumatic pseudoaneurysms of the extracranial ICA managed by stent placement. Statistical analysis assessed the association between the type of injury and stent type, dual antiplatelet therapy (DAPT) duration, and clinical presentation, and the association between stent type and DAPT duration. Our search yielded 82 publications with 135 patients with extracranial ICA PSA treated with stenting. The odds of neck hematoma presentation was 12.2 times greater for patients with penetrating rather than blunt injuries (P= 0.000002). Covered stents had 2.02 times higher odds of use for penetrating rather than blunt injuries compared to bare metal stents. (P= 0.0029). Shorter duration DAPT was seen with bare metal stents having 1.25 higher odds of DAPT duration less than one month compared to covered (P= 0.001). In traumatic extracranial ICA pseudoaneurysms, covered stents are used more commonly for penetrating injuries compared to blunt injuries. Penetrating injuries are more strongly associated with the presentation of a hematoma compared to blunt injuries. Stent type may influence the recommended DAPT duration. Surgeons should consider these findings when selecting stent type and DAPT duration with patients presenting with traumatic extracranial ICA pseudoaneurysm.

Abstract WP200: Endovascular Therapy for Isolated Carotid Occlusion in the Neck

Background and Study Purpose: Existing guidelines on endovascular treatment (EVT) of acute ischemic stroke do not include isolated cervical internal carotid artery occlusions (CICAO). These occlusions are still treated, but the effect remains unclear. This study aimed to compare the baseline characteristics and treatment outcomes between patients with isolated CICAO and patients who underwent EVT due to occlusions mentioned in guidelines. Methods: A retrospective study was conducted on 1162 patients who underwent EVT due to ischemic stroke at Aarhus University Hospital between June 2017 and June 2022. Univariate analysis of outcomes and baseline characteristics were compared between patients with isolated CICAO and tandem occlusions or isolated CICAO and occlusion of the middle cerebral artery (M1)/intracerebral internal carotid artery (ICA-T). Results: 731 patients were eligible for inclusion. Patients with isolated CICAO were more likely male (67.8% vs 50.9%, p-value = 0.0009) and active smokers (42.2% vs 26.4%, p = 0.0016) compared to patients with M1/ICA-T occlusions where atrial fibrillation (35.5% vs. 23.5%, p = 0.0158) and an equal sex distribution was more frequently seen. The groups showed similar favorable outcomes and mortality. Notably, a statistically significant difference in mortality between patients with isolated CICAO (precent) and M1/ICA-T occlusions (percent) could not be excluded (p = 0.0584). Conclusion: Patients with isolated CICAO and M1/ICA-T occlusions seem to differ in sex, smoking status, and atrial fibrillation. This study did not find any differences between isolated CICAO and tandem occlusions. EVT appears beneficial in patients with isolated CICAO, however randomized-controlled trials are necessary to examine and compare the effect between occlusion sites.

Abstract WMP116: A P2X4 Inhibitor Dramatically Suppresses the Progression of Cervical Internal Carotid Artery Stenosis - An Attempt to Develop a Therapeutic Agent for Carotid Artery Stenosis Focusing on the Role of Hemodynamic Factors-

Introduction: Medical treatment of internal carotid artery stenosis consists of treatment of underlying conditions such as hypertension, dyslipidemia, and diabetes mellitus, as well as antiplatelet therapy. Hemodynamic studies suggest that endothelial cells sense disturbances and stagnation of blood flow caused by vessel geometry, which trigger the progression of stenosis. Similarly, cerebral aneurysms are known to progress due to hemodynamic effects. We have shown in animal studies that inhibition of P2X4 purinoceptor, an endothelial blood flow sensing-related protein, significantly inhibits the development of cerebral aneurysms. In the present study, we examined whether P2X4 disruption can suppress the progression of internal carotid artery stenosis using an animal model of carotid artery stenosis. Methods: Carotid stenosis coils were implanted in the left carotid artery of 7-week-old P2X4(-/-) and (+/+) mice fed a high-cholesterol diet. Four weeks after placement, the carotid arteries were removed and the occlusion rates of the carotid arteries were compared. The expression of known stenosis-related inflammatory factors was also examined by Western blotting. Results: The carotid occlusion rate was significantly lower in the P2X4 gene-deficient mice, with 5 of 16 occlusions, compared with 9 of 13 occlusions in the control group (p=0.0394, Student's t-test). The expression levels of MCP-1, COX-2, TNFα, and IL-1β were significantly increased in the carotid arteries of P2X4(+/+) mice with the coil compared to the non-operated group (p=0.0073, 0.0012, 0.0016, 0.0031, respectively, Wilcoxon's signed rank test). The carotid arteries of P2X4(-/-) mice with coils showed significantly lower expression of all of the above compared to those of P2X4(+/+) mice (p=0.0233, 0.0020, 0.0098, 0.0046, respectively). Conclusions: These results suggest that inhibition of endothelial blood flow sensing by P2X4 disruption may have reduced the progression of carotid artery stenosis by suppressing the expression of a group of inflammatory factors associated with carotid artery stenosis. This may lead the way to new drug therapies for carotid artery stenosis.

Effectiveness of S-Shaping of the Tip of the FUBUKI Guiding Catheter to Match the Shape of the Cervical Internal Carotid Artery in Anterior Circulation Cerebral Aneurysm Embolization

Effectiveness of S-Shaping of the Tip of the FUBUKI Guiding Catheter to Match the Shape of the Cervical Internal Carotid Artery in Anterior Circulation Cerebral Aneurysm Embolization

Acute bilateral middle cerebral artery occlusion treated with thrombectomy via the anterior communicating artery in a patient with chronic left cervical internal carotid artery occlusion: a case report

Acute bilateral middle cerebral artery occlusion treated with thrombectomy via the anterior communicating artery in a patient with chronic left cervical internal carotid artery occlusion: a case report

Correlation between intravascular pressure gradients and ultrasound velocities in carotid artery stenosis: An exploratory study.

Grading of carotid stenosis is routinely performed with non-invasive techniques, such as carotid ultrasound (CUS) and computerized tomography angiography (CTA), which have limitations in grading definition. Moreover, the actual hemodynamic impact of a stenosis remains poorly defined. Preliminary studies explored the application of the resting full-cycle ratio (RFR), measured with pressure wire (PW), but the correlation between RFR and morphological/hemodynamic parameters is still undefined. This study aims to test the correlation between RFR and CUS-CTA-DSA based degree of stenosis, to define the suitability of RFR as carotid stenosis index. We included patients with symptomatic carotid stenosis receiving carotid artery stenting (CAS), between November 2022 and May 2023. We performed CUS and PW measurements before and after stenting, at four different sites (trans-lesion, distal cervical, petrous and supraclinoid internal carotid artery [ICA] segments). We compared CUS and PW parameters by Pearson's or Spearman test for continuous variables. Among 15 patients included the mean stenosis degree was 81.3%. Trans-lesion RFR was significantly higher than other sites (0.72 ± 0.2 trans-lesion vs. 0.69 ± 0.18 distal cervical ICA vs. 0.66 ± 0.2 petrous ICA vs. 0.6 ± 0.2 intracranial ICA, p < 0.05). All RFR values significantly increased after treatment; the highest relative increase was registered at stenosis site (0.72 ± 0.2 pre-stent vs. 1.01 ± 0.1 post-stent, p < 0.01). Trans-lesion RFR was significantly associated with the CTA and DSA stenosis degree and CUS measurements. Pressure wire in carotid artery stenosis seems safe and suitable. Resting full-cycle ratio has a significant correlation with CUS values and stenosis degree and might be used as carotid stenosis index during CAS.

Endovascular Embolization of Traumatic Vessel Injury Using N-butyl Cyanoacrylate: A Case Series.

There is limited evidence of N-butyl cyanoacrylate (n-BCA) use in endovascular embolization of traumatic face and neck vessel injuries. We investigated the safety and effectiveness of n-BCA for this purpose. We retrospectively analyzed consecutive patients presenting to a Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18years old with any vessel injury in the face and neck circulation requiring n-BCA embolization. The primary endpoint was n-BCA effectiveness defined as immediate control of active bleeding post-embolization. In total, 13 patients met the inclusion criteria. The median decade of life was 3 (IQR 3 - 5) with a male predominance (n = 11, 84.6%). Median Glasgow Coma Scale score on presentation was 15 (IQR 3-15). Eleven patients suffered gunshot wound injuries; two patients suffered blunt injuries. Injured vessels included facial artery (n = 6, 46.2%), buccal branch artery (n = 3, 23.1%), internal maxillary (n = 5, 38.5%), cervical internal carotid artery (n = 1, 7.7%), and vertebral artery (n = 1, 7.7%). All patients were treated with 1:2 n-BCA to ethiodol mixture with immediate extravasation control. No bleeding recurrence or need for retreatment occurred. One patient died in-hospital (7.7%). Patients were discharged to home (n = 8, 61.5%), day rehabilitation (n = 1, 7.7%), or acute rehabilitation (n = 3, 23.1%). One patient developed a right posterior cerebral artery infarct with hemorrhagic transformation. To our knowledge, this is the first study demonstrating the safety and effectiveness of n-BCA liquid embolism in traumatic vessel injuries, especially penetrating gunshot wounds.

Abstract 059: The Tenzing‐Dotter Technique for Endovascular Management of Atherosclerotic Cervical ICA Tandem Large Vessel Occlusions

Introduction The endovascular treatment of acute ischemic stroke due to atherosclerotic occlusion/near‐occlusion of the cervical internal carotid artery (ICA) and a concurrent intracranial large vessel occlusion (LVO) remains challenging, and the optimal approach remains unclear. Options include initial angioplasty and/or stenting of the cervical lesion followed by intracranial thrombectomy versus Dotter navigation of catheters through the cervical lesion to first target the intracranial LVO. We describe a novel Tenzing‐Dotter technique which utilizes a Tenzing device for the Dotter delivery of large bore (0.070”) and super‐large bore (0.088”) catheters through cervical atherosclerotic lesions to gain access to the intracranial circulation in tandem LVO patients. Methods We performed a retrospective review our single center experience of atherosclerotic tandem occlusion patients in which the Route 92 Medical Tenzing ® 7 (T7®) and Tenzing ® 8 (T8®) delivery catheters were used to Dotter‐deliver large bore or super‐large bore catheters, respectively, through the cervical ICA lesion to gain access to the intracranial circulation. We reviewed clinical, radiographic and procedural data to describe the safety and efficacy of this approach. Results Twenty patients were identified that that atherosclerotic occlusion/near‐occlusion of the cervical ICA and a single symptomatic intracranial LVO. The mean age was 65 (44 – 89), and 40% were female. The mean NIHSS was 14 (7‐25) and 40% were treated initially with intravenous thrombolytics. The ipsilateral cervical ICA was occluded in 11 of 20 patients (55%) and nearly‐occluded (degree of stenosis 90‐99%) in 9 of 20 patients (45%). The intracranial occlusions were carotid terminus (5), M1 middle cerebral artery (14) and M2 middle cerebral artery (1). Seven patients were treated with Tenzing 7 paired with a large bore catheter (6 with Medtronic React 71 and 1 with Route 92 Medical Hipoint 70), while 13 were treated with Tenzing 8 paired with a super‐large bore catheter (11 with Route 92 Medical Hipoint 88 catheter and 2 with Route 92 Medical Freeclimb 88 catheter). In all cases, successful navigation of the paired catheter through the cervical lesion was achieved in 100% of patient using the Tenzing‐Dotter delivery technique. The mean time from groin puncture to successful Tenzing‐Dotter delivery was 11 minutes, and the mean time from groin puncture to device delivery to the intracranial occlusion was 15 minutes. TICI 2B or greater reperfusion (self‐adjudicated) as achieved in 100% of patients, with a mean time to best TICI of 21 minutes. The degree of cervical ICA stenosis following thrombectomy improved from 96.5% to 67.4%. No symptomatic intracranial hemorrhage or cervical arterial dissections were noted. Conclusion The Tenzing‐Dotter technique, in which a Route 92 Medical Tenzing ® delivery catheter is utilized to Dotter navigate a large or super‐large bore catheter through an occluded or nearly‐occluded cervical atherosclertotic lesion, may be a promising technique for safe and fast access to the intracranial circulation in patients presenting with tandem large vessel occlusion acute ischemic strokes.

Abstract 103: Acute Onset Rhythmic Tremor In Acute Frontal Cortical Infarction: A Case Report

Introduction Acute ischemic stroke varies in presentation, and it is crucial to quickly identify patients presenting with stroke for timely intervention. Secondary movement disorders occurring after a delayed period following ischemic stroke have been well‐documented, though rare. Holmes tremor specifically has been described as a delayed result of ischemic infarction involving subcortical structures such as mollaret triangle, thalamus, and basal ganglia. However, it is novel for frontal cortical infarcts to present with acute‐onset contralateral limb tremor, especially as an isolated symptom. Our case suggests a “secondary insult” involving the frontal cortex can disinhibit the motor pathway that leads to tremor in preexisting midbrain and thalamic lesions. We present a 67‐year‐old male with acute onset, constant, rhythmic tremor in the setting of acute ischemic frontal cortical infarction. Methods n/a, case report Results A 67‐year‐old male with medical history of pineal gland cyst status‐post shunt placement and hypertension who presented for evaluation of acute onset right upper extremity rhythmic tremor that started 24 hours prior. He did not have any associated weakness, numbness, vision changes, nausea, or vomiting. He had never had this tremor before. Neurologic examination was significant for a 4.0 Hz rhythmic resting tremor that was present throughout exam and was non‐distractible. This tremor remained consistent even with kinetic movements and postures. Electroencephalogram (EEG) was performed STAT during this tremor and was not based in seizure. Non‐contrast head computerized tomography (CT) was negative for any acute hemorrhage or intracranial pathology. CT angiogram head and neck showed left internal carotid artery (ICA) long segment tapered occlusion from the proximal cervical ICA to the distal petrous segment, likely dissection of undetermined chronicity. Magnetic resonance imaging (MRI) Brain with and without contrast was significant for acute punctate foci involving the precentral cortex of the left frontal lobe consistent with acute ischemic infarction. Encephalomalacia was also present involving the bilateral posterior thalami and left midbrain chronic ischemic infarctions. This suggests the tremor was caused by disinhibition of the motor pathway from the ischemic insult to the frontal cortex, as he had pre‐existing asymptomatic ischemic insult to the typical structures known to cause this tremor. He was outside of the Tenecteplase window and was given a load of Aspirin followed by aspirin 81 mg daily. He was trialed on propranolol for treatment of symptomatic tremor however this was discontinued before discharge as it was ineffective and patient preferred to hold off on other treatments. He is now awaiting outpatient Neurology follow up. Conclusion This case suggests that acute onset Holmes tremor can be the sole presenting sign in acute ischemic frontal cortical infarction. The pre‐existing asymptomatic infarctions in the midbrain and thalamus also support that a “second hit” located in the frontal cortex can disinhibit the motor pathway between the cortex and rubral tract. This is important as Holmes tremor is more commonly known to be from a mechanism of damage to the red nucleus or thalamic structures in a delayed manner, typically at least two weeks after stroke. This knowledge will help identify rare strokes in a timely manner.

Abstract 018: External carotid artery Pseudo aneurysm induced Internal Carotid Artery compression causing acute ischemic stroke

Introduction Here, we describe a patient in whom ischemic stroke was caused by compression of the Internal Carotid Artery (ICA) by a Pseudoaneurysm (PSA) of the External Carotid Artery (ECA) after Gun Shot injury. Eventually, the PSA of the Internal maxillary artery (IMAX) was embolized, resulting in resolution of the patient's symptoms. Methods Case Report Results A 75‐year‐old male with a history of atrial fibrillation on Eliquis presented to the emergency department after sustaining a gunshot wound to the left face. He had extensive injuries through the left masticator and submandibular space with an inferior orbital wall fracture. A Computed Tomography Angiography (CTA) neck showed injuries to the left proximal IMAX with a small PSA. As the PSA was asymptomatic it was managed with observation. On HOD day 13, CTA was done for a brief period of unresponsiveness, which showed high‐grade narrowing of left cervical ICA due to extrinsic compression from PSA which was supplied by a branch of the left ECA with distal re‐constitution (image A). The next day, patient developed right sided plegia and aphasia with NIHSS of 17. A CT head showed no acute intracranial abnormality. The patient underwent emergent Digital Subtraction Angiography (DSA), which demonstrated occlusion of the left cervical ICA from compression from a left IMAX PSA which was treated with n‐butyl‐cyanoacrylate TRUFILL embolization with resolution of flow limitation in the left cervical ICA (Image B1,B2). After embolization, the patient was oriented and able to lift right arm and leg anti‐gravity. Magnetic Resonance Imaging (MRI) was contraindicated due to retained bullet fragments. Repeat CT head did not show stroke. Conclusion A Pseudo aneurysm is characterized by a rupture of the arterial wall and the formation of an aneurysmal sac by the adjacent structures while the sustaining artery remains intact. The most prevalent causes are penetrating or acute blunt neck trauma, hyperextension injury, and injury to the base of the skull (1). Predisposing factors for PSA include carotid endarterectomy or a late complication of carotid artery dissection, infection, radiotherapy, and malignancy (1‐2). Cox et al. reported 124 patients with significant neck and head penetrating injuries. Eleven patients were found to have thirteen head and neck PSA: two in the ICA, one in the vertebral artery, and ten involving branches of the ECA. Two of seven symptomatic PSAs manifested with episodes of massive hemorrhage (3). There have been case reports describing the consequences of an elongated styloid process causing an ischemic stroke due to subsequent dissection and PSA formation (4). According to our knowledge, this case report is one of the first to describe acute ischemic symptoms resulting from ECA PSA‐induced ICA compression, with resolution of symptoms following PSA embolization. The educational value of our case lies not only in the rarity of the condition but also in the uniqueness of its presentation. This case is a fundamental addition to the existing literature on rare neuro‐vascular anomalies leading to potential catastrophic outcomes.

Abstract 098: Symphony of Risk: A Case Report of Carotid Artery Dissection Associated with Violin Playing

Introduction Carotid artery dissection (CAD) is an uncommon and potentially life‐threatening condition that can have a delayed presentation. More commonly associated with blunt cervical trauma, CAD due to repetitive stress to the neck goes under‐recognized, making it challenging to diagnose. Herein, we aim to shed light on a unique instance of CAD after continuous microtrauma, as well as highlight diagnostic challenges associated with CAD. Methods We present a case of a 57‐year‐old man who presented with a one‐week course of unequal pupils, left‐sided headaches, left sided ptosis, and intermittent blurry vision. Exam revealed a callous where he held a violin against his left neck, having endorsed playing for several years with repeated contortion of his head to the left (Figure 1A). Magnetic resonance angiogram (MRA) of the head and neck revealed an acute dissection of the left internal carotid artery (ICA) (Figure 1B). A diagnosis of Horner’s syndrome secondary to acute dissection of the left cervical ICA was made. Consent to share this information was obtained from the patient and witnessed by another physician. Results MRA head and neck showed a 2.5 cm irregularity of the distal left ICA with high signal on fat saturated T1‐weighted images consistent with an acute dissection (Figure 1B). The patient underwent an apraclonidine test and was positive for left sided Horner’s syndrome with reversal of anisocoria after application of drops (Figure 1C). Given no evidence of stroke or thrombus on imaging, he was placed on dual antiplatelet therapy (DAPT) for three months. He was advised not to play violin for a month and to restart cautiously with a pad between his neck and the instrument. Follow‐up imaging showed eventual resolution of the CAD, while physical exam revealed improvement in ptosis and miosis. Conclusion While playing the violin involves repetitive stress on the neck, there is limited research on this specific activity as a cause of carotid artery dissection, making it a rare occurrence. Common clinical manifestations of CAD include neck pain, headache, Horner’s syndrome, tinnitus, stroke, and lower cranial nerve palsies, occurring suddenly or over time. Diagnosing CAD typically involves a combination of thorough history, physical examination, and diagnostic imaging. Ongoing research in the optimal management of CAD focuses on minimizing the risk of stroke, after factoring in variables such as location of dissection and whether it is symptomatic or not.