External Carotid Artery Occlusion Research Articles

Direct superficial temporal artery access for middle meningeal artery embolization.

Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.

Transcarotid artery revascularization (TCAR) – first experience

Abstract Objective In transcarotid artery revascularization (TCAR) the carotid stent used to treat carotid artery stenosis is introduced via a cut-down to the common carotid artery (CCA). Stent placement is performed during flow reversal using an external shunt to the femoral vein. The advantages compared to transfemoral carotid stenting are that the risks of embolization from the aortic arch and origin of the arch vessels are avoided and that clamping of the common carotid artery allows complete flow-reversal during stent placement. TCAR was developed in 2015 and is extensively used predominately in the USA. To our knowledge, TCAR has until now not been used in Switzerland. We present our first experience with TCAR. Methods Retrospective analysis of consecutive patients. Results We treated 4 patients with TCAR from Dec 2019 to May 2020. All patients were male, median age was 66y. All had high-grade internal carotid artery (ICA) stenosis (3 asymptomatic, 1 symptomatic). All procedures were performed in a hybrid operation room. Technical success was achieved in 3 patients. In these patients there was no peri-interventional stroke or TIA and duplex sonography 6 months postoperatively showed a patent stent without restenosis. In the fourth patient previous attempted transfemoral stenting for symptomatic ICA-stenosis had failed because of a very tortuous CCA. During TCAR, puncture of the CCA was difficult because of atherosclerotic thickening of the vessel wall, furthermore the tip of the guidewire for insertion of the dedicated sheath into the CCA needed to be placed in the CCA rather than in the external carotid artery (ECA) because of ECA occlusion. This led to inadvertent crossing of the stenosis with the guide wire. The procedure was abolished and converted to a conventional carotid endarterectomy. The patient had a perioperative minor stroke with signs of embolization into branches of the medial cerebral artery. He underwent transfemoral intracranial thrombectomy and eventually recovered with only minor deficits. Conclusion Our first experience with TCAR confirmed that patient selection is important: A combination of atherosclerotic disease of the CCA and occlusion of the ECA, both in themselves only relative contraindications to TCAR, led to technical failure and perioperative stroke. With good patient selection TCAR could be performed safely.

Nociceptive receptors are expressed differently in trigeminal nociception after lingual nerve injury and unilateral external carotid artery occlusion in rats

ObjectivesTo investigate the different changes in nociceptive activity between two animal models of trigeminal neuropathic pain: unilateral external carotid artery ischemic reperfusion and lingual nerve crush in rats. DesignIn this study, changes in nociceptive activity were investigated in unilateral external carotid artery ischemic reperfusion and lingual nerve crush models of trigeminal neuropathic pain in rats. Field excitatory postsynaptic potentials (fEPSPs) evoked by capsaicin application on the tongue of rats were recorded in the trigeminal nucleus caudalis. In addition, immunohistochemistry was performed in the trigeminal ganglia and trigeminal nucleus caudalis. ResultsThe fEPSP in unilateral external carotid artery ischemic reperfusion and lingual nerve crush rats was irregular relative to that in sham rats. In particular, the fEPSP spike in lingual nerve crush rats had a higher amplitude and shorter duration than that in sham rats. Unilateral external carotid artery ischemic reperfusion and lingual nerve crush also increased c-fos expression in the trigeminal nucleus caudalis. Upregulation of transient receptor potential vanilloid 1 in trigeminal ganglion was observed in unilateral external carotid artery ischemic reperfusion and lingual nerve crush rats, whereas upregulation of purinergic receptor subtype 3 in trigeminal ganglion was observed only in lingual nerve crush rats. ConclusionsAlthough unilateral external carotid artery ischemic reperfusion and lingual nerve crush similarly increased nociceptive activity at the trigeminal nucleus caudalis, the fEPSPs and expression of nociceptive peripheral afferent neurons were different. Therefore, direct and indirect nerve injuries apparently induced the same nociceptive activity by different signaling responses dependent on nociceptive receptors.

Thirty-Day Results of the Novel CGuard-Covered Stent in Patients Undergoing Carotid Artery Stenting

Objective: The aim of this study was to provide early-term evaluation, safety, and efficacy of the novel CGuard (Inspire MD, Tel Aviv, Israel) micromesh self-expanding stent with embolic protection system (EPS) during carotid artery stenting (CAS) procedure. Materials and Methods: All patients who underwent CAS with CGuard carotid stent system from January 2018 to September 2020 in a tertiary center were prospectively evaluated. Primary endpoints included technical success and perioperative neurological events (0–48 hours). Secondary endpoint was the rate of neurologic, cardiac events, and death (major adverse event or MAE) at 30 days. Patency of CGuard, peak systolic velocity (PSV), and end diastolic velocity (EDV) were evaluated at 30 days with duplex ultrasound. Results: A total of 103 patients underwent CAS procedure. Forty patients were symptomatic, and 63 patients were asymptomatic with stenosis greater than 70%. Technical success was 100%. Local anesthesia was applied in 94 patients (93%). Embolic protection devices were used in 6 patients (5.8%). Access site complications were 1.9%. Mean internal carotid artery stenosis diameter reduced from 79.47% to 14.68%. Two patients had transient ischemic attack (1.9%) and 1 patient experienced a cerebral hyperperfusion syndrome (CHS) perioperatively. External carotid artery (ECA) occlusion occurred in 1.9%. Four patients experienced jaw claudication (3.8%) postoperatively. Mean time of operation was 41 minutes. Mean duration of hospitalization was 3.1 days. The 30-day rate of MAE was 0%. CGuard patency was 100%, mean internal carotid PSV was reduced from 251.57 to 77.29 cm/s, and mean internal carotid EDV was reduced from 154.62 to 24.63 cm/s at 30 days. Conclusion: Our study shows that CGuard stent with EPS is an effective and safe device for treatment of carotid artery stenosis with acceptable low perioperative neurologic events, even with low embolic protection device usage. Larger multicenter and randomized studies are necessary to confirm its long-term efficacy.

Balloon catheter occlusion of the maxillary, internal, and external carotid arteries in standing horses

To assess the feasibility of balloon catheter occlusion of the internal carotid artery (ICA), external carotid artery (ECA), and maxillary artery (MA) in standing horses. Experimental and clinical cases series. Eight healthy horses (phase 1) and 11 clinical cases (phase 2). Occlusions were performed on standing horses under sedation and local anesthesia. In phase 1, four horses underwent bilateral ICA balloon catheter occlusion, and four horses underwent balloon catheter occlusion of the ECA and MA. In phase 2, horses were treated by occlusion of ICA (n = 7), ECA (n = 2), or ECA and ICA (n = 2). Internal carotid artery occlusion was successful in seven of eight and seven of nine arteries in phases 1 and 2, respectively. The procedures lasted 53 and 50 minutes, respectively, and catheters were inserted over 13 ± 0.7 cm (mean ± SD). External carotid artery occlusion was successful in seven of seven and four of four arteries in phases 1 and 2, respectively, with mean durations of 31 and 26 minutes, respectively, and a mean distance of catheter insertion of 11.9 cm. Maxillary artery occlusion was successful in five of seven arteries (phase 1), with a mean surgical duration of 47 minutes and a mean distance of catheter insertion of 42.8 cm. Balloon catheter occlusion of the ICA, ECA, and MA was achieved in most standing horses. Balloon catheter occlusion in standing horses provides an alternative to prevent or treat hemorrhage related to guttural pouch mycosis, particularly in horses in which general anesthesia might pose a risk.

One-month results from a prospective experience on CAS using C-GUARD stent system: the IRONGUARD-2 study

Abstract Objectives To evaluate 30-day safety and efficacy of dual layered mesh covered carotid stent systems (DLS) for carotid artery stenting (CAS) in the clinical practice. Background When compared to carotid endarterectomy CAS has been associated to an higher rate of post procedural neurologic events; these could be related to plaque's debris prolapsing through stent's mesh. Consequently, the need for increased plaque coverage has resulted in the development of DLS. Methods From January 2017 to June 2019 a physician-initiated, prospective, multispecialty, registry enrolled 733 consecutive patients undergoing CAS using the CGuard Embolic Prevention System (EPS) in 20 centres. Primary endpoint was the stroke up to 30 days; secondary endpoints were the technical and procedural success; external carotid artery (ECA) occlusion; in-hospital and 30 days transient ischemic attack (TIA), acute myocardial infarction (AMI) and death rates. Results Symptoms were present in 131 patients (17.87%). An embolic protection device (EPD) was used in 731 patients (99.72%). Procedural success was 100%, technical success was obtained in all but one patient (99.86%), who died in-hospital due to a haemorrhagic stroke. Six TIAs, 2 minor strokes, and 1 AMI occurred during in-hospital stay, ECA occlusion was evident in 8 patients (1.09%). Between hospital discharge and 30-day, 2 TIAs, 1 minor stroke and 3 AMIs occurred. Therefore, the stroke rate at 30 days was 0.13. Conclusion This real-world registry suggests that use of CGuard EPS in clinical practice is safe and associated to a minimal occurrence of adverse neurological events up to 30 days follow up. Funding Acknowledgement Type of funding source: None

Novel method for glomus-saving carotid endarterectomy sensu A. N. Kazantsev: cutting the internal carotid artery on the site from external and common carotid artery

Aim. To analyze the results of using a novel method of glomus-saving carotid endarterectomy (CEE) sensu A. N. Kazantsev.Materials and methods. This cohort, comparative, prospective, open-label study from January 2018 to April 2020 included 475 patients who undergone one of the three glomus-saving types of CEE. Depending on the implemented revascularization strategy, all patients were divided into 3 groups: group 1 — 136 patients (28,631%) CEE sensu R. A. Vinogradov; group 2 — 125 patients (26,316%) — sensu K. A. Antsupov; group 3 — 214 patients (45,053%) — sensu A. N. Kazantsev. Glomus-saving CEE sensu A. N. Kazantsev was carried as follows. Arteriotomy was performed along the inner edge of the external carotid artery (ECA) adjacent to the carotid sinus, 2 to 3 cm above the mouth, depending on the atherosclerotic lesion, with a transition to the common carotid artery (CCA) (also 2 to 3 cm below the mouth of the ECA). The internal carotid artery (ICA) was cut off at the site formed by the wall of the ECA and CCA. Next, an endarterectomy from the ICA was performed using the eversion technique. The next step was an open endarterectomy from EСA and СCA. Next, the ICA at the saved site was implanted in the previous position.Results. No intergroup differences were observed during hospitalization. Due to intraoperative visualization of an extended lesion of the ICA, in some cases it became necessary to transform the operation: in group 1, 4,4% of cases required ICA prosthetics; in groups 2 and 3 — autologous ICA transplantation in 4,8% and 4,7% of cases, respectively. Also, 1 case of ischemic stroke was recorded in groups 1 and 2. The cause of the latter was ICA thrombosis due to intimal detachment distal to the removed plaque. All cases of ECA thrombosis in the hospital postoperative period were differentiated in group 2.In the long-term follow-up, the groups were also comparable in the complication rate. The cause of all ischemic strokes was the development of restenosis or thrombosis of the ICA/prosthesis. Among patients who underwent forced autologous transplantation of the ICA, restenosis was not recorded. It should also be noted that new ECA occlusions (n=12; 9,6%) were visualized 6 months after reconstruction only in group 2.Conclusion. CEE sensu A. N. Kazantsev is the simplest technique of glomus-saving reconstructions, which have demonstrated their safety and effectiveness.

1-Month Results From a Prospective Experience on CAS Using CGuard Stent System: The IRONGUARD 2 Study

ObjectivesThis study sought to evaluate 30-day safety and efficacy of dual-layer mesh-covered carotid stent systems for carotid artery stenting (CAS) in the clinical practice. BackgroundWhen compared with carotid endarterectomy, CAS has been associated with a higher rate of post procedural neurologic events; these could be related to plaque’s debris prolapsing through stent’s mesh. Consequently, the need for increased plaque coverage has resulted in the development of dual-layer mesh-covered carotid stent systems. MethodsFrom January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system in 20 centers. The primary endpoint was stroke up to 30 days; secondary endpoints were technical and procedural success; external carotid artery occlusion; and in-hospital and 30-day transient ischemic attack (TIA), acute myocardial infarction (AMI), and death rates. ResultsSymptoms were present in 131 (17.87%) patients. An embolic protection device was used in 731 (99.72%) patients. Procedural success was 100%, technical success was obtained in all but 1 (99.86%) patient, who died in hospital due to a hemorrhagic stroke. Six TIAs, 2 minor strokes, and 1 AMI occurred during in-hospital stay, and external carotid artery occlusion was evident in 8 (1.09%) patients. Between hospital discharge and 30-day follow-up, 2 TIAs, 1 minor stroke, and 3 AMIs occurred. Therefore, the cumulative stroke rate was 0.54%. ConclusionsThis real-world registry suggests that use of CGuard embolic prevention system in clinical practice is safe and associated with a minimal occurrence of adverse neurological events up to 30-day follow-up.

Transient Retinal Ischemia During Carotid Endarterectomy Estimated by Intraoperative Visual Evoked Potential Monitoring: Technical Note

Carotid revascularization surgery is known to carry a risk of postoperative visual deterioration associated with retinal ischemia. We checked intraoperative visual evoked potential (VEP) monitoring in carotid endarterectomy (CEA). Ten consecutive patients who underwent CEA in Shinshu University Hospital under total intravenous anesthesia were checked by intraoperative VEP and electroretinogram (ERG) recording in addition to somatosensory evoked potential monitoring. Two of 10 patients presented decreased amplitude of VEP and ERG on the ipsilateral affected side by clamping the common carotid artery and persistent attenuation of VEP and ERG during external carotid artery occlusion, using an internal carotid shunt. These findings disappeared immediately after releasing the cervical carotid artery clamping. In the other 8 patients, VEP and ERG did not change throughout the surgery. Transient retinal ischemia during even brief carotid artery occlusion in the CEA procedure could be estimated by intraoperative VEP and ERG monitoring.

Results From a Prospective Real-World Multicenter Clinical Practice of CAS Using the CGuard Embolic Prevention System: The IRONGUARD 2 Study

To evaluate periprocedural, 30-day, and 12-month outcomes in a prospective series of patients submitted to protected CAS with the CGuard Embolic Prevention System (EPS). From January 2017 to June 2019 a physician-initiated prospective multispecialty, multicenter study was initiated enrolling consecutive patients admitted for protected carotid artery stenting and treated using the CGuard EPS in twelve Italian centers. Primary end points were technical and procedural success, immediate (24 hours) and postprocedural (1-30 days) major and minor stroke, transient ischemic attack (TIA), and death rates. Secondary end points were 12-month neurologic adverse events, acute myocardial infarction (AMI), and external carotid artery occlusion rates. Seven hundred thirty-three patients (73.03 ± 7.84 years of age; 516 male) were enrolled. Mean carotid stenosis was 80.13 ± 8.51% (range, 50%-99%). Symptoms were present in 131 patients (17.87%): 96 TIAs, 23 minor strokes, and 12 major strokes. An embolic protection device was used in 731 (99.72%) cases: distal filter in 593 (80.9%) and proximal occlusion in 138 (18.82%). Procedural success was 100%, technical success was achieved in all but one patient (99.86%). At 24 hours, one patient died due to a hemorrhagic conversion after urgent carotid artery stenting procedure performed for unstable symptoms. Two minor strokes, 6 TIAs, and 1 AMI occurred before hospital discharge. External carotid artery occlusion was evident in eight patients (1.09%). At 30 days, the rate of new averse cardiac and cerebrovascular adverse event was 0.81%: three new neurologic events (2 TIAs, and 1 minor stroke); and three nonfatal AMI. Therefore, up to 30 days, the cumulative rates of death and stroke were 0.13% and 0.54%, respectively. Our analysis suggests that use of the CGuard-EPS in routine clinical practice was associated with an extremely low occurrence of adverse neurologic events in a nonselected patients’ population.

Novel triple coaxial system to navigate 9French balloon guiding catheter into common carotid artery.

It is often hard to navigate a 9 French (F) balloon guiding catheter in patients with type III or bovine aortic arch. Also, a common carotid artery stenosis is challenging, because a guidewire cannot be advanced distally. We developed the combination of a 4F Simmons-type catheter and a 6F distal access catheter as a coaxial inner catheter to navigate a 9F balloon guiding catheter to overcome these difficulties. Medical record at our institution was retrospectively reviewed and carotid artery stenting cases in which the 4F Simmons-6F distal access catheter system was employed as a coaxial catheter to navigate a 9F balloon guiding catheter were identified. To construct this system, a 4F 145cm SY3 (Hanako Medical, Saitama, Japan) and a 6F 118cm Cerulean DD6 (Medikit Co. Ltd., Tokyo, Japan) were usually employed. A rotating hemostatic valve should be as short as possible and was attached to only a 9F balloon guiding catheter. The length of a 0.035-in. guidewire needed to be 180cm or longer. During the study period, 106 carotid artery stenting cases were identified. Of these, this system was employed in 29 cases that included 5 cases with a steno-occlusive lesion at common carotid artery/external carotid artery, 10 with type III or bovine arch, and 11 harboring both. In all the cases, a 9F balloon guiding catheter was successfully navigated. The 4F Simmons-6F distal access catheter system was useful in navigating a 9F balloon guiding catheter in patients with a common carotid artery stenosis, an external carotid artery occlusion, and an in-stent restenosis, especially when they also harbored type III or bovine aortic arch.

Intra-arterial in-situ bevacizumab injection effect on angiogenesis. Results on a swine angiogenesis model

Background and purposeIn this study we tested the effect of antiangiogenics on a swine angiogenesis model that shares some brain AVM histological characteristics. The objective was to determine bevacizumab effects on retia volumes and on vessels’ wall. Materials and methodsFifteen pigs were divided into 3 groups: Five animals served as controls (group A), 5 animals underwent endovascular left external and common carotid artery occlusion (group B) and 5 animals underwent the same procedure and had an intra-arterial in-situ injection of bevacizumab (groupC) 2 months after the occlusion. A DSA associated with 3D-rotational angiography was performed at day 0 and at 3 months in all groups in order to measure rete mirabile volumes. The animals were sacrificed at 3 months and the retia were harvested for pathological and immunohistochemistry examinations. ResultsAll VEGF-A receptors were blocked at the site of injection and there was a local enhanced endothelial proliferation and apoptosis. The volume of the retia remained unchanged after the bevacizumab injection. Retia vessels presented comparable media thickness, higher endothelial proliferation and apoptosis after the anti-VEGF injection. ConclusionA single in-situ injection of bevacizumab in this swine angiogenesis model showed no change in retia volume and an extensive blockage of VEGF receptors at the site of injection one month later. Rete mirabile vessels presented comparable media thickness, higher endothelial proliferation and apoptosis after the anti-VEGF injection, suggesting that bevacizumab antiangiogenic effect does not fragilize vessel wall. More studies are needed to confirm these preliminary insights of in-situ antiangiogenic effect on vascular malformations.

General vs Local Anesthesia and Completion Angiography Findings After Carotid Endarterectomy

Introduction: To assess the differences of completion angiography after carotid endarterectomy between local and general anesthetic approach. Our secondary outcomes were to evaluate the relationship between intraoperative reparations and postoperative strokes; and to assess the usefulness of external carotid reparation when it was occluded during the procedure. Methods: A prospective study from January 2003 to January 2019 was performed including 1470 consecutive patients having 1559 carotid endarterectomies. Exclusion criteria were patients with allergy to contrast media. In our cohort, the surgical technique performed was carotid endarterectomy with patch in 96,95% of cases and carotid eversion in 3,05% of patients. 42,8% of them were asymptomatic, 11,4% had a stroke and 45,8% had a transient ischemic attack. Angiography was performed on 1289 cases. Findings included stenosis of common, external or internal carotid artery, occlusion of external carotid artery and intimal flap or intraluminal filling defect on internal carotid artery. The decision to repair the defect was based on the consensus of the surgical team. Intrahospitalary stroke rate was recorded. Categorical data were analyzed by the chi-square test and continuous data were expressed as mean standard deviation, median and interquartile range. Results: Comparing both anesthetic groups, we found more angiographic defects on the general anesthetic group (236 patients (22%)) than in the local anesthetic group (35 patients (13,7%))(p = 0.001) and more shunt need (42,2% vs 23,3% p = 0,001) but it did not result in more stroke rates (2,8% vs 1,9% p = 0.57). Of those 271 defects, 174 affected the common or internal carotid artery, and 45 were suitable for reparation (26% in general anesthesia group vs 25% in local anesthesia group (p = 0.9)). Postoperative strokes were similar among patients who underwent reparation or not (0% vs 3,9% p = 0.18). We found 64 external carotid occlusions. 37 of them underwent reparation, without differences among postoperative stroke rates (3,6% vs 2,8% p = 0.85). Conclusion: Patients under general anesthesia for carotid endarterectomy have more postoperative angiographic defects, but its reparation does not seem to affect postoperative stroke rate. External carotid artery repair may not be clinically relevant. Disclosure: Nothing to disclose

Assessment of therapeutic window for poly-arginine-18D (R18D) in a P7 rat model of perinatal hypoxic-ischaemic encephalopathy.

Hypoxic-ischaemic encephalopathy (HIE) remains the leading cause of mortality and morbidity in neonates, with no available neuroprotective therapeutic agent. In the development of a therapeutic for HIE, we examined the neuroprotective efficacy of the poly-arginine peptide R18D (arginine 18 mer synthesised with D-arginine) in a perinatal model of hypoxia-ischaemia (HI; common carotid and external carotid occlusion + 8%O2 /92%N2 for 2.5hr) in the P7 Sprague-Dawley rat. R18D was administered intraperitoneally 30min (doses 10, 30, 100, 300 and 1,000nmol/kg), 60min (doses 30 and 300nmol/kg) or 120min (doses 30 and 300nmol/kg) after HI. Infarct volumes and behavioural outcomes were measured 48hr after HI. When administered 30min after HI, R18D at varying doses reduced infarct volume by 23.7% to 35.6% (p=0.009 to < 0.0001) and resulted in improvements in the negative geotactic response and wire-hang times, at a dose of 30nmol/kg. When administered 60min after HI, R18D at the 30nmol/kg dose reduced total infarct volume by 34.2% (p=0.002), whilst the 300nmol/kg dose improved wire-hang time. When administered 120min after HI, R18D at the 30 and 300nmol/kg doses had no significant impact on infarct volume, but the 300nmol/kg dose improved the negative geotactic response. This study further confirms the neuroprotective properties of poly-arginine peptides, demonstrating that R18D can reduce infarct volume and improve behavioural outcomes after HI if administered up to 60min after HI and improve behavioural outcomes up to 2hr after HI.

Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions

ObjectiveThe external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions. MethodsThis was a prospective observational study that included patients undergoing CEA for severe stenosis (≥70%) of the cervical ICA. When blood flow through the ECA measured using an electromagnetic flow meter decreased rapidly on clamping of only the ECA before carotid clamping for endarterectomy and was not changed by clamping of only the ECA after carotid declamping following endarterectomy, the patient was determined to have developed ECA occlusion. These patients underwent additional endarterectomy for the ECA. TCD monitoring in the ipsilateral middle cerebral artery was also performed throughout surgery to identify microembolic signals (MESs). Brain magnetic resonance diffusion-weighted imaging (DWI) was performed before and after surgery. ResultsThere were 104 patients enrolled in the study. Eight patients developed ECA occlusion during surgery. The incidence of intraoperative ECA occlusion was significantly higher in patients without MESs at the phase of ECA and CCA declamping (8/12 [67%]) than in those with MESs (0/92 [0%]; P < .0001). Six patients exhibited new postoperative ischemic lesions on DWI. The incidence of intraoperative ECA occlusion (P < .0001) and the absence of MESs at declamping of the ECA and CCA while clamping the ICA (P <. 0001) were significantly higher in patients with development of new postoperative ischemic lesions on DWI than in those without. Sensitivity and specificity for the absence of MESs at declamping of the ECA and CCA while clamping the ICA for predicting development of new postoperative ischemic lesions on DWI were 100% (6/6) and 94% (92/98), respectively. ConclusionsECA occlusion at declamping of the ECA and CCA while clamping the ICA during CEA is a risk factor for development of new postoperative ischemic lesions. Intraoperative TCD monitoring accurately predicts the risk for development of such lesions.

Retrograde suction decompression of a large internal carotid aneurysm using a balloon guide catheter combined with a blood-returning circuit and STA-MCA bypass: a technical note.

It is difficult to treat large internal carotid aneurysms with simple surgical clipping. Here, we present a retrograde suction decompression (RSD) procedure for large internal carotid aneurysms using a balloon guide catheter combined with a blood-returning circuit and a superficial temporal artery to middle cerebral artery (STA-MCA) bypass.All patients underwent an STA-MCA bypass before the temporary occlusion of the internal carotid artery (ICA). A 6-French sheath was inserted into the common carotid artery (CCA), and a 6-French Patrive balloon catheter was placed into the ICA 5cm past the bifurcation. Aneurysm exposure was obtained; temporary clips were placed on the proximal M1, A1, and posterior communicating (Pcom) segments; and an extension tube was then connected to the balloon catheter. A three-way stopcock was placed, and aspiration was performed through the device to collapse the aneurysm. The aspirated blood was returned to a venous line with an added heparin to prevent anemia after aspiration. During the decompression, the blood flow to the cortical area was supplied through the STA-MCA bypass. After the aneurysm collapse, the surgeon carefully dissected the perforating artery from the aneurysm dome or neck, and permanent clips were then placed on the aneurysm neck. Our procedure has several advantages, such as STA-MCA bypass without external carotid artery occlusion for preventing ischemic complications of the cortical area, anemia may be avoided because of the return of the aspirated blood, and a hybrid operation room is not required to perform this method.

Development of an angiogenesis animal model featuring brain arteriovenous malformation histological characteristics

BackgroundAngiogenesis has a key role in the formation and evolution of brain arteriovenous malformations (AVMs). Numerous models have been developed aiming to recreate configuration of brain AVMs.ObjectiveTo develop an animal...

Evaluation of cerebrovascular reserve in patients undergoing carotid artery stenting and its usefulness in predicting significant hemodynamic changes during temporary carotid occlusion.

We investigated the usefulness of cerebrovascular reserve (CVR) testing to predict severe hemodynamic changes during proximally protected carotid artery stenting. Of 90 patients referred, 63 eligible underwent complete evaluation of the extent of carotid artery disease and transcranial Doppler ultrasound (TCD) assessment of CVR by means of a breath-holding test and ophthalmic artery flow pattern evaluation. Periprocedural TCD monitoring of the ipsilateral middle cerebral artery flow was performed in 24 patients undergoing proximally protected procedure (requiring induction of flow arrest within internal carotid artery). Abnormal CVR was significantly less common in patients with unilateral compared to bilateral carotid artery disease (26.3 % vs. 76.9 %, p=0.02), while ophthalmic artery flow reversal was rare in patients with unilateral carotid artery disease (2.5 % vs. 42.9 %, p<0.01). During the induction of carotid flow arrest, the average mean flow velocity drop following external carotid artery occlusion was low (3.5 %, p=0.67) compared to the induction of complete flow arrest (32.8 %, p<0.01). Six patients had a total mean flow velocity drop >50 %, including 2 patients with normal pre-procedural CVR. Our results suggest that TCD evaluation of CVR is not a reliable predictor of hemodynamic changes induced during proximally protected carotid artery stenting in patients with unilateral carotid artery disease.

BRAIN NEURON REGENERATION IN POST-STROKE REHABILITATION TREATMENT USING GRAPE PEEL AND SEED EXTRACT (Vitis vinifera) IN INDUCING ERK1 / 2 PATHWAY

Background. Ischemic stroke can cause hypoxia in brain tissue and damage the neuron. The defense ability and plasticity is activated by ERK1/2 pathway. Grape peel and seed extract (Vitis vinifera can induce release neurotrophic factor that contribute in ERK1/2 pathway mechanism. Objective. To prove that grape peel and seed extract can regenerate neuron in anatomical and functional view. Methods. This research use true experimental design with sample in this research is 20 male 8-10 weeks old wistar strain rats which are induced stroke by internal and external carotid artery occlusion method. Results. The repairment is monitored from four parameters, namely cylinder test score, ladder rung walking test score, extensive infarct volume, and number of damaged neuron. Conclusion. The result is 50mg/KgBW is effective in repairing neuron. It is seen from the result of improvement in four parameters explained above.

Endovascular external carotid artery occlusion for brain selective targeting: a cerebrovascular swine model.

BackgroundThe choice of an animal model for cerebrovascular research is often determined by the disease subtype to be studied (e.g. ischemic stroke, hemorrhage, trauma), as well as the nature of the intervention to be tested (i.e. medical device or pharmaceutical). Many initial studies are performed in smaller animals, as they are cost-effective and their encephalic vasculature closely models that of humans. Non-human primates are also utilized when confirmation or validation is required on higher levels and to test larger devices. However, working with primates is complex and expensive. Intermediate sized animal models, such as swine and sheep, may represent a valuable compromise. Their cerebrovascular anatomy, however, comes with challenges because of the natural higher external carotid artery perfusion and the existence of a rete mirabile. We describe a modification to the traditional swine cerebrovascular model that significantly enhances selective brain hemispheric perfusion, limiting external carotid perfusion and dilution.ResultsWe investigated whether unilateral endovascular coil-embolization of external carotid artery branches in swine would lead to increased brain perfusion, altering cerebral circulation so that it more closely models human cerebral circulation. Equal amounts of approximately 4 °C cold saline were injected in 6 Yorkshire pigs into the ipsilateral common carotid artery before and after embolization. Hemispheric temperature changes from pre- and post-embolization were obtained as a measure of brain perfusion and averaged and compared using non-parametric statistical tests (Wilcoxon signed rank test, Mann–Whitney U Test). Graphs were plotted with absolute changes in hemispheric temperature over time to determine peak temperature drop (PTD) and corresponding time to peak (TTP) following the cold bolus injection. There was a 288 ± 90 % increase in ipsilateral brain cooling after embolization indicating improved selective blood flow to the brain due to this vascular modification.ConclusionWe have developed an effective, selective vascular brain model in swine that may be useful as a practical and cost-reducing intermediate step for evaluating target dose–responses for central nervous system drugs and brain selective interventions, such as local hypothermia.Electronic supplementary materialThe online version of this article (doi:10.1186/s13104-015-1714-7) contains supplementary material, which is available to authorized users.