Extracranial Internal Carotid Research Articles

Extracranial Internal Carotid and Vertebral Dissecting Pseudoaneurysms: Clinical Features and Long‐Term Outcomes

Background The formation of dissecting pseudoaneurysms (dPSAs) is a common sequela of cervical artery dissection, which has been suggested to increase thrombotic risk in previous studies. This study reported clinical features and long‐term outcomes of cervical internal carotid (cICA) and vertebral artery (cVA) dPSAs. Methods We performed a retrospective chart review over a 10‐year period (January 2012–December 2021). Baseline demographics and clinical characteristics, medical and endovascular treatments, and long‐term outcomes were reported for cICA and cVA dPSA groups separately. Nonparametric tests were used to compare group differences. Results In our cohort, 120 (12%) of 999 cervical artery dissection patients had dPSA, with 85% occurring in the cICA and 15% in the cVA. Most dPSAs occurred spontaneously or in association with minor trauma. Compared with cICA dPSA, patients with cVA dPSA were younger (median age [range]=34.5 [24–70] versus 52 [30–77]; P <0.01), had a smaller dPSA size (median size [range]=4.5 mm [2–17] versus 8 mm [1.2–32]; P <0.01), and were more likely to reduce in size at follow‐up (median size change [range]=−2.8 mm [−17;0] versus 0 [−24;10.8]). Antithrombotic therapy was predominately aspirin monotherapy. No patients with cVA dPSA experienced recurrent strokes and only 3% of patients with cICA dPSA developed new/recurrent stroke in the territory of dPSA while on an antithrombotic regimen requiring endovascular intervention, and none of the dPSAs ruptured. A total of 98% of the patients had an excellent outcome (modified Rankin scale 0–2 at final follow‐up). Conclusion Most cICA and cVA dPSAs have a benign prognosis with medical therapy alone. Further prospective randomized clinical trials are needed to provide high quality evidence on the necessity of additional endovascular therapy at diagnosis in addition to medical therapy alone.

"Doppler Flow Velocity Measurements in the Extracranial Internal Carotid and Vertebral Arteries in Healthy Adults"

Objective: To analyze normal hemodynamics in the extracranial part of the internal carotid arteries (ICA) and vertebral arteries (VA) with reference to age and gender. Methods: Angle-corrected flow velocities (peak-systolic velocity, PSV and end-diastolic velocity, EDV) and VA diameter were measured, and waveform parameters calculated (pulsatility index, PI and resistive index, RI) on 227 healthy adults (125 women). Results: Except for a slight increase of PSV in the left VA in men, and wider left VA diameter in both genders, there were no clinically significant side-to-side differences in the investigated parameters. In 10-year periods, expected decreases in PSV ICA, EDV ICA, PSV VA, and EDV VA were 3-3.7, 2.2-2.8, 0.6-1.5, and 0.7-1 cm/s, respectively while expected increases in RI ICA, PI ICA, RI VA, PI VA, and VA diameter were small, in a range of 0.01-0.07. Average velocities were higher in women up to 60 years on both sides in ICA and VA. In the women, expected values of PSV ICA, EDV ICA, PSV VA, and EDV VA were 5.9-6.2, 1.9-2.2, 2.1-4.3, and 1 cm/s, respectively, i.e., higher than in the men. PI and RI showed no association with gender. Measurements showed that PSV ICA, EDV ICA, PSV VA, and EDV VA ranged 40-108, 10-39, 24-63, 2-22 cm/s in women and 35-114, 7-36, 24-66, and 5-18 cm/s in men, respectively. RI ICA, PI ICA, RI VA, PI VA, and VA diameter were in the ranges 0.5-0.8, 0.9-1.9, 0.6-21, 1.1-24, and 1.4-4.9 in women; 0.5-0.9, 0.8-2.1, 0.6-0.9, 1.1-2 mm, and 2.1-5.3 mm in men, respectively. Conclusion: Velocity was higher in the women up to 60 years. In older age groups the flow rates equalized in both genders. EDV ICA decreased with age in both genders. PSV ICA showed a declining trend only in women. RIs and PIs showed a slight tendency to increase with age in both genders. In the vertebral arteries, a slight tendency to decreased flow velocities with age was seen mostly in EDV in both genders, whereas PSV showed decline and diameter increase only in women.

Continuous Intraarterial Nimodipine Infusion for the Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Retrospective, Single-Center Cohort Trial

BackgroundDelayed cerebral ischemia (DCI) occurs after aneurysmal subarachnoid hemorrhage (aSAH). Continuous intraarterial nimodipine infusion (CIAN) is a promising approach in patients with intracranial large vessel vasospasm (LVV). The objective of this retrospective single-center cohort study was to evaluate the outcome in aSAH-patients treated with CIAN.MethodsCIAN was initiated and ended based on the clinical evaluation and transcranial Doppler (TCD), CT-angiography, CT-perfusion (PCT), and digital subtraction angiography (DSA). Nimodipine (0.5–2.0 mg/h) was administered continuously through microcatheters placed in the extracranial internal carotid and/or vertebral artery. Primary outcome measures were Glasgow Outcome Scale (GOS) at discharge and within 1 year after aSAH, and the occurrence of minor and major (<⅓ and >⅓ of LVV-affected territory) DCI-related infarctions in subsequent CT/MRI-scans. Secondary outcome measures were CIAN-associated complications.ResultsA total of 17 patients underwent CIAN. Median onset of CIAN was 9 (3–13) days after aSAH, median duration was 5 (1–13) days. A favorable outcome (GOS 4–5) was achieved in 9 patients (53%) at discharge and in 13 patients within 1 year (76%). One patient died of posthemorrhagic cerebral edema. Minor cerebral infarctions occurred in five and major infarctions in three patients. One patient developed cerebral edema possibly due to CIAN. Normalization of PCT-parameters within 2 days was observed in 9/17 patients. Six patients showed clinical response and thus did not require PCT imaging.ConclusionThe favorable outcome in 76% of patients after 1 year is in line with previous studies. CIAN thus may be used to treat patients with severe therapy-refractory DCI.

Hybrid interventions for tandem occlusions in acute phase of ischemic stroke

To evaluate the effectiveness of hybrid interventions, i.e. endovascular mechanical thrombectomy from intracranial arteries combined with open thrombectomy or carotid endarterectomy from extracranial internal carotid artery. We analyzed 16 patients who underwent mechanical thrombectomy/thrombaspiration combined with open surgery between January 2014 and March 2021. All patients had occlusion of extracranial and intracranial segments internal carotid artery or initial segments of the middle cerebral artery. Baseline data, diagnostic algorithm, timing and results of treatment were analyzed. Study endpoints were technical success of revascularization, clinically significant hemorrhagic transformation, NIHSS and modified Rankin score of neurological impairment, as well as outcome of disease within 90 days. We restored patency of ICA and intracranial arteries in 13 out of 16 patients. In 9 patients, we obtained a positive effect with significant regression of neurological symptoms (mRS <2). In 3 patients, severe neurological deficit persisted throughout the entire follow-up period. Four patients died. Thus, effectiveness of technique was 56.2% (t=3), mortality rate was 25% (t=2.3). There was a relationship between the timing of interventions and outcomes of disease. Indeed, all dead and most of disabled patients underwent surgery later than 6 hours from the onset of disease. Hybrid interventions for tandem occlusions of carotid arteries can significantly increase efficiency and accelerate recanalization of great extracranial vessels in patients with tandem lesions in acute phase of ischemic stroke. Moreover, hybrid interventions significantly reduce the cost of reperfusion procedure. In case of severe atherosclerotic stenosis, simultaneous open endarterectomy from common and internal carotid arteries has a significant advantage over stenting due to no need for antithrombotic therapy.

Sex differences in intracranial and extracranial atherosclerosis in patients with acute ischemic stroke.

Background and aimTo investigate sex differences with respect to presence and location of atherosclerosis in acute ischemic stroke patients.MethodsParticipants with acute ischemic stroke were included from the Dutch acute stroke trial, a large prospective multicenter cohort study performed between May 2009 and August 2013. All patients received computed tomography/computed tomography-angiography within 9 h of stroke onset. We assessed presence of atherosclerosis in the intra- and extracranial internal carotid and vertebrobasilar arteries. In addition, we determined the burden of intracranial atherosclerosis by quantifying internal carotid and vertebrobasilar artery calcifications, resulting in calcium volumes. Prevalence ratios between women and men were calculated with Poisson regression analysis and adjusted prevalence ratio for potential confounders (age, hypertension, hyperlipidemia, diabetes, smoking, and alcohol use).ResultsWe included 1397 patients with a mean age of 67 years, of whom 600 (43%) were women. Presence of atherosclerosis in intracranial vessel segments was found as frequently in women as in men (71% versus 72%, adjusted prevalence ratio 0.95; 95% CI 0.89–1.01). In addition, intracranial calcification volume did not differ between women and men in both intracranial internal carotid (large burden 35% versus 33%, adjusted prevalence ratio 0.93; 95% CI 0.73–1.19) and vertebrobasilar arteries (large burden 26% versus 40%, adjusted prevalence ratio 0.69; 95% CI 0.41–1.12). Extracranial atherosclerosis was less common in women than in men (74% versus 81%, adjusted prevalence ratio 0.86; 95% CI 0.81–0.92).ConclusionsIn patients with acute ischemic stroke the prevalence of intracranial atherosclerosis does not differ between women and men, while extracranial atherosclerosis is less often present in women compared with men.

Prognosis of Tandem Occlusions versus Isolated Intracranial Occlusions

BackgroundBoth acute single intracranial and tandem occlusions are managed with intravascular thrombectomy with success, but little evidence exists about the differences in their mid-term outcome. We aim to compare the outcome at 3 months after tandem (extracranial internal carotid and/or middle cerebral artery) and single intracranial (M1 division) occlusions, and to identify the factors, which determine such prognosis. MethodsA total of 66 patients (33 with tandem and 33 with singleM1 occlusions) who underwent emergent intravascular therapy in our center between November of 2013 and November of 2016 were collected. Patients’ medical histories were reviewed for clinical and radiological variables. A modified Rankin Scale of 3 or more was considered as bad outcome. An interobserver concordance analysis evaluated the quality of collaterals in the initial computed tomography through the Maas, Miteff, and CGS (collateral grading scale) scales. ResultsNo differences were found in theprognosis of tandem versus single M1 occlusions (P = .30). The kappa index for the Maas scale was .77 (95% confidence interval [CI] .59-.94) and bad collaterals were defined by a score of 1 or 2. The factors independently associated with a worse prognosis were the presence of bad collaterals (adjusted odds ratio [OR] 6.03, 95% CI 1.01-35.9, P = .048) and an incomplete revascularization (adjusted OR 6.01, 95% CI 1.01-35.7, p = .049). ConclusionsThe outcome of patients with acute stroke secondary to tandem or M1 occlusions has not been found to depend on their localization. The bad quality of collaterals is the main factor related to an unfavorable prognosis.

Coexistent Ipsilateral Internal Carotid Artery Occlusion and Cerebral Venous Thrombosis in Hepatitis C.

A 58-year-old male, known to have hepatitis C virus (HCV), presented with intermittent headaches and left-sided sensorimotor symptoms. There were no focal neurological deficits on examination. Electrocardiogram was unremarkable. Computed tomography angiography head and neck displayed extracranial right internal carotid artery occlusion. Magnetic resonance imaging showed right cortical vein thrombosis, with hemorrhagic infarction. Echocardiography with bubble study was unremarkable. Hypercoagulable workup was significant for protein S deficiency. He was treated with warfarin for 6 months. Repeat protein S levels remained low 9 months later. The coexistence of arterial and venous thrombotic events gives rise to a limited differential. In this case, it may be related to chronic HCV infection. The underlying pathogenesis is not clear; however, it is possible the patient had chronic high-grade internal carotid artery stenosis, which occluded leading to his presenting symptoms. The cortical vein thrombosis is likely an incidental finding here. The extent by which HCV contributed to the cerebral thrombosis and carotid artery occlusion in our case is not clear; however, the hypercoagulable and atherosclerotic properties of the virus cannot be disregarded. The virus can promote carotid atherosclerosis and cerebral venous thrombosis as well as other venous and arterial thromboembolic events. Furthermore, HCV is associated with impaired venous flow and procoagulant properties, which can fuel a hypercoagulable state. Also of note cirrhosis is associated with protein S deficiency. We recommend considering an underlying hypercoagulable state including both arterial and venous thrombosis in HCV infection.

Quantitative Analysis of Extracranial Arterial Tortuosity in Patients with Sickle Cell Disease

Compared to the intracranial vasculature in sickle cell disease (SCD) patients, the morphologic changes of the extracranial vasculature in SCD patients are less well understood. The purpose of this study was to evaluate the tortuosity of the extracranial carotid and vertebral arteries in patients with SCD compared to age-matched controls. Following Institution Review Board approval, between January 2004 and December 2013, Magnetic resonance angiogram neck examinations were retrospectively reviewed on 56 patients with SCD and 56 age-matched controls. Vessel tortuosity was measured as curved vector lengths in the common carotid, extracranial internal carotid, and vertebral arteries bilaterally. Correlation of vessel tortuosity with age and hematocrit level was assessed. Paired and unpaired Student's t-tests were performed to determine within and between group differences. Greater tortuosity in extracranial carotid and vertebral arteries were noted in patients with SCD as compared to age-matched control patients (P < .001). Greater differences in tortuosity between carotid and vertebral arteries were noted in SCD patients as compared to differences in control patients. Incidence of infarction was significantly associated with greater tortuosity of right carotid (P = .002), right (P = .004), and left (P = .020) vertebral arteries. Extracranial carotid and vertebral arterial tortuosity is increased in SCD patients. This could be related to aberrations in hemodynamics from nonlaminar flow in these vessels. These increases in extracranial vascular tortuosity could potentially lead to alterations in intracranial vascular tortuosity and may be an independent risk factor for cerebral infarct.

Cerebral blood flow indices in children and adolescents with hypertension and metabolic syndrome

A total of 141 patients aged 10 to 17 years were examined. Doppler ultrasonography was carried out to assess blood flow in the intracranial (basilar and middle cerebral arteries) and extracranial (common and internal carotid arteries, vertebral arteries) cerebral arteries and cerebral vein (tentorial venous sinus) and the velocity characteristics of the flow and the level of peripheral vascular resistance were analyzed in all the children. Normal weight children with stable hypertension were found to have high peripheral vascular resistance in the beds of intracranial (basilar and right middle cerebral arteries) and extracranial arteries with the phenomena of hyperperfusion in the bed of the common carotid artery. Obese children having different stages of hypertension were, on the contrary, observed to have lowered peripheral resistance in the intracranial arteries and increased peak systolic blood flow velocity in the tentorial venous sinus. The found cerebral hemodynamic differences may suggest that obese children have secondary hypertension.

Estimación de valores hemodinámicos mediante el uso del doppler transcraneal en un grupo de voluntarios habitantes de Cali (Colombia), una ciudad a 995 m sobre el nivel del mar

Transcranial doppler measures the velocity of blood flow in cerebral arteries and the pulsatility index for each artery. The aim of this study was to determine the hemodynamic behaviour in a city located 995 m above sea level, and its association with gender, age and body mass index. The test was performed by an expert on a group of volunteers with no cerebrovascular disease.The study was performed on 51 volunteers (24 men, mean age 46.2 years, and 27 women, mean age: 48.5 years, standard deviation 6.2 years). There were insufficient readings in 6 participants due to an inadequate acoustic window. Statistical differences (P<.01) in the arteries of the left region of the middle cerebral arteries (P<.01), anterior cerebral (P<.1), and extracranial internal carotid (P<.01) suggest the need for gender differentiation among participants. A slower blood flow in male participants compared to female participants is associated with age (P<.05).While the value of the mean in some results is suggestive of a difference between groups, the standard deviations are wide, thus this difference does not have enough power to be considered. Future studies are suggested with a larger number of participants.

Viability of anastomoses with coupler in extra-intracranial bypass: cadaveric study.

The time required to perform an anastomosis in extra-intracranial bypass is approximately 20 to 60 minutes. The search for alternative methods to reduce the ischemic time remains vital. To evaluate Coupler anastomosis for extra-intracranial bypass in cadavers. In 8 fresh adult cadavers, the saphenous vein and radial artery were used as donor vessels. The superficial temporal and the extracranial internal and external carotid arteries were dissected. A wide craniotomy with a sylvian fissure opening was performed, exposing the middle cerebral and supraclinoid internal carotid arteries. The Coupler devices were tested in all 8 cadavers. The diameter of the donor and recipient vessels as well as the time required to perform the anastomosis were measured. Bypass permeability was evaluated by injecting saline solution under pressure, checking for leaks. The anastomoses were successfully performed in all specimens. The size of the head of the fitting Coupler required the performance of a wide craniotomy (6 × 6 cm) and a wide opening of the sylvian fissure. The time required to perform each anastomosis ranged from 4 to 7 minutes, being easier with the radial artery than with the saphenous vein. Coupler devices are helpful to perform the anastomoses, because they significantly reduce ischemia time. Their use is easier at the M1 segment, just before the bifurcation and after takeoff of the lenticulostriate arteries, and in the M2 segment. It would be advisable to have a smaller coupling system, allowing maneuverability in the deeper areas where space is limited.

The effect of sumatriptan on cephalic arteries: A 3T MR-angiography study in healthy volunteers

To explore a possible differential effect of sumatriptan on extracerebral versus cerebral arteries, we examined the superficial temporal (STA), middle meningeal (MMA), extracranial internal carotid (ICAextra), intracranial internal carotid (ICAintra), middle cerebral (MCA) and basilar arteries (BA). The arterial circumferences were recorded blindly using high-resolution magnetic resonance angiography before and after subcutaneous sumatriptan injection (6 mg) in 18 healthy volunteers. We found significant constrictions of MMA (16.5%), STA (16.4%) and ICAextra (15.2%) ( P ≤ 0.001). Smaller, but statistically significant, constrictions were seen in MCA (5.5%) and BA (2.1%) ( P ≤ 0.012). ICAintra change 1.8% was not significant ( P = 0.179). The constriction of cerebral arteries was significantly smaller than the constriction of extracerebral arteries ( P < 0.000001). Sumatriptan constricts extracerebral arteries more than cerebral arteries. We suggest that sumatriptan may exert its anti-migraine action outside of the blood-brain barrier.

Benefits of Intravenous Thrombolysis in Acute Ischemic Stroke Related to Extra Cranial Internal Carotid Dissection. Dream or Reality?

Small clinical series have reported the safety of intravenous thrombolysis in ischemic stroke related to extracranial internal carotid dissection. However, no studies specifically analyzing the effects on stroke outcome are available. Aims Our goal was to evaluate whether patients with ischemic stroke related to extracranial internal carotid dissection obtain any benefit from intravenous thrombolysis. Multicenter, prospective and observational study conducted in four university hospitals from the Madrid Stroke Network. Consecutive ischemic stroke patients who received intravenous thrombolysis were included, as well as patients with extracranial internal carotid dissection regardless of intravenous thrombolysis treatment. Stroke severity (NIHSS) and three-month outcome (modified Rankin Scale) were compared between the following groups: (1) intravenous thrombolysis-treated patients with ischemic stroke related to extracranial internal carotid dissection vs. other causes of stroke; (2) intravenous thrombolysis-treated extracranial internal carotid dissection patients vs. nonintravenous thrombolysis treated. Outcome was rated at three-months using the modified Rankin Scale. A good outcome was defined as a modified Rankin Scale score ≤2. A total of 625 intravenous thrombolysis-treated patients were included; 16 (2·56%) had extracranial internal carotid dissection. Besides, 27 patients with extracranial internal carotid dissection and ischemic stroke who did not receive intravenous thrombolysis were also included. As compared with other etiologies, patients with extracranial internal carotid dissection were younger, had similar stroke severity and showed less improvement in their NIHSS score at Day 7 (1·38; (95% CI -3·77 to 6·54) vs. 6·81; (95% CI -5·99 to 7·63) P=0·004), but without differences in good outcomes at three-months (43·8% vs. 58·2%; NS). Extracranial internal carotid dissection intravenous thrombolysis-treated patients had more severe strokes at admission than those who were nonintravenous thrombolysis treated (median NIHSS: 15 vs. 7; P=0·031). Intravenous thrombolysis was safe in extracranial internal carotid dissection with no symptomatic hemorrhagic events; however, without differences in good outcome compared with the natural course of extracranial internal carotid dissection (nonintravenous thrombolysis treated) after adjustment for stroke severity (46·7% vs. 64·3%; NS). As compared with other etiologies, stroke due to extracranial internal carotid dissection seems to obtain similar benefits from intravenous thrombolysis in outcome at three-months. Although intravenous thrombolysis is safe in stroke attributable to extracranial internal carotid dissection, no differences in outcome were found when comparing intravenous thrombolysis treated with nonintravenous thrombolysis-treated patients, even after adjustment for stroke severity.

Endovascular treatment of bilateral internal carotid artery aneurysm

BACKGROUND: Aneurysms of the extra cranial internal carotid artery (ICA) are rare and caused by infection, arteriosclerosis, fibro muscular dysplasia, neurofibromatosis, Behcet disease, Ehlers-Danlos syndrome, radiotherapy, iatrogenic injury or trauma. Increasing number of high-risk patients and more accurate diagnosing of unapproachable lesions make the consideration of endovascular treatment more acceptable. METHODS: We are reporting a case of a 36-year-old male with bilateral aneurysms of ICA and a history of several transitory ischemic attacks. Bilateral successive implantation of a 19 mm long covered stent (Jostent) was performed, with a delay of one month between the two procedures. After exclusion of the right ICA with covered stent, patient developed transitory ischemic attack and control multi detector computed tomography revealed occlusion of the left ICA. RESULTS: Further recovery of the patient was uneventful and a control examination after 2 years show patent right ICA, occluded left ICA with no clinical consequences. CONCLUSIONS: Patients with recurrent symptoms associated with extra cranial aneurysm need prompt treatment. Surgical resection with various reconstruction techniques is established method. Endovascular exclusion by covered stent in surgically unapproachable aneurysms is feasible; however, there is still need for more technical improvement and experience before it becomes preferable treatment option.

Cognitive dysfunction in patients with asymptomatic ischaemic disturbances of the cerebral circulation and carotid stenosis

BACKGROUND: Impairment of cognitive function is often present in patients with carotid artery stenosis but the details of this dysfunction have rarely been reported. Our purpose was to elucidate the cognitive dysfunction in patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and unilateral asymptomatic severe carotid stenosis using comprehensive neuropsychological testing, and also to identify the specific underlying clinical and neuroimaging factors. METHODS: We analyzed the results of neuropsychological testing, the clinical history, and MR findings in 10 patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and severe (70-99%) stenosis of the extra cranial internal carotid artery (ICA) on Doppler sonography. Cognitive functions were examined. We excluded patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation with contra lateral ICA occlusion or severe stenosis. RESULTS: Our neuropsychological testing revealed obvious cognitive deficits in all patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and unilateral asymptomatic severe ICA stenosis. The mean cognitive score on the memory test was also significantly lower in patients with asymptomatic ICA stenosis and score 3 lesions on MRI than in asymptomatic patients and lesions score 1 on MRI (p<0.05). CONCLUSIONS: Cognitive deficits are common in patients with Asymptomatic Ischaemic Disturbances of the Cerebral Circulation and unilateral asymptomatic severe ICA stenosis. Our findings suggest that an additional mechanism beyond the structural lesion such as chronic hypoperfusion may affect cognitive function in patients with high-grade ICA stenosis.

Listening to the diagnosis: a physician’s account of spontaneous carotid artery dissection

A healthy 52-year-old male (J.L.A.) experienced a right pulsatile tinnitus (PT). It was synchronous with cardiac systole, was noticed initially at night, and became objectively audible. Valsalva’s maneuver markedly diminished its intensity. There were no previous trauma, otalgia, hypoacusis, fever, nasal congestion, cough, headache or any neurological symptom. Arterial pressure, ECG, chest X-ray, neuro-otological examination, otoscopy, audiometric testing, tympanometry and cerebral magnetic resonance (MR) imaging were unrevealing. A cerebral magnetic resonance angiography (MRA) raised the suspicion of a possible dissection of an extracranial right internal carotid artery (ICA) near the skull base. Subsequently, a cervical CT angiography (CTA) and a cervical MR angiography (MRA) yielded the diagnosis of right steno-occlusive (less than 50% luminal stenosis) ICA dissection, extending from 1 cm above the carotid bulb to the cranial base, ending just proximal to the petrous carotid canal. The dissection was associated with a medium-sized saccular pseudoaneurysm located near the skull base—C1-C2 level. Digital subtraction angiography (DSA) confirmed the diagnosis and showed bilateral fibromuscular dysplasia of carotid arteries as the cause of the dissection (Fig. 1). No intravascular intervention (i.e., stenting) was considered necessary due to the high location of the pseudoaneurysm and the lack of neurological symptoms. Treatment with intravenous heparin was followed by aspirin. Tinnitus gradually disappeared in 4 days. At follow-up, CT demonstrated resolution of the luminal stenosis and thrombosis of the false lumen, although the pseudoaneurysm remained unchanged.

Systemic Hypertension and Transient Ischemic Attack in a 6-Year-Old Girl with Fibromuscular Dysplasia Treated with Percutaneous Angioplasty

We describe a 6-year-old girl with arterial hypertension secondary to fibromuscular dysplasia with stenoses of both renal arteries and transient ischemic attack due to extracranial right internal carotid artery subtotal occlusion as well as left internal carotid artery stenosis. She was treated with percutaneous angioplasty of both renal and both carotid arteries.

ステント留置術により血栓化・治癒に至った頸動脈狭窄を合併する頭蓋外巨大内頸動脈瘤の１例

【目的】動脈瘤の増大に伴って脳虚血症状を呈した頭蓋外内頸動脈瘤の症例を報告する．【症例】症例は73歳男性，嗄声と頸部拍動性腫瘤にて発症した．左側の総頸動脈分岐部に長径35mm大の嚢状動脈瘤と，同側内頸動脈に高度狭窄を認めた．動脈瘤の増大とともに同側頸動脈領域の脳虚血症状が進行したため，内頸動脈の狭窄部および動脈瘤の入口部をカバーするようにステントを留置した．ステント留置直後には動脈瘤内の血流は残存していたが，数週間の経過で頸部の拍動性腫瘤は縮小していき，術後３ヵ月目に行われた血管撮影で頸部動脈瘤の血栓化・血管撮影上治癒が確認された．【結論】ステント留置による動脈瘤内の血流動態の変化が動脈瘤を治癒に導いたと推察された．

Response to Letter by Menon and Norris

HomeStrokeVol. 38, No. 5Response to Letter by Menon and Norris Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Letter by Menon and Norris Wibke G. Janzarik Peter A. Ringleb Matthias Reinhard and Sebastian Rauer Wibke G. JanzarikWibke G. Janzarik Department of Neurology, University of Freiburg, Freiburg, Germany Search for more papers by this author Peter A. RinglebPeter A. Ringleb Department of Neurology, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany Search for more papers by this author Matthias ReinhardMatthias Reinhard Department of Neurology, University of Freiburg, Freiburg, Germany Search for more papers by this author and Sebastian RauerSebastian Rauer Department of Neurology, University of Freiburg, Freiburg, Germany Search for more papers by this author Originally published15 Mar 2007https://doi.org/10.1161/STROKEAHA.106.480202Stroke. 2007;38:e17Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 15, 2007: Previous Version 1 Response:Norris and Menon suspect that both patients whom we reported to have recurrent vasospasms of the internal carotid artery1 were likely to have carotid artery dissection (CAD). In fact, CAD had been the initial diagnosis in both patients. There were, however, several findings which could not be explained in the context of CAD and led us to the assumption of internal carotid artery vasospasm.We agree that MRI with MR angiography is sensitive in the diagnosis of CAD. Ultrasound detects dissection mainly by its hemodynamic sequelae than by depiction of the vessel wall hematoma itself, particularly in submandibular dissection. It may thus not consistently differentiate between vasospasm and dissection in case of poor insonation conditions. In both of our patients, T1-fat–suppressed MRI (several times in patient 1, once during the course of repeated high-grade stenoses in patient 2) had been performed. However, no wall hematoma was detected in MRI2 or in repeated sonographic examinations with insonation conditions allowing clear depiction of the vessel wall. The possibility to perform repeated sonographic examinations as a noninvasive monitoring with detection of recurrent high-grade stenoses gave the ultrasound method a high impact during the clinical course of our patients.In both patients we observed repeated changes in severity and side of stenosis within days. A resolution of CAD within 2 days from high-grade stenosis to no stenosis, which implies the rapid reabsorption of a considerable carotid wall hematoma, is not very plausible. Moreover, recurrence of arterial dissection in the same vessel is rare.3 In addition, we documented a regression of a high-grade internal carotid artery stenosis during intraarterial infusion of papaverine which cannot be explained by CAD.Migraine is a moderate risk factor for CAD.4 On the other hand, migraine is known to go along with vasospasms.5 In 1 of our 2 patients, migrainous headaches had occurred for several years. They were clearly associated with the recurrent vasospasms. We therefore suggest that in this patient recurrent vasospasms had regularly occurred long before the ischemic event. We do not know whether vasospasms occurred during a migraine attack or whether the pulsatile headaches were secondary to vasospasm.In both patients we observed no stabilization of the vascular situation for several weeks, and the patients were repeatedly at high risk for new ischemic events. Both patients received antithrombotic therapy to prevent thromboembolic complications—the same rationale is used to justify antithrombotic treatment in CAD. This modus operandi in CAD has not yet been investigated in a randomized trial.6 Assuming that the observed high-grade stenoses of internal carotid artery were caused by vasospasms, we additionally initiated an antivasospastic treatment as well as, in patient 2, an antiphlogistic treatment.DisclosuresNone.1 Janzarik WG, Ringleb PA, Reinhard M, Rauer S. Recurrent extracranial carotid artery vasospasms: report of 2 cases. Stroke. 2006; 37: 2170–2173.LinkGoogle Scholar2 Ozdoba C, Sturzenegger M, Schroth G. Internal carotid artery dissection: MR imaging features and clinical-radiologic correlation. Radiology. 1996; 199: 191–198.CrossrefMedlineGoogle Scholar3 Pelkonen O, Tikkakoski T, Leinonen S, Pyhtinen J, Lepojarvi M, Sotaniemi, K. Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course and prognosis. Neuroradiology. 2003; 45: 71–77.CrossrefMedlineGoogle Scholar4 Pezzini A, Granella F, Grassi M, Bertolino C, Del Zotto E, Immovilli P, Bazzoli E, Padovani A, Zanferrari C. History of migraine and the risk of spontaneous cervical artery dissection. Cephalalgia. 2005; 25: 575–580.CrossrefMedlineGoogle Scholar5 Rothrock JF, Walicke P, Swenson MR, Lyden PD, Logan WR. Migrainous stroke. Arch Neurol. 1988; 45: 63–67.CrossrefMedlineGoogle Scholar6 Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Stroke. 2004; 35: 613–614.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2007Vol 38, Issue 5 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.106.480202 Originally publishedMarch 15, 2007 PDF download Advertisement

Extracranial Carotid and Vertebral Artery Ultrasonography: Resistive Indices for Diagnosing Cerebral Brain Death

Introduction —Transcranial Doppler (TCD) has been used to document blood flow indicative of patients who are clinically brain dead. Limitations of TCD include signal loss in the absence of an adequate acoustic window, or extensive craniotomies that interfere with TCD insonation. Additionally, when compared with duplex ultrasonography of extracranial carotid and vertebral arteries, TCD is more technically difficult to master, with limited availability in many institutions. Objective —We sought to evaluate the use of carotid and vertebral artery ultrasound resistive indices in patients with clinically diagnosed brain death. Methods —Standard carotid and vertebral duplex ultrasound protocol was used to evaluate extracranial arteries in 2 groups: I: 8 control subjects, mean age of 49 years, without evidence of carotid or vertebral atherosclerosis, and II: 8 patients, mean age of 48 years, diagnosed with brain death confirmed by electroencephalography. All patients had insignificant (&lt; 50% stenosis) carotid and vertebral atherosclerosis. T-test was used to compare common carotid, internal carotid (ICA), external carotid, and vertebral (VERT) artery resistive indices between Groups I and II. Results —Common carotid (0.74 ± 0.04 vs. 0.88 ± 0.08), ICA (0.60 ± 0.06 vs. 1.00 ± 0.00), and VERT (0.61 ± 0.05 vs. 1.00 ± 0.00) artery resistive indices were significantly lower in normal subjects than in brain death patients ( p &lt; 0.05). Both ICA and VERT waveforms in brain death patients demonstrated the oscillatory, “to-and-fro,” pattern already established with TCD. Conclusion —Extracranial ICA and VERT waveforms in patients diagnosed with clinical brain death have the same resistive indices and waveform patterns that have been used to identify brain death intracranially with TCD. Because standard duplex ultrasonography is the most commonly used noninvasive modality for cerebrovascular evaluation, we believe this method may be easier to understand and more readily available for the initial diagnosis of cerebral brain death.