Origin Of Internal Carotid Artery Research Articles

Impact on hemodynamics in carotid arteries with carotid webs at different locations: A Numerical Study Integrating Thrombus Growth Model

ObjectiveCarotid webs (CWs), lesions in the carotid arteries, are gaining research interest due to the unclear link to ischemic stroke. Similarity to atherosclerosis in lesion location adds the complexity. The main purpose of study is to investigate the hemodynamic effects of CWs at different locations in carotid arteries. MethodsThree types of models with CWs were reconstructed from the CTA dataset of 8 healthy carotid arteries (Models A: CWs at the common carotid artery; B: at the origin of internal carotid artery; C: at the carotid sinus). Wall shear stress (WSS)-based parameters, including time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and endothelial cell activation potential (ECAP) were analyzed. A thrombus growth model was also incorporated to assess long-term thrombus formation across different carotid webs locations. ResultsModels A exhibited helical flow, whereas models B and C showed disturbed flow in the carotid sinus. Recirculation in Models A and B was mainly downstream of CWs, while Models C had both upstream and downstream recirculation. In addition, models A had higher overall TAWSS levels, with the smallest region of TAWSS < 0.4 pa (7.78 ± 8.35%). In contrast, Models C had larger areas with TAWSS < 0.4 pa, RRT > 100, and ECAP > 1.5, accounting for 14.18 ± 5.28%, 1.51 ± 1.17%, and 10.36 ± 4.10%, respectively. Noting that thrombus volume was highest in Models C (7.20 ± 3.95%). ConclusionsNumerical simulations indicate that: 1) CWs have less hemodynamic impact when located in the CCA, but may increase flow resistance leading to distal branch ischemia; 2) CWs contribute to thrombus formation, primarily downstream in the common carotid artery and internal carotid artery origin, and both upstream and downstream in the sinus; 3) CWs at the origin of the ICA are more likely to result in disturbed blood flow patterns and thrombus aggregation than the other two locations, which may increase the risk of ischemic stroke in distal cerebral arteries.

Evaluation of ocular blood flow in the assessment of symptomatic carotid stenosis.

The degree of internal carotid artery (ICA) stenosis determined by criteria from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) is not the most accurate index to assess distal flow compromise. Distal ICA perfusion is also determined by factors such as tandem carotid stenosis and collateral circulation. Quantification of end-organ ocular perfusion using non-invasive laser speckle flowgraphy (LSFG) may provide insights into distal ICA flow. This study prospectively assessed the degree of ICA flow using LSFG. Eighteen patients with symptomatic carotid stenosis underwent LSFG evaluation. LSFG was used to extract ocular blood flow metrics recorded simultaneously in the retina, choroid, and optic nerve head. The following ocular flow parameters were measured with LSFG: mean blur rate (MBR), flow acceleration index (FAI), and rising rate (RR). Syngo iFlow perfusion imaging was used to objectively quantify contrast flow in the ICA and brain parenchyma during digital subtraction angiography. Time to peak (TTP) and contrast delay were extracted from seven different regions of interest (ROIs). MBR, FAI, and RR were correlated with NASCET degree of stenosis. FAI and RR also improved after stenting. TTP improved after stenting in three ROIs. A moderate negative correlation was observed between FAI and contrast delay. LSFG non-invasively quantifies end-organ blood flow distal to the ICA origin. LSFG metrics have the potential to quantify end-organ perfusion and determine if a proximal carotid stenosis is symptomatic.

Vertical Levels of the Occipital Artery Origin

Background and Objectives. The occipital artery (OA) is a posterior branch of the external carotid artery (ECA). The origin of the OA is commonly referred to a single landmark. We hypothesized that the origin of the OA could be variable as referred to the hyoid bone and the gonial angle. We thus aimed at patterning the vertical topographic possibilities of the OA origin. Materials and Methods. One hundred archived computed tomography angiograms were randomly selected, inclusion and exclusion criteria were applied, and 90 files were kept (53 males, 37 females). The cases were documented bilaterally for different levels of origin of the OA origin: type 1-infrahyoid; type 2-hyoid; 3-infragonial; 4-gonial; 5-supragonial; 6-origin from the internal carotid artery (ICA). Results. The incidence of unilateral types in the 180 OAs was: type 1-1.11%, type 2-5.56%, type 3-40.56%, type 4-28.33%, type 5-23.33% and type 6, ICA origin of the OA-1.11%. There was found a significant association between the location of the left and right origins of the OAs (Pearson Chi2 = 59.18, p < 0.001), which suggests the presence of a strong symmetry of the origins. Bilateral symmetry of the vertical types of the OA origin was observed in 56.67% of cases; in 43.33% there was bilateral asymmetry. Conclusions. The ICA origin of the OA is an extremely rare variant. For surgical planning or prior to endovascular approaches the topography of the OA origin should be carefully documented, as it may be located from an infrahyoid to a supragonial level.

Cerebral Aneurysms Repair Using Direct Carotid Artery Cutdown: A Case Series

Background: Cerebral Aneurysms (CA) including dissecting pseudoaneurysms are treated endovascularly through a trans-radial or trans-femoral approach. When these options are not available, a trans-carotid approach via Direct Carotid Artery Cutdown (DCAC) may be used as the last option. However, the safety and feasibility of DCAC is not well studied or defined in these contexts. Our objective is to present our four unique patients who were treated by the DCAC approach for their cerebral aneurysm and/or internal carotid artery dissecting pseudoaneurysm using flow diversion. Method: This is a report of a case series and retrospective review. Results: Patient 1; A 75-year-old woman with known left internal carotid artery (ICA) petrocavernous aneurysm that enlarged from 6 mm to 10 mm resulting in double vision and headaches. Trans-femoral approach failed due to the tortuosity in the common carotid artery (CCA). A multidisciplinary team was formed; A vascular surgeon began the surgery followed by FD by a neuroendovascular surgeon. A 6 French sheath was placed on the right common carotid artery via DCAC then brought to right ICA by vascular surgeon, and a neuroendovascular surgeon confirmed the placement with digital subtraction angiography (DSA). The DSA confirmed a large 10 x 8 x 5mm broad-based aneurysm. Flow diversion was performed with pipeline flex measuring 5 x 30mm. Patient was discharged home and achieved baseline modified Rankin Scale (mRS )1 which sustained in 5 years with aneurysm obliteration. Patient 2; A 65- year-old woman with multiple symptomatic left ICA-Para-ophthalmic artery aneurysm measuring 9 mm. Both femoral and radial arteries were occluded and underwent DCAC and flow diversion with pipeline flex of 4x30 mm using the similar technique described above. Patient discharged home in 48 hours with National Institute of Health Stroke Scale (NIHSS) of 0 and achieved her baseline mRS. However, this patient refused to have any further follow-up studies done. Patient 3; A 67-year-old man with aortic arch endograph with stent graft after previous aortic dissection and diagnosed with bilateral internal carotid artery dissecting pseudoaneurysm (ICADP) by computed topographic angiography (CTA). The right ICADP measured 19 x 15 x 20 mm, was multilevel, extending from skull base to the internal carotid artery (ICA) origin. The left ICADP was 16 x 9 x 22 mm with inflow-zone stenosis. The DSA was attempted but failed due to the aortic stent. The right ICADPA was repaired first using Surpass streamline (Stryker Neurovascular, Irving, CA) device measuring 4 x 50 mm x2 and 5 x 40 mm covering the entire dissecting artery. Patient was discharged home in 48 hours. Three months after the first procedure, using similar technique the left ICADPA was treated with a 5 x 50 mm Surpass evolve flow diverter. Patient achieved mRS 0. In 24-months follow up CTA demonstrated complete resolution of left ICDAP, but occlusion of the right ICA without impairing his mRS 0. Patient 4; a 76-year-old-woman with tinnitus, headaches and dizziness; DSA demonstrated RICA dissecting large 16 x 8 mm pseudoaneurysm. Trans-femoral approach failed and underwent DCAC, and flow diversion with a single surpass evolve flow diverter 4.5 x3 0 mm. Patient was discharged with NIHSS 0 and achieved her baseline mRs 0.

Ultrasound diagnosis of carotid artery stenosis and occlusion.

Carotid artery ultrasonography is capable of diagnosing or inferring the presence or absence of stenosis or occlusion of the internal carotid artery (ICA) and vertebral artery (VA), as well as the not directly observable distal ICA, middle cerebral artery (MCA), and basilar artery (BA). Stenosis at the origin of the ICA is mainly evaluated using the parameter peak systolic velocity (PSV), with values of ≥ 200-230cm/s indicating severe stenosis. Recently, the acceleration time ratio has been reported for diagnosis of ICA origin stenosis. An indicator called the end-diastolic (ED) ratio can be used for diagnosing occlusion of the distal ICA or the M1 segment of the MCA. The PSV of stenosis can be used to diagnose stenosis at the beginning of the VA or V1, and mean flow velocity, mean ratio, and diameter ratio can be used to diagnose distal VA occlusion. Furthermore, the usefulness of the VA pulsatility index and resistance index has been suggested for diagnosing stenosis or occlusion of the BA. This review outlines diagnostic sonography criteria for stenosis and occlusion of extracranial and intracranial arteries.

Bilateral Cerebral Infarctions Secondary to Unilateral ICA Stenosis

A 76-year-old diabetic man presented to us with complaints of sudden-onset right-sided weakness for the last 4 days. On evaluation, he was found to have right hemiparesis (Modified Medical Research Council grade 4-/5) along with left leg weakness (4+/5). Neuroimaging revealed acute infarcts in the right anterior cerebral artery (ACA) territory and left cerebral external watershed territory. Magnetic resonance (MR) angiogram of the brain showed a hypoplastic right A1-ACA with bilateral A2-ACA arising from the left A1-ACA (bi-hemispheric A1-ACA). MR angiogram of the neck revealed significant left internal carotid artery (ICA) origin stenosis. It was concluded that the origin of right A2-ACA from left ACA was the probable because of right ACA infarcts, along with left cerebral watershed infarcts (embolic phenomenon). This represents a very important variation, as in these cases, even a unilateral ICA stenosis can lead to bilateral ACA stroke and thus necessitates urgent revascularization.

Separate origin of left external and internal carotid arteries directly from aortic arch in a patient with double outlet right ventricle

We report a case of a 1-year-old boy with double outlet right ventricle where computed tomography(CT) angiography incidentally demonstrated the separate origin of the left external and internal carotid arteries directly from the left-sided aortic arch with absence of a left common carotid artery. The case highlights the underlying embryological hypothesis as well as the importance of CT angiography in identifying anomalies of the aortic arch and arch vessels in the setting of complex congenital heart defects.

Abstract 1122‐000205: Bilateral ACA Stroke ‐ A Case Report of an Unusual Presentation

Introduction : Bilateral ACA strokes are rare, with one stroke registry reporting 2 cases out of 1490 strokes (1). These strokes are even less common in the absence of anatomic variants, such as an azygos ACA. Diagnosis may be difficult given the variability in clinical presentation. Methods : This is a case report. Results : A 51‐year‐old right handed man with no cerebrovascular risk factors on no antithrombotic medications presented two hours from last known well with complaints of generalized weakness, inability to speak or move, and feeling numb all‐over during intercourse. He reported rapid improvement in symptoms. Emergency room exam was notable for right leg weakness (3/5) and left leg plegia with intact sensation. Hoover’s sign was positive in the left leg and the patient was able to bear some weight while standing with a two‐person assist. A computed tomography angiogram (CTA) of his head and neck was preliminarily interpreted as normal. No azygos ACA or single internal carotid artery origin for the ACAs were present. His exam improved to an isolated left foot dorsiflexor and plantar flexor weakness. The decision was made not to use thrombolytics based on his symptoms and exam which were improving and not entirely consistent with acute stroke. Brain magnetic resonance imaging demonstrated bilateral parasagittal acute strokes. It was later noted the that non‐contrast head CT demonstrated bilateral hyperdense ACAs. Conclusions : This case demonstrates the difficulty in diagnosing bilateral ACA infarcts in a previously healthy adult in the setting of whole‐body numbness and positive Hoover’s sign. In retrospect, his transient inability to speak or move may have been transient akinetic mutism or callosal disconnection syndrome. Additionally, this case emphasizes the importance of evaluating for the hyperdense ACA sign (2) in patients complaining of bilateral leg weakness.

Carotid artery stenosis in correlation with neck and carotid artery anatomy.

The purpose of this study was to examine the relationship between neck anatomy, especially its largest muscle - sternocleidomastoid and carotid space, with carotid artery anatomy and stenosis. We analysed 102 computed tomography carotid angiograms. The study included the measurement of the neck and sternocleidomastoid length, diameter and volume and the size of the carotid space. Analysis of carotid artery geometry, the length, angle and height of carotid artery bifurcation and the direction of the internal carotid artery origin was also included. We found a positive correlation only between the neck and carotid length. There was no correlation between other neck characteristics and a carotid anatomy or internal carotid artery stenosis. Direction of internal carotid artery origin was significantly different (p < 0.01) between the left and right sides. We have not found a correlation between the size of sternocleidomastoid and carotid space and carotid stenosis as a hypothetical factor for atherosclerosis. Also, the degree of carotid artery stenosis did not correlate with other neck and carotid measurements. Neck and carotid anatomy correlated only in their lengths. The left internal carotid artery showed mostly posterolateral origin, and right internal carotid artery had no predominate direction.

Prevalence and site of predilection of carotid webs focusing on symptomatic and asymptomatic Japanese patients.

Carotid webs (CWs) have increasingly been recognized as a cause of recurrent ischemic stroke. However, the natural history and clinical course of CWs remain unclear. The authors aimed to clarify the prevalence, imaging features, and optimal treatment of CWs in a Japanese cohort study. A series of 444 consecutive Japanese patients who had undergone CTA of the head and neck between April 2011 and October 2016 was retrospectively reviewed. CW was diagnosed on CT angiograms as a membrane-like intraluminal filling defect along the posterior wall of the carotid bulb or the origin of the internal carotid artery (ICA) on oblique sagittal images and a corresponding thin septum on axial images. Two patients with CWs were identified among 132 patients with suspected stroke. The prevalence of CWs among symptomatic patients with suspected stroke was 1.5%. The prevalence of asymptomatic CWs was 2.2% (7 of 312 cases). The CWs were located in the posterior wall of the carotid bulb in 7 patients and just distal to the ICA origin in 2 patients. There were no apparent differences in the location or lesion length between symptomatic and asymptomatic CWs. Four of the 7 asymptomatic CWs remained asymptomatic for at least 2 years of follow-up. Two patients with symptomatic CWs developed recurrent cerebral infarction and transient ischemic attack despite being on a regimen of oral antiplatelet agents, and carotid endarterectomy was performed as radical treatment. Patients with CWs were younger than controls (median age 55 vs 69 years, p = 0.003) and were less frequently male than controls (33% vs 72%, p = 0.025). CW cases showed significantly fewer common atherosclerosis risk factors than the control group (p < 0.05). Although limited to CTA patients, this study reported on the prevalence and common site of CWs, focusing on symptomatic and asymptomatic Japanese patients. Extensive cross-sectional and prospective observational studies are warranted to elucidate the overall prevalence and natural history of CWs.

Carotid ultrasound findings among patients successfully treated with endovascular thrombectomy for atherosclerotic internal carotid artery origin occlusion

Carotid ultrasound findings among patients successfully treated with endovascular thrombectomy for atherosclerotic internal carotid artery origin occlusion

Predictors of Clopidogrel Hyper-Responsiveness in Neuro-Interventional Procedures

BackgroundHyper-responsiveness to clopidogrel abnormally inhibits platelet aggregation and increases hemorrhagic complications. The present study investigated clinical factors related to clopidogrel hyper-responsiveness in neuro-interventional procedures. MethodsTwo hundred twenty-four patients receiving clopidogrel for coil embolization to treat unruptured cerebral aneurysm or carotid artery stenting to treat carotid artery stenosis at the internal carotid artery origin were retrospectively reviewed for their P2Y12 reactivity unit (PRU) values and clinical characteristics. Hyper-responsiveness to clopidogrel was defined as a PRU of <95. ResultsThe mean PRU was 218.2 ± 77.8. Hyper-responsiveness to clopidogrel was observed in 12 patients (5.4%). Hyper-responsiveness was observed in younger patients, patients with a lower concentration of hemoglobin A1c, and patients with a higher low-density lipoprotein cholesterol (LDL-C) concentration compared with non-hyper-responsive patients (P = 0.01, P < 0.01, P < 0.01, respectively). On analysis of concomitant drugs, the patients in the hyper-responsive group were less frequently administered calcium channel blockers (CCBs) compared with the non-hyper-responsive group (P = 0.01). No significant differences in the usage of proton pump inhibitors or statins were observed. A LDL-C concentration of >120 mg/dL and no usage of CCBs were significant independent predictors of hyper-responsiveness to clopidogrel with a multivariate analysis (OR; 6.16, 95% CI, 1.57–26.64, P = 0.01, OR; 0.09, 95% CI, 0.01–0.82, P = 0.03, respectively). ConclusionThe present study shows that a higher LDL-C concentration and no usage of CCBs are independent predictors of clopidogrel hyper-responsiveness. These results are useful to predict perioperative hemorrhagic complications. Considering dose reduction of clopidogrel or alternative drugs in high risk cases is necessary to prevent perioperative hemorrhagic complications.

A cadaveric study of variations in the origin and cervical part of internal carotid artery

The Internal carotid artery (ICA) is one of the branches arising from the Common carotid artery. A study of variability in the origin and course of the cervical part of the ICA is clinically important for vascular surgeons in performing certain stenting procedures.The present study was conducted to study the variations in the origin and course of the cervical part of the ICA by cadaveric dissection method. A cadaveric study was conducted on fifty, formalin fixed head and neck specimens in the department of Anatomy, Pushpagiri Institute of medical sciences and research centre, Tiruvalla, Kerala, India. The pattern of origin, course of the cervical part of ICA were dissected and variations, if any, were noted.Internal carotid artery originated from the Common carotid artery in 100% of the specimens. High origin of the ICA (38%) was the commonest variation in the origin observed with a higher incidence on the right side. The commonest variations in the cervical part were kinks (32%) with a higher frequency on the left side and aneurysms (4%) with equal distribution on both sides.Anomalous origin and course of ICA may damage the vessel while performing certain surgical procedures like stenting. Thus sound knowledge of the variations in the origin and course of the vessel is essential for general and vascular surgeons in performing surgical procedures without unnecessary complications.

Suitable methods of measuring acceleration time in the diagnosis of internal carotid artery stenosis

PurposeTo enhance the utility of acceleration time (AcT) in the diagnosis of internal carotid artery (ICA) stenosis, we assessed the value of AcT measurements with different waveform patterns.MethodsNinety-three patients with acute atherothrombotic cerebral infarction were enrolled, and they underwent both carotid ultrasonography and digital subtraction angiography (DSA). AcT was determined by a conventional procedure (using the first peak point or the bending point) and the peak systolic velocity (PSV) procedure. The AcT ratio was calculated as (AcT of ICA)/(AcT of the ipsilateral common carotid artery). We evaluated the correlation of stenosis rate as assessed by the North American Symptomatic Carotid Endarterectomy Trial method using DSA (DSA-NASCET) with the AcT of ICA (ICA-AcT), the AcT ratio measured by the conventional procedure (conventional AcT ratio), and the AcT ratio measured by the PSV procedure (PSV AcT ratio). The area under receiver operating characteristic curves (AUC) for DSA-NASCET was calculated based on the ICA-AcT and AcT ratio.ResultsForty-five vessels had 50% or greater ICA stenosis. DSA-NASCET was positively correlated with the conventional AcT ratio (r = 0.723), conventional ICA-AcT (r = 0.638), and PSV AcT ratio (r = 0.245). The corresponding AUCs for ICA stenosis ≥ 50% were 0.971, 0.886, and 0.572, respectively.ConclusionWe demonstrated the usefulness of the conventional procedure for diagnosing stenosis of ICA origin using AcT and showed that the AcT ratio was a more beneficial parameter than AcT.

Vertebral-carotid transposition can treat various diseases

Vertebral-carotid transposition (VCT), which is a treatment of vertebral artery stenosis, has excellent long-term efficacy. VCT can also be suitable for various situations where the blood supply of the vertebral artery must be reconstructed. Here, we present an early result of six cases for these anomalies by VCT. Case 1: A 58-year-old male presented with the severe stenosis at the left vertebral V1 segment. Case 2: A 59-year-old female suffered from moderate-to-severe stenosis at the first portion of the left subclavian artery. Case 3: A 55-year-old female experienced severe stenosis at the left vertebral V1 segment, which the wire could not pass through. Case 4: A 53-year-old female presented with the subclavian aneurysm at the origin of the right vertebral artery. Case 5: A 65-year-old male suffered from the long complete occlusion at the origin of the left subclavian artery, a severe stenosis at the origin of the left internal carotid artery, a severe stenosis at the origin of the right internal carotid artery, and a severe stenosis at the right vertebral V1 segment. Case 6: A 56-year-old male experienced the thrombus in the stent of the vertebral artery which had been placed 6 months ago. There are six cases, in which VCT was adapted. VCT is safe and effective for various situations when the blood supply of the vertebral artery must be reconstructed.

Anti-phospholipid antibody syndrome presenting with seizure, stroke and atrial mass: A case report

Antiphospholipid antibody syndrome (APS) has a broad spectrum of thrombotic and non-thrombotic clinical manifestations. We present a case of APS presenting with seizure, stroke and atrial mass. A 38 year-old male presented with headache of 10 days duration and tonic-clonic seizure. Neurological examination was normal. MRI brain showed small acute right cerebellar infarct. MRA brain and neck showed focal narrowing in origin of internal carotid artery bilaterally. EEG was normal. He was started on aspirin, atorvastatin and carbamazepine. Transthoracic and transesophageal Echo showed atrial mass pedunculated and lobular measuring 1 * 1.5 cm freely mobile across mitral valve opening across the left ventricular inflow. Antiphospholipid (aPL) antibodies were positive in higher titer (IgG> 120). B2 glycoprotein was 90. ANA was negative. ESR and CRP were normal. Platelet count was low. APS was diagnosed. He underwent successful surgical removal of the mass, which looked like a thrombotic clot, Histopathological analysis confirmed fibrinous clot, with no evidence of tumor cells. He was started on full anticoagulation treatment and was followed up regularly in the clinic, where he did not have any further complications from the disease. Our patient was diagnosed to have APS based on the features of high positive anticardiolipin antibody IgG and B2 glycoprotein IgG, Stroke, thrombocytopenia and abnormal ECHO findings. Thrombotic vegetation can mimic an atrial myxoma on ECHO. APS can present with neurological and cardiac manifestations and therefore high index of suspicion is necessary for diagnosis.

Coexistent ipsilateral venous sinus thrombosis and arterial stroke in iron deficiency anemia

Concomitant ipsilateral cerebral venous sinus thrombosis and arterial infarction are exceedingly rare clinical entity. We suggest that iron deficiency anemia caused the simultaneous affection of the two arterial beds. We report a 34-year-old right-handed male who presented with headache, vomiting, left hemiplegia and drowsiness. On arrival to ER, he had hypotension and sinus bradycardia necessitating inotropic support. He was drowsy and had signs of right middle cerebral artery involvement confirmed by unenhanced CT brain showing acute right temporo-parietal ischemic infarction. The investigations revealed anemia (Hb 8.8 g/dL, MCV 57.7fL), hypoferritinemia (<5 ng/mL) and hypochromic microcytic anemia suggesting iron deficiency anemia. Other investigations including inflammatory markers, bacterial cultures, anticoagulation profile, lipids, glycemic indices, Hb Electrophoresis, autoimmune markers including antiphospholipid syndrome, cryoglobulins, thrombophilia screen, viral markers for hepatitis B and C as well as HIV were negative. The echocardiogram and a pan CT abdomen and chest were unremarkable. A repeat CT brain on the same day revealed right middle cerebral artery territory infarction with hyperdense right transverse and sigmoid sinuses. CT cerebral angio- and venogram showed dural sinus thrombosis involving the right transverse and sigmoid sinuses, jugular bulb and proximal jugular vein along with linear filling defect at the origin of the right internal carotid artery. Later, he underwent decompressive hemicraniectomy. He received blood transfusions, iron supplementations and therapeutic anticoagulation. Inotropic support was weaned off gradually. Neurologically, residual hemiplegia prevailed.

The Chalice Sign : Characteristic Morphology of the Cervical Carotid Bifurcation in Patients with Loeys-Dietz Syndrome.

Loeys-Dietz syndrome (LDS) is aconnective tissue disorder characterized by arterial aneurysms and dissections. This study sought to assess and describe the arterial changes of the cervical arterial vasculature of such patients, with an emphasis on the carotid bifurcation. Aretrospective review of patients with aknown diagnosis of LDS was carried out. The maximum diameters of the external carotid artery (ECA) and internal carotid artery (ICA) origins, common carotid artery (CCA) terminus, maximum transverse and craniocaudal dimensions of the carotid bulb, and bifurcation angle were measured. The presence of achalice sign was defined as acarotid bifurcation angle of ≥80°. Asemi-quantified analysis of vertebral artery tortuosity was completed as well. All measurements were compared to acohort of age-matched controls. A total of 21patients with LDS were included. Compared to normal controls, the presence of achalice sign had 61.9% sensitivity and 100.0% specificity for LDS if present bilaterally; the sensitivity and specificity of aunilateral chalice sign were 66.7% and 82.3%, respectively. Patients with LDS also had significantly higher rates of abilateral chalice sign compared to patients with vascular Ehlers-Danlos syndrome (vEDS) (61.9% versus 0%, P <0.0001) and patients with Marfan syndrome (61.9% versus 14.3%, P = 0.001). Patients with LDS have characteristic findings of the cervical arterial vasculature that enables them to be distinguished from normal controls as well as patients with connective tissue diseases, such as Marfan syndrome and vEDS; most notably including marked widening of the carotid bifurcation angle in what is proposed to be named the chalice sign.

275 A Case Study of Retinal Artery Occlusion Following Mechanical Thrombectomy via Direct Carotid Puncture.

Abstract Background This case study reviews the role of carotid puncture as arterial access in mechanical thrombectomy and an associated rare complication. Methods This case reviews the management of a 74-year-old gentleman who presented with a left MCA ischaemic stroke. On presentation NIHSS was 21 consistent with a left total anterior circulation stroke syndrome (TACS) with a very severe clinical deficit. He underwent IV thrombolysis and attempted mechanical thrombectomy via femoral puncture. However the intracranial middle cerebral artery (MCA) occlusion could not be reached as a near occlusion at the internal carotid artery (ICA) origin could not be passed. A carotid puncture was successfully attempted followed by mechanical thrombectomy with complete recanalization of occluded MCA. Despite carotid puncture occurring in the setting of IV thrombolysis there were no post procedure bleeding complications. On day 2 post-procedure, the NIHSS score was 1 (residual facial droop) representing remarkable neurological recovery. On day 4 post-procedure, acute left eye vision loss developed with subsequent diagnosis of left central retinal artery occlusion (CRAO). The mechanism of this retinal artery occlusion may have been a direct delayed complication of carotid artery puncture propagating clot into the ophthalmic artery, or may have been due to the underlying stroke mechanism such as new embolism from ICA origin or failure of collaterals. Results Persistent residual left eye blurred vision and right facial droop. Conclusion Proximal intracranial occlusion can effectively be treated with mechanical thrombectomy. Carotid puncture is a rarely used but effective alternative method of arterial access (11 out of 498 procedures between August 2016 and August 2018). Retinal artery occlusion is a possible complication from mechanical thrombectomy with carotid puncture.

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication.

Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication.