Patency Of Internal Carotid Artery Research Articles

Treatment of Traumatic Direct Carotid-Cavernous Fistula with a BeGraft-Covered Stent.

The widely accepted option for treating traumatic direct carotid-cavernous fistula (dCCF) has been endovascular treatment using detachable balloons, coils, or embolic agents. Covered stent deployment has been applied by a few operators and has shown promising results. This is a retrospective study on patients with dCCF treated by an endovascular approach using BeGraft, a covered stent. In 4 cases, this device was successfully deployed without any complications. Immediate complete occlusion was achieved in 3 patients (75%) after deployment of the covered stents. One patient required transvenous coiling for occlusion of the remaining endoleak. Follow-up imaging demonstrated 100% fistula occlusion with complete internal carotid artery patency. No early or late complications occurred following treatment. In conclusion, the BeGraft-covered stent could be a promising safe and effective alternative option for the endovascular treatment of dCCF.

Internal Carotid Artery Injury in Endoscopic Endonasal Surgery: The Value of Intraoperative Magnetic Resonance Imaging

BACKGROUND AND IMPORTANCE: Internal carotid artery (ICA) injury is a devastating complication of endoscopic endonasal surgery. We report a case of completely resected clival chordoma using endoscopic endonasal surgery despite intraoperative ICA injury. Intraoperative MRI (iMRI) was used to localize the bleeding site, confirm resection degree and ICA patency distal to the injury site, and rule out intraoperative ischemia. CLINICAL PRESENTATION: A 16-year-old girl presented with right-sided facial paresthesia and was diagnosed with a large, invasive skull base lytic lesion centered in the clivus. The patient's neurological examination was normal, except for decreased sensation on the right side of the face. During tumor resection, massive bleeding occurred from the ICA paraclival segment, which was by applying direct pressure using hemostatic agents. Partial tumor resection, no clear signs of ischemic injury, and a patent flow distal to the ICA injury site were observed using iMRI. These findings helped in the decision to proceed with surgery and complete gross total resection. Postoperative angiography immediately performed after surgery revealed a pseudoaneurysm that was successfully embolized with coils. After discharge with no new neurological deficits, the postoperative imaging showed complete resection and no evidence of ischemic stroke in the injured ICA distribution. CONCLUSION: Although not commonly used to detect skull base lesions, iMRI was valuable in our chordoma case and enabled the surgical team to proceed with a complete surgical resection. It provided real-time evaluation of the injury and possible complications. Thus, iMRI should be considered for high-risk skull base ICA injuries.

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

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

Balloon‐Expandable Stenting as a Bridging Therapy in Patients With Acute Stroke and Tandem Occlusions

Background Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear. Methods We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage. Results A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) ( P <0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) ( P =0.031). No differences in extracranial ICA high‐grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%]; P =0.673). Conclusions In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less‐aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency.

Bailout technique for entangled stent retriever and carotid stent during tandem large vessel occlusion endovascular therapy.

Endovascular thrombectomy for patients with tandem occlusions could be challenging. Exposure to potential technical complications and bailout rescue techniques are of utmost importance. A 73-year-old woman with tandem internal carotid artery and middle cerebral artery lesions underwent an unsuccessful retrograde revascularization approach in the setting of tortuous anatomy. Antegrade approach revascularization was then pursued. Following cervical internal carotid artery revascularization, a triaxial system of aspiration catheter, microcatheter and micro guidewire was navigated through the stented curved cervical ICA and intracranial stent retriever pass was performed. Upon retrieving the clot-incorporated stent retriever with the intention to retrieve the entire stent retriever into the locally placed aspiration catheter, the triaxial system collapsed into the distal common carotid artery. Large thrombus was recovered from the aspiration catheter aspirate however the proximal end of stent retriever and distal internal carotid artery stent got tangled. After unsuccessful maneuvering to disentangle stent retriever from the internal carotid artery stent, we decided to attempt safe separation of the stent retriever from its pusher wire and leave behind the patent internal carotid artery stent/stent retriever metal construct in place. Gradual pulling pressure was applied to the stent retriever wire while maintaining distal exchange-length microwire access and fully inflated extracranial balloon over the entangled portion to ensure continuous vascular access. The stent retriever wire was then safely separated from the stent retriever and fully retracted outside the body. Delayed angiographic runs continued to demonstrate full patency of the internal carotid artery lumen. No residual dissection, spasm, or thrombus was noted. This case illustrates a novel bailout endovascular salvage technique that could be considered in such cases. These techniques minimize intraoperative complication, focus on patient safety, and promote efficiency for endovascular thrombectomy in unfavorable anatomy.

Concomitant occurrence of Cerebral Hyperperfusion Syndrome (CHS) and Reversible Cerebral Vasoconstriction Syndrome (RCVS) after right Carotid Endarterectomy (CEA) (P2-5.018)

<h3>Objective:</h3> To describe an interesting case of CHS and RCVS occurring concomitantly following CEA <h3>Background:</h3> Both CHS and RCVS are known complications of CEA. On rare occasions both complications can occur concomitantly after CEA. <h3>Design/Methods:</h3> Case report <h3>Results:</h3> A 58-year-old female with long-standing history of smoking and hyperlipidemia presented to outside hospital (OSH) with pressure-like headache on top of her head and feeling of facial swelling. CT angiogram of head and neck (CTA) showed right internal carotid artery (ICA) stenosis of 85% and left ICA stenosis of 80%. Three months after the initial presentation she underwent right CEA. Immediately following procedure, she had severe throbbing headache on right side which responded to Toradol. Neurologic examination was otherwise unremarkable, and she was discharged home on dual anti-platelet therapy. After discharge, she continued to have headache. Ten days after the procedure, she developed left sided weakness and presented to an outside hospital where she had a seizure and was started on levetiracetam. MRI of the brain showed edematous changes on the right consistent with CHS without evidence of acute stroke. Right ICA was patent and there was segmental vasoconstriction and dilation of cerebral vasculature consistent with RCVS. Due to increased risk of hemorrhagic strokes with CHS and RCVS, left CEA was not recommended and maximal medical therapy was recommended. There was resolution of edematous changes in right cerebral hemisphere on MRI two months later. CTA at two months follow up showed resolution of segmental vasoconstriction and vasodilation, patent right ICA and unchanged left ICA stenosis. <h3>Conclusions:</h3> CHS and RCVS can occur concomitantly after CEA and can lead to devastating hemorrhagic strokes. In patients who develop CHS and RCVS concomitantly maximal medical therapy should be recommended for contralateral ICA stenosis. <b>Disclosure:</b> Dr. Anjum has nothing to disclose. Dr. Burton has nothing to disclose. Dr. Javalkar has nothing to disclose. Dr. Chernyshev has nothing to disclose.

Internal carotid artery patency after mechanical thrombectomy for stroke due to occlusive dissection: Impact on outcome.

Internal carotid artery dissection (ICAD) is a rare cause of acute ischemic stroke with large vessel occlusion (AIS-LVO). We aimed investigating the impact on outcome of internal carotid artery (ICA) patency after mechanical thrombectomy (MT) for AIS-LVO due to occlusive ICAD. We included consecutive patients with AIS-LVO due to occlusive ICAD treated with MT from January 2015 to December 2020 in three European stroke centers. We excluded patients with unsuccessful intracranial reperfusion after MT (modified Thrombolysis in Cerebral Infarction (mTICI) score < 2b). We compared 3-month favorable clinical outcome rate, defined as a modified Rankin scale (mRS) score ⩽2, according to ICA status (patency vs occlusion) at the end of MT and at 24-h follow-up imaging, using univariate and multivariable models. Among 70 included patients, ICA was patent in 54/70 (77%) at the end of MT, and in 36/66 (54.5%) patients with 24-h follow-up imaging. Among patients with ICA patency at the end of MT, 32% presented ICA occlusion at 24-h control imaging. Favorable 3-month outcome occurred in 41/54 (76%) patients with ICA patency post-MT and in 9/16 (56%) patients with occluded ICA post-MT (p = 0.21). Rates of favorable outcome were significantly higher in patients with 24-h ICA patency compared to patients with 24-h ICA occlusion (32/36 [89%] vs 15/30 [50%]), with an adjusted odds ratio of 4.67 (95% CI: 1.26-17.25). Obtaining sustained (24-h) ICA patency after MT could be a therapeutic target for improving functional outcome in patients with AIS-LVO due to ICAD.

"The importance of being external": review of the literatureof the rare phenomenon of common carotid occlusion with bulb reverse-crossed stenosis and external collaterals activation. Is still correct speaking about carotid steal?

Common carotid artery occlusion (CCAO) is a rare phenomenon associated with the development of neurological symptoms. In CCAO, diversion of blood flow from the external carotid artery (ECA) to the internal carotid artery (ICA) via the carotid bulb (CB) may occur. This pathway activation has been called "carotid steal". Starting from a particular case we describe the ECD finding of a complete occlusion of CCA with patency of ICA and ECA. In case of occlusion of CCA, inversion of the ECA flow may occur, towards the ICA, and it can be damped by a significant stenosis crossed in retrograde direction that may concur to maintain the pressure balance between the two circulations. Usually, this particular compensation can guarantee normal flow velocities in middle cerebral arteries without signs of activation of anterior collateral pathways. In this review we underline the protective role of ECA and we propose a new definition for this phenomenon. The ECA may provide blood to the cerebral circulation through several anastomotic secondary channels. Finally, only with an extensive knowledge of hemodynamic information of all intracranial and extracranial arteries, including ECA, we can estimate cerebral ischemic risk of the patient and choose the correct management of this occlusion.

Excision and End-to-End Anastomosis of a Giant Partially Thrombosed Cervical Internal Carotid Artery Aneurysm Mimicking a Neck Tumor: 2-Dimensional Operative Video.

Aneurysms of the cervical internal carotid artery (ICA) are a rare entity1,2 accounting for less than 0.2% to 0.5% of all carotid surgeries3 and less than 1% of all arterial aneurysms.4 There are several types of aneurysms, which include dissecting aneurysms, pseudoaneurysms, mycotic aneurysms, and fusiform and saccular aneurysms.5 The causes can include atherosclerosis, trauma, infection, and dysplasia. We present the case of a 70-yr-old otherwise healthy female found to have a neck mass. She was referred from a peripheral vascular surgeon to a head and neck surgeon for potential biopsy. The head and neck surgeon obtained vascular imaging and referred the patient to neurosurgery for definitive management. The patient gave informed consent for the procedure. An excision of the cervical ICA aneurysm and reanastomosis of the cervical ICA was performed. The patient remained neurologically intact postoperatively and imaging demonstrated complete aneurysm occlusion and a patent cervical ICA anastomosis. The patient gave verbal consent for this case to be published.

Correlation Between Internal Carotid Artery Patency and Middle Cerebral Artery Waveform During CEA

The blunted signal distal to an arterial occlusion is a well-known phenomenon. Here we try to assess this entity, correlate it to different hemodynamic parameters and understand its modification in case of internal carotid artery (ICA) status.

Disobliteration of an Occluded Common Carotid Artery with Patent Bifurcation via Antegrade Ring Stripping.

There is a lack of guidelines concerning common carotid artery (CCA) occlusive disease in the presence of a patent internal carotid artery (ICA). A novel surgical technique that disobliterates an occluded CCA was successfully performed in three cases. The detailed surgical steps are presented herein. After proximal division of the CCA behind the sternoclavicular junction, the occluded CCA was endarterectomized via antegrade ring stripping. After removal of the atheromatous core, the CCA was everted, and the wall remnants were cleaned under direct vision. Simultaneous eversion endarterectomy of the ICA was performed when necessary. After reversion of the CCA, it was transposed and anastomosed to the ipsilateral subclavian artery distal to the orifice of the vertebral artery. This novel technique can be used in selected cases by experienced surgeons.

Endovascular treatment of acute tandem occlusion of the left internal carotid and middle cerebral arteries, which is a complication of carotid endarterectomy

Case of endovascular treatment of a patient with tandem left internal carotid artery (ICA) and middle cerebral artery (MCA), which was a complication of carotid endarterectomy, are presented. The rupture at the location of the suture in the bulb of the ICA during endovascular intervention required implantation of a graft-stent and subsequent removal of the hematoma in the neck soft tissues.A 51 year old man in the residual period of ischemic stroke in the left carotid basin with elements of sensory speech disorders, with subtotal stenosis in the bulb of the left ICA, stenosis 35 % in the bulb of the right ICA and severe hypoplasia of the A1-segment of the left anterior cerebral artery underwent left-side carotid endarterectomy. The next morning after surgery, 1 hour after awakening, a right-sided hemiparesis progressing to hemiplegia, total aphasia. The level of consciousness deteriorated to the sopor. A computer tomography was performed immediately. New ischemic lesions were not identified. Cerebral angiography revealed the occlusion from the mouth of the left ICA, occlusion in the M1-segment of the left MCA. Thrombospiration from MCA and ICA was performed with Sofia Plus distal approach catheter. The MCA was recanalized in one pass (mTICI 3), but the patency of the left ICA was not recovered. The anti-embolic device SpiderFX was introduced and opened in the C2-segment of the left ICA. Then, a slow inflation of the Submarine 5 × 20 mm balloon catheter was performed in the left ICA bulb. At a pressure of 4.0 atm, the balloon opened like an hourglass, indicating a rough rigid stenosis in the ICA bulb. At a pressure of 4.5 atm, the balloon fully opened. Immediately after balloon deflation, intense contrast extravasation is determined at the level of the ICA bulb. Inflation of the balloon at a pressure of 4 atm was performed again. Intubation of the trachea of ​​the patient was performed. Intravenous administration of 300 mg acetylsalicylic acid was initiated. The balloon catheter is deflated and withdrawn from vessels, the carotid stent Protégé 8–6×40 mm was implanted into the left ICA bulb and the left common carotid bifurcation segment. The bloodstream above the stent is not determined, but extravasation through the stent cells at the level of the former defect is determined. Stent graft Graftmaster 4×15 mm was implanted into the carotid stent at the level of the defect in the ICA. Stent graft was additionally opened in its lower part by a 5×20 mm balloon-catheter. Thrombaspiration from the left ICA was performed again. Patency of the ICA and intracranial arteries was totally restored – mTICI3, stenosis in the left ICA bulb was completely eliminated. The patient’s neurological status was restored to baseline. A large hematoma in the soft tissues of the neck to the left was determined. Only “old” ischemic foci in the left temporal lobe were determined on brain CT, a large hematoma laterally and anteriorly to the carotid artery was determined in the soft tissues of the left side of the neck on computer tomography. Ticagrelor was added to aspirin therapy. Hematoma was removed surgically. The postoperative period was unremarkable. The patient was discharged from the clinic in good condition with an level modified Rankin scale 1.In the presented case, the friendly work of different profiles specialists avoided the devastating consequences of such a relatively rare complication of carotid endarterectomy as cerebral arteries tandem thrombosis. The availability of graft-stents in access to interventional neuroradiologists is extremely important in such cases.

Bypass strategies for common carotid artery occlusion.

Common carotid artery occlusion (CCA-occlusion) is a rare condition where standard revascularization is not feasible. Here, we analyzed our experience with surgical revascularization of CCA-occlusion to develop an algorithm for selection of the most suitable bypass strategy according to the Riles classification. During a 10-year period, 16 out of 288 patients with cerebrovascular disease and compromised hemodynamic reserve underwent revascularization for unilateral CCA-occlusion. The utilized bypass strategies included (1) a saphenous vein graft from the subclavian artery (SA) to the internal carotid artery (ICA), (2) a radial artery graft from the V3 segment of the vertebral artery (VA) to a superficial branch of the middle cerebral artery (MCA), or (3) a saphenous vein graft from the SA to a deep branch of the MCA. In CCA-occlusion with maintained external carotid artery (ECA)/ICA patency (Riles type 1A), an SA-ICA bypass was performed (25%). In cases without ECA/ICA patency (Riles type 1B or 2) but suitable VA, a VA-MCA bypass was grafted (31%). In cases with unsuitable VA, a long SA-MCA interposition bypass was performed (38%). Transient postoperative neurological deficits occurred in 5 patients (31%) with 1 patient (6%) suffering permanent neurological worsening and 1 mortality (6%). Overall, no difference was found between the median preoperative mRS (2; range, 1-4) and the mRS at the time point of the last follow-up (2; range, 1-6; p = 0.75). The long-term graft patency was 94%. Although surgical revascularization for CCA-occlusion is feasible, it is associated with a higher risk than standard bypass grafting. Considering the poor natural history of CCA-occlusion, however, this risk may be justified in carefully selected patients.

Stable Extracranial ICA Patency after Mechanical Thrombectomy for Ischemic Stroke Patients with Tandem Occlusions: Major determinant of favorable outcome

Mechanical thrombectomy (MT) for acute ischemic stroke (AIS) with tandem occlusion is efficient, but optimal management of the extracranial occlusive component remains controversial. We investigated the association between extracranial internal carotid artery (ICA) patency on day 1 follow-up MR-Angiography and clinical outcome after MT in AIS patients with tandem occlusion. Consecutive AIS patients with tandem occlusion were identified from a hospital-based prospective registry from January 2011 to January 2017. Baseline clinical-imaging characteristics, angiographic outcomes and day 1 follow-up imaging findings (including extracranial ICA patency as assessed by MR-Angiography) were analyzed with regards to their associations with 3-month modified Rankin scale (mRS) scores. Favorable outcome was defined as a mRS score 0–2 at 3 months. Out of 594 AIS patients treated with MT during the study period, 83 met inclusion criteria (69.9% male, aged 62.3 ± 12.3). Mean NIHSS was 17.9 ± 4.8 and median ASPECTS was 7. Successful re-canalization (mTICI 2b/3) was achieved in 61.5%. Extracranial ICA was patent in 37/83 patients (44.6%) at day 1, more frequently in those with prior IV thrombolysis (P = 0.035) or with cervical re-vascularization procedure (balloon angioplasty or stenting, P = 0.034). Favorable 3-month functional outcome was more frequent in patients with patent extracranial ICA at day 1 (64.9% vs 21.7%, P < 0.0001) independently of intracranial recanalization success. No difference was found in terms of sICH (13.5% vs 10.9%, P = 0.75) or 3-month mortality rate (8.1% vs 17.4%, P = 0.33). This study highlights the importance of stable extracranial ICA patency in determining outcome of AIS patients with tandem occlusions. Randomized studies are needed.

Hemodynamic characteristics associated with cerebral aneurysm formation in patients with carotid occlusion.

The pathogenesis of cerebral aneurysms in patients with internal carotid artery (ICA) occlusion is hypothesized to be hemodynamic. For the first time, the authors quantify the hemodynamic characteristics associated with aneurysm formation in patients with ICA occlusion. Records of patients with unilateral ICA stenosis or occlusion ≥ 90% who underwent hemodynamic assessment before treatment using quantitative MR angiography were retrospectively reviewed. The patients were classified into 2 groups based on the presence or absence of aneurysms. The hemodynamic parameters of flow volume rate, flow velocity, and wall shear stress (WSS) were measured in each vessel supplying collateral flow-bilateral A1 segments and bilateral posterior communicating arteries-and then compared between the groups. A total of 36 patients were included (8 with and 28 without aneurysms). The mean flow (72.3 vs 48.9 ml/min, p = 0.10), flow velocity (21.1 vs 12.7 cm/sec, p = 0.006), and WSS (22.0 vs 12.3 dynes/cm2, p = 0.003) were higher in the A1 segment contralateral to the side of the patent ICA in patients with versus without aneurysms. All de novo or growing aneurysms in our cohort were located on the anterior communicating artery (ACoA) or P1 segment. Flow velocity and WSS are significantly higher across the ACoA in patients who harbor an aneurysm, and de novo or growing aneurysms are often located on collateral vessels. Thus, robust primary collaterals after ICA occlusion may be a contributing factor in cerebral aneurysm formation.

Superior ophthalmic vein and ophthalmic artery in immediate evaluation after endovascular treatment of carotid-cavernous fistulas.

PurposeTo validate superior ophthalmic vein (SOV) and ophthalmic artery (OA) usefulness in immediate evaluation of new endovascular approaches to treat carotid-cavernous fistulas (CCFs).Material and methodsA retrospective review of 597 intracerebral malformation embolisations yielded 40 embolisations of CCF in the treatment of 18 patients. Two interventional radiologists performed detailed radiological angiographic assessments.ResultsMean age at initial admission was 58.9 years (SD 18.5 years, range 24-85 years). Patients presented with: chemosis (50%), ocular bruit (50%), exophthalmos (61%), diminished visual acuity (77.8%), headache (16.7%), and intracerebral haemorrhage (5.55%), and 5.55% were asymptomatic. Unilateral fistulas (10-55.5%) showed more diversified venous drainage pattern than bilateral ones (8-44.4%). There were statistically significant differences in post-traumatic and spontaneous CCF regarding age (p = 0.036), type of fistula (p = 0.0008), and presence of pseudoaneurysm (p = 0.036). 77.8% of patients had increased ipsilateral SOV diameter. SOV enlargement was not associated with type of fistula, history of trauma, or degree of exophthalmos. Ipsilateral ophthalmic artery was visible in all patients on both pre- and postprocedural angiography on lateral projection. Pre- and post-procedural SOV diameter was significantly different. Internal carotid artery patency was 100%, while the overall final angiographic or clinical success was 85.7%. We had three cases of peri-procedural complications.ConclusionsWe reported changeable dynamics of SOV and OA after endovascular treatment of CCFs and proved the feasibility of coils and Onyx-18 in the treatment thereof.

Hybrid operation to revascularize long-segment occluded internal carotid artery prevent further ischemic events.

The effects and complications of hybrid procedure (combined carotid endarterectomy and carotid stenting) to revascularize chronic long-segment occlusion of internal carotid artery (ICA) are currently unknown and the purpose of this study. Sixty-five patients with long-segment occlusion of ICA were prospectively enrolled and divided into two groups of revascularization with hybrid operation (n = 30) and medication group (n = 35), and clinical and angiographic data were analyzed. The duration from symptom onset to revascularization ranged 17-120days (mean 40.5 ± 5.0) in the hybrid operation, with a success revascularization rate of 100%. All patients had thrombi extracted with the clot length ranging 5-8cm (mean 6.3 ± 0.9). The thrombolysis in cerebral infarction grade (TICI) was significantly (P < 0.0001) greater immediately after (median 2,) than before recanalization (0). Periprocedural complications included recurrent laryngeal nerve injury in one patient and intracranial hemorrhage in another (6.7%), but no severe neurological deficits occurred. The symptoms were significantly (P < 0.0001) improved after compared with before operation, with the modified Rankin score of 2.5 ± 0.6 at 3months postoperation which was significantly (P < 0.0001) improved compared with before revascularization (3.4 ± 0.6). Follow-up angiography revealed patent ICA in all patients with hybrid operation. In the medication alone group, no significant (P > 0.05) improvement was observed with the mRS score of 3.5 ± 0.8 at admission and 3.4 ± 0.7 at 3months, which was significantly (P < 0.001) greater than in the hybrid operation. Hybrid operation may be safe and effective in revascularizing long-segment occlusion of internal carotid artery for prevention of further ischemic events.

Efficacy evaluation of embolization with Scepter balloon-assisted coils and Onyx glue for traumatic carotid cavernous fistula

Objective To evaluate the efficacy and safety of embolization with Scepter balloon-assisted coils and Onyx glue in treatment of traumatic carotid cavernous fistula (TCCF). Methods A retrospective case series study was conducted on the clinical data of 24 patients with TCCF managed with embolization with Scepter balloon-assisted coils and Onyx glue from February 2012 to February 2017. There were 20 males and 4 females, aged 21-65 years[(42.6±6.8)years], with Glasgow coma scale (GCS) of 15 points. All patients were with unilateral lesions, with 13 on the right and 11 on the left. Among TCCF patients, 23 patients were with cranial bruit, 22 with pulsating exophthalmos and bulbar conjunctiva congestion edema, 19 with orbital symptoms, and 9 with visual impairment. A micro-catheter was sent into the cavernous sinus of lesion side, and the location of traumatic carotid cavernous fistula and draining characteristics were identified by micro catheter contrast. With a balloon inflated to cover the fistula and protect the internal carotid artery, Onyx was injected into the cavernous sinus after several coils were deployed adjacent to the fistula until the complete occlusion of fistula. Cranial bruit, pulsating exophthalmos, visual impairment, and orbital symptoms before operation and 2 weeks after operation were observed. Six months after operation, digital subtraction angiography (DSA) was reviewed to evaluate the carotid artery patency and TCCF recurrence. Results The cranial bruit, pulsating exophthalmos, and bulbar conjunctiva congestion edema in all TCCF patients disappeared 2 weeks after operation. No obvious improvement was seen in 2 out of 9 patients with visual impairments and 2 out of 19 patients with orbital symptoms, but there was significant improvement after operation (P<0.05). Onyx glue adhering to the surface of the protective balloon occurred in one patient. The balloon and catheter were delivered to the external carotid artery and then removed, with no complication seen. Follow-up found no recurrence or operative complications in 6-12 months. Complete occlusion of fistula was seen in all patients, and the internal carotid artery showed good patency. Conclusion Embolization with Scepter balloon-assisted coils and Onyx glue can occlude fistula, eliminate ocular symptoms, and maintain internal carotid artery patency and hence is an effective and safe treatment option for TCCF. Key words: Carotid-cavernous sinus fistula; Embolization; Coils

Feasibility and Efficacy of Intra-Arterial Administration of Mesenchymal Stem Cells in an Animal Model of Double Toxin-Induced Multiple System Atrophy.

Multiple system atrophy (MSA) is a sporadic neurodegenerative disease of the central and autonomic nervous system. Because no drug treatment consistently benefits MSA patients, neuroprotective strategy using mesenchymal stem cells (MSCs) has a lot of concern for the management of MSA. In this study, we investigated the safety and efficacy of intra‐arterial administration of MSCs via internal carotid artery (ICA) in an animal model of MSA. The study was composed of feasibility test using a ×10 and ×50 of a standard dose of MSCs (4 × 107 MSCs) and efficacy test using a ×0.2, ×2, and ×20 of the standard dose. An ultrasonic flow meter and magnetic resonance imaging (MRI) showed that no cerebral ischemic lesions with patent ICA blood flow was were observed in animals receiving a ×10 of the standard dose of MSCs. However, no MSA animals receiving a ×50 of the standard dose survived. In efficacy test, animals injected with a ×2 of the standard dose increased nigrostriatal neuronal survival relative to a ×0.2 or ×20 of the standard dose. MSA animals receiving MSCs at ×0.2 and ×2 concentrations of the standard dose exhibited a significant reduction in rotation behavior relative to ×20 of the standard dose of MSCs. Cerebral ischemic lesions on MRI were only observed in MSA animals receiving a ×20 of the standard dose. The present study revealed that if their concentration is appropriate, intra‐arterial injection of MSCs is safe and exerts a neuroprotective effect on striatal and nigral neurons with a coincidental improvement in motor behavior. Stem Cells Translational Medicine 2017;6:1424–1433

Aetiologies of internal carotid artery pseudo-occlusions in acute stroke patients: what neurointerventionalists can expect.

In cases of acute stroke, differentiation between an occluded and a patent internal carotid artery (ICA) is crucial for diagnosis and management. Although CT angiography (CTA) can be highly accurate in defining high-grade stenosis and ICA occlusions, misleading ICA occlusion patterns are not rare in patients with acute stroke. We investigated the underlying causes of ICA pseudo-occlusions with CTA with respect to digital subtraction angiography. 11 out of 72 patients had pseudo-occlusion on CTA. Of these, there were three cases of tandem occlusions accompanying high-grade ICA stenosis, five cases of Distal ICA bifurcation occlusion as a result of atrial fibrillation, two cases of cervical ICA dissection and one acute thrombosis of the stent. Consideration of the aforementioned aetiologies by interventionists is warranted, as it may change the planning of endovascular intervention and treatment of acute stroke.