Internal Carotid Artery Stenosis Research Articles

High wall shear stress is related to complicated AHA lesion type VI plaques in mild to moderate internal carotid artery stenosis - a 3D cardiovascular MRI study.

Complicated American Heart Association (AHA) lesion type VI plaques (cCAPs), characterized by the presence of intraplaque hemorrhage, surface defect or thrombus, are strongly associated with ischemic stroke and stroke recurrence. Hemodynamics seem to play a relevant role for their development. Thus, we investigated the association of 4D flow-MRI derived local wall shear stress (WSS) and oscillatory shear stress (OSI) with the presence of cCAPs in patients with mild to moderate internal carotid artery (ICA) stenosis. From a prospective and consecutive cross-sectional study with 121 patients with high cardiovascular risk, 39 patients (49 carotid arteries) demonstrated a 10-50% ICA-stenosis and were included in this analysis. Plaque composition was determined according to the modified AHA classification of lesions by high-resolution multi-contrast 3T-MRI. We determined WSS (minimum, mean and maximum) and OSI in vivo by 4D flow-MRI at different locations within the stenosis (upstream, stenosis center and downstream). We studied the association of each hemodynamic parameter with the presence cCAPs by logistic regression analysis adjusted for age, sex and plaque thickness. 11 (22.4%) of the 49 ICA-stenosis in our cohort showed cCAP. WSS and OSI at the beginning of the stenosis did not differ between complicated and stable plaques. By contrast, WSS was significantly higher in the stenosis center and poststenotic region in cCAPs. OSI was significantly higher in the stenosis center of stable plaques. Logistic regression analysis revealed a significant association for WSSmean (OR per SD increase 1.97, 95%-CI 1.14-3.39, p=0.015) and for WSSmax (OR per SD increase 1.84; 95%-CI 1.10-3.08; p=0.020), but not for WSSmin and OSI with the presence of cCAPs. Higher wall shear stress in ICA stenosis was significantly associated with the presence of cCAPs underlining the potential role of hemodynamics in their development. cCAP, complicated carotid artery plaque; WSS, wall shear stress; OSI, oscillatory shear index.

Retinal vasculature changes in patients with internal carotid artery stenosis.

To evaluate the retinal vasculature in patient with internal carotid artery (ICA) stenosis and to highlight association between ICA stenosis severity and retinal vasculature changes. Seventy-five subjects were included in this prospective study. Twenty-five healthy subjects were included in the Group 1, 25 subjects with 1-49% ICA stenosis were included in the Group 2, and 25 subjects with 50-69% ICA stenosis were included in the Group 3. Visual acuity, intraocular pressure (IOP), and anterior and posterior segment examinations were performed. Macular superficial and deep capillary density, optic nerve head capillary density, and choroidal thickness data were measured using optic coherence tomography angiography. There was a statistically significant difference between the three groups regarding superficial vascular density, deep vascular density, vascular density of radial peripapillary capillary and choroid thickness (p < 0.05 for all). Mean parafoveal and perifoveal area vascular density of the superficial capillary plexus was significantly lower in the Group 3 than Group 1 (p < 0.05 for all). Mean whole area vascular density of the deep capillary plexus was significantly lower in Group 3 than both groups (p < 0.05 for all). Mean parafoveal area vascular density of the deep capillary plexus was significantly lower in the Group 3 than Group 1 (p < 0.05). Mean subfoveal choroid thickness in group 3 was significantly lower in the Group 3 than both groups (p < 0.05 for all). Compared to healthy controls, patients with moderate ICA stenosis revealed decreased density of superficial, deep and radial peripapillary capillary vasculature and subfoveal choroidal thickness.

Symptomatic Severe Stenosis of Cavernous Internal Carotid Artery Stenting: A Case Report with Short Literature Review

AbstractIntracranial internal carotid artery (ICA) stenosis is rarely reported as compared with extracranial ICA stenosis. Atherosclerosis is one of the major beginnings of stenosis of vasculatures, which may lead to ischemic stroke causing morbidity and mortality. We report the case of a 60 -year-old man presented to us with complaints of multiple episodes of dizziness, mild headache, and transient left arm weakness for 3 months and had history of smoking, hypercholesterolemia (high level of low-density lipoprotein level = 220 mg/dL), diabetes mellitus, and hypertension under medication. No neurological deficits were observed at the time of admission. Patient underwent angioplasty and stenting with drug-eluting balloon-expandable coronary stent. Patient was discharged well at the 3rd day of procedure. No recurrence of stroke and restenosis were noted till 3 months of follow-up period. Stenting following angioplasty for treatment of symptomatic severe cavernous ICA stenosis with everolimus-eluting coronary balloon-expandable stent, Xience Xpedition, is safe and effective.

High-Resolution Vessel Wall Imaging in Primary CNS Vasculitis: A Case Series

High-resolution vessel wall imaging (HRVWI) is a relatively new technique in which vessel walls can be imaged suppressing the cerebrospinal fluid and blood signals. If there is inflammation of the vessel wall (vasculitis) it will show contrast enhancement. This is the only modality which is available to study vessel walls. All angiography techniques including Magnetic Resonance Angiography(MRA), Contrast computerized tomography angiography (CT -Angiography), and digital subtraction angiography (DSA) shows only the state of the lumen of the blood vessel. Involvement of blood vessels in Central Nervous system (CNS) can occur in systemic vasculitis (like microscopic polyangiitis, Polyarteritis nodosa, etc) where there is evidence of other organ involvement or primary CNS vasculitis (PCNSV) in which only involvement of the brain and spinal cord occurs. PCNSV is a rare disease and till now only the brain biopsy is the gold standard for definitive diagnosis. Brain biopsy is an invasive procedure, not always available, and many patients don’t give consent for the procedure. HRWVI can complement the angiography in the diagnosis of CNS vasculitis, especially PCNSV. Here we describe a case series of 4 cases of CNS vasculitis (3 cases of possible PCNSV and one vasculitic moya- moya syndrome) who had presented with stroke, All had abnormal Cerebrospinal fluid (CSF) and HRVWI showed contrast enhancement of the vessel wall indicating the possibility of vasculitis. In two cases, there was involvement of medium-sized arteries (middle cerebral artery), one patient had unilateral internal carotid artery (ICA) involvement and one had bilateral supra- clinoid stenosis of ICA associated with hyperthyroidism (vasculitic Moyamoya syndrome).

An Interventional Quandary—Clipping vs Coiling vs STA-MCA Bypass in a Ruptured Basilar Tip Aneurysm with Bilateral ICA Stenosis: A Rare Case Report and a Comprehensive Review

Our primary goal is to report a detailed case outlining the clinical and radiological characteristics of an extremely rare condition: bilateral internal carotid artery (ICA) stenosis with ruptured basilar tip aneurysm, and bilateral posterior cerebral arteries (PCAs) arising from the sac, treatment options, as well as its outcome. We searched the PUBMED database from 1980 to 2023 for similar case reports. Among seven similar cases found, two were conservatively managed, focusing on reducing intracranial pressure (ICP). One out of two survived, while one ended in fatality. In the other five cases, interventions (endovascular in four/STA-MCA (superficial temporal artery–middle cerebral artery) bypass in one) were pursued, resulting in significant recovery and discharge. Dealing with such complex cases with uncommon pathoanatomy poses treatment challenges due to their hemodynamics and the risk of collateral flow cessation despite multiple available treatment options.

Moyamoya disease: insights into the clinical implications of the RNF213 gene

Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by progressive stenosis of the terminal internal carotid arteries and the formation of compensatory collateral vessels, which appear as a “puff of smoke” on cerebral angiography. It is a significant cause of stroke in East Asia, with an incidence of 0.5 to 1.5 cases per 100,000 people annually. The etiology of MMD remains unclear; however, the identification of the RNF213 gene, particularly the R4810K variant, as a major susceptibility factor among the East Asian population, has provided crucial insights into the disease's pathophysiology and clinical manifestations. MMD typically presents with transient ischemic attacks, ischemic and hemorrhagic strokes, seizures, headaches, and cognitive deficits. Diagnostic criteria have evolved to emphasize advanced imaging techniques. Pathological features include fibrocellular intimal thickening, irregular undulation of the elastic lamina, and the formation of moyamoya vessels. The mutation in the RNF213 gene impairs the degradation of proteins involved in vessel development, leading to abnormal angiogenesis. Genotype-phenotype studies indicate that the RNF213 variant is associated with an earlier onset, transient ischemic attacks, infarctions, and involvement of the posterior cerebral artery, although its effects vary between regions. Additionally, the homozygous RNF213 variant consistently correlates with an earlier age of onset and a higher risk of cerebral infarction. However, further research is necessary to fully understand its long-term impacts and its relationship with revascularization outcomes. Ongoing research is crucial to fully comprehend the pathophysiology and genetics of MMD, improve prognostic predictions, and develop novel therapies.

Recruitment of pial collaterals and carotid occlusive disease in large-vessel occlusion ischemic stroke.

Despite the fundamental role of pial collateral vessels in limiting the progression of ischemic tissue injury in acute stroke with large vessel occlusion (LVO), in addition to the fact that collateral vessel abundance varies naturally from person to person for genetic reasons, there is limited knowledge regarding potential factors contributing to inherent interindividual variation in pial collateral supply. As it has been repeatedly hypothesized that chronic carotid occlusive disease may favor pial collateralization, we aimed to investigate the association between quantitatively assessed leptomeningeal collateral supply and pre-existing carotid stenosis in patients with acute stroke due to LVO. Patients with proximal middle cerebral artery (MCA) occlusion with or without additional internal carotid artery (ICA) occlusion were included. The degree of collateral supply was quantitatively assessed based on signal variance in T2*-weighted time series in perfusion-weighted magnetic resonance imaging (PWI). Patients were stratified into two groups according to quantitative collateral status (poor and fair to good collateral supply). The prevalence of high-grade ICA stenosis (≥70%) was evaluated in both groups. A total of 98 patients (mean age 68.8 ± 16.1 years, n = 52 (53.1%) of whom were female individuals) with MCA and/or ICA occlusion were included in the final analysis. Out of these patients, 42 had poor collateral supply, while 56 exhibited fair to good collateral supply. Additionally, 18 patients showed ipsilateral high-grade ICA stenosis. After classifying the entire cohort based on their collateral status (poor vs. fair to good collateral supply), there was no significant difference in the proportion of the patients with ipsilateral high-grade ICA stenosis between the two groups. Specifically, 6 (14.3%) patients had poor collateral supply, and 12 (21.1%) patients had fair to good collateral supply. The odds ratio (OR) was 1.58, with a 95% confidence interval (CI) of 0.490-5.685 and the p-value of 0.440. In the entire patient cohort, signal variance-based collateral supply was significantly correlated with initial stroke severity (r = -0.360, p < 0.001), baseline ischemic core volume (r = -0.362, p < 0.001), and functional outcomes (score on the modified Rankin Scale) at discharge (r = -0.367, p < 0.01). In this study, we performed a quantitative and observer-independent MRI-based collateral assessment in patients with LVO. We found no significant difference in the prevalence of pre-existing high-grade ICA stenosis between patients with fair to good collateral supply and those with poor collateral supply. The potential influence of demographic and clinical variables on pial collateral supply in patients with acute stroke warrants further exploration in future studies. MRI-based collateral supply is significantly related to initial stroke severity, ischemic core volume, and early functional outcomes.

Stenting for symptomatic intracranial arterial stenosis with different qualifying arteries: a preplanned pooled individual patient data analysis

BackgroundThe efficacy of percutaneous transluminal angioplasty and stenting (PTAS) relative to medical management in treating symptomatic intracranial arterial stenosis (ICAS) varies based on the qualifying artery. This study aims to...

More severe cerebral small vessel disease associated with poor leptomeningeal collaterals in symptomatic intracranial atherosclerotic stenosis.

We investigated the association between cerebral small vessel disease (CSVD) and ipsilateral leptomeningeal collateral (LMC) status in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). In 108 patients with 50-99% symptomatic intracranial internal carotid artery or M1 middle cerebral artery stenosis, 4 CSVD imaging markers (lacunes, cerebral microbleeds, enlarged perivascular spaces [EPVSs], and white matter hyperintensities [WMHs]) were assessed in MRI. Score of 0 or 1 was assigned to each marker and added up as a summary CSVD score (ranging 0-4) to reflect an overall CSVD burden. Ipsilateral LMC status was assessed by determining the laterality of distal vessels in anterior and posterior cerebral artery territories on CT angiography. Moderate-to-severe EPVSs (adjusted odds ratio [aOR] = 4.15; p = 0.031) and WMHs (aOR = 5.90; p = 0.010), and higher summary CSVD score (aOR = 1.66; p = 0.030) were independently associated with poor LMCs. There was significant interaction between stenosis percentage in sICAS and summary CSVD score on poor LMCs (p = 0.022 for interaction), when higher CSVD score was significantly associated with poor LMCs in patients with severe sICAS (aOR = 2.84; p = 0.011) but not in those with moderate sICAS. The findings indicated possibly adverse effect of CSVD on the recruitment or development of LMCs in sICAS patients, especially in patients with severe sICAS.

Convexity subarachnoid hemorrhage revealed contralateral internal carotid artery dissection due to Eagle syndrome: a case report

BackgroundAtraumatic localized convexity subarachnoid hemorrhage (cSAH) is an uncommon form of nonaneurysmal subarachnoid hemorrhage characterized by bleeding limited to the cerebral convexities. Ipsilateral cSAH can result from a variety of causes, such as internal carotid artery stenosis, obstruction, and dissection, although concomitant contralateral cSAH is exceptionally rare. In this case, the initial findings of cSAH led us to discovering contralateral internal carotid artery dissection (ICAD) and an elongated styloid process (ESP). ESP is recognized as a risk factor for ICAD, which is a hallmark of Eagle syndrome. This sequence of findings led to the diagnosis of Eagle syndrome, illustrating a complex and intriguing interplay between cerebrovascular conditions and anatomical variations.Case presentationA 47-year-old Japanese woman experienced acute onset of headache radiating to her neck, reaching its zenith approximately two hours after onset. Given the intractable nature of the headache and its persistence for three days, she presented to the emergency department. Neurological examination revealed no abnormalities, and the coagulation screening parameters were within normal ranges. Brain computed tomography (CT) revealed right parietal cSAH, while CT angiography (CTA) revealed ICAD and an ESP measuring 30.1 mm on the left side, positioned only 1.4 mm from the dissected artery. The unusual occurrence of contralateral cSAH prompted extensive and repeated imaging reviews that excluded reversible cerebral vasoconstriction syndrome (RCVS), leading to a diagnosis of left ICAD secondary to Eagle syndrome. The patient underwent conservative management, and the dissected ICA spontaneously resolved. The patient has remained recurrence-free for two and a half years.ConclusionsManaging cSAH requires diligent investigation for ICAD, extending beyond its identification to explore underlying causes. Recognizing Eagle syndrome, though rare, as a potential etiology of ICAD necessitates the importance of evaluating ESPs. The method for preventing recurrent cervical artery dissection due to Eagle syndrome is controversial; however, conservative management is a viable option.

Curve-centered plaques raise the risk of peri-operative neurological and cardiovascular complications during angioplasty and stenting for severe carotid stenosis.

Carotid artery stenting is an alternative interventional treatment to carotid endarterectomy. However, preprocedural considerations and anatomical risk factor analyses for carotid artery stenting are currently insufficient. Therefore, we investigated the high-risk anatomical appearance of carotid artery stenting from the neurointerventionist perspective to predict periprocedural complications. We retrospectively reviewed patients with carotid stenosis who underwent carotid artery stenting at a comprehensive stroke center between January 2012 and December 2021. We compared the demographic characteristics, medical history, and anatomical appearance of the stenotic segment in patients with and without complications. We analyzed a total of 148 patients (64 women [43.2%]; median age, 73.0 [interquartile range, 65.5-79.0]). Complications occurred in 39 of the 148 patients, primarily minor and transient. Of baseline or procedural characteristics, a high initial National Institutes of Health Stroke Scale score (p = 0.04), symptomatic stenosis (p = 0.01), and curve-centered plaque of the proximal ICA (p = 0.01) were significantly associated with carotid artery stenting complications in unadjusted analysis. Curve-centered plaque remained an independent risk factor for carotid artery stenting complications after adjustment (odds ratio 2.23[1.02-4.88], p = 0.04). High-risk vascular anatomical features, such as curve-centered plaque, are associated with a high frequency of periprocedural complications of carotid artery stenting. Tailored patient selection for carotid stenosis is crucial to prevent complications. Patients with curve-centered plaque should consider alternative treatment options such as carotid endarterectomy to achieve optimal clinical results.

8291 Graves’ Disease and Moyamoya Syndrome: A Complex Case of Thyroid Dysfunction and Neurovascular Abnormalities

Abstract Disclosure: A. Jamil: None. Q.V. Luong: None. A. Llorens Bonilla: None. A. Siddiqui: None. Background: Moyamoya disease is a cerebrovascular disease characterized by progressive stenosis and occlusion of cerebral arteries, particularly the internal carotid arteries, proximal anterior and middle cerebral arteries associated with a net-like collateral vessel formation. Moyamoya disease in association with certain systemic conditions (e.g. Graves’ disease, sickle cell anemia, neurofibromatosis type 1, and Down Syndrome) has been referred to as moyamoya syndrome. Graves’ disease is an autoimmune disease in which the development of thyroid-stimulating hormone (TSH) receptor autoantibodies leads to overproduction of thyroid hormones. Although the pathophysiology is unclear, Graves’ disease can adversely impact the clinical course of moyamoya syndrome.Clinical Case: A 26-year-old woman diagnosed with Graves’ disease at the age of 20 years who was in remission presented to the ED with right upper extremity weakness and headache. A stroke work-up was performed, and an initial CT head without contrast showed an acute infarct in the left temporal area. Extensive workup for hypercoagulability and cardiac causes were negative. MRI brain showed multiple infarcts of the left cerebral hemisphere with ivy sign, which are prominent linear or punctate high intensity areas in the subarachnoid space reflecting the development of collaterals that occurs in moyamoya disease. TSH at the time was noted to be &amp;lt;0.01 uIU/mL (range: 0.30-4.20 uIU/mL), indicating a thyrotoxic state. She was discharged on methimazole and antiplatelet therapies. However, the patient continued to have hypertension and headaches which did not resolve with the return to euthyroidism. At age 29, she again developed acute right upper and lower extremity weakness, and consequently presented to the ED. Imaging studies showed multiple punctate infarcts in her bilateral frontal lobes and bilateral ICA stenosis consistent with moyamoya disease. However, her biochemical studies showed euthyroidism. Ultimately, she underwent right frontotemporal craniotomy and direct parietal superficial temporal artery to middle cerebral artery bypass by neurosurgery to decrease her future stroke risk for her moyamoya syndrome, and her Graves’ disease remains in remission.Conclusions: The coexistence of Graves’ disease in moyamoya syndrome may suggest a pathophysiologic connection. It has been suggested that hemodynamic changes in cerebrovascular flow due to thyrotoxicosis might contribute to ischemic neurologic deficits. Surgical intervention for revascularization procedures should be attempted after optimal control of thyrotoxicosis, as this may help to prevent further ischemic events in the future and improve patient outcomes. Presentation: 6/1/2024

Effect of remote ischemic preconditioning on cerebral circulation time in severe carotid artery stenosis: Results from the RIC-CCT trial.

In patients with severe internal carotid artery stenosis (sICAS), cerebral circulation time (CCT) is associated with cerebral hyperperfusion syndrome. This study aims to investigate the effect of remote ischemic preconditioning (RIC) on CCT in patients with sICAS. Patients are randomly assigned to the RIC group (RIC twice daily, for 2-4days before carotid artery stenting [CAS] as an adjunct to standard medical therapy) and the control group. The results show that RIC produces a significant decrease in CCT of the stenosis side (sCCT) from baseline to pre-CAS, and the occurrence of contrast staining on brain computed tomography (CT) is lower in RIC versus control group after CAS. In addition, significant changes in some serum biomarkers suggest that anti-neuroinflammation, anti-oxidative stress, protecting endothelial injury, and improving cerebral autoregulation may be associated with the effect of RIC. These findings provide supporting evidence that RIC can modulate cerebral circulation in patients with sICAS. This study was registered at ClinicalTrials.gov (NCT05451030).

Systemic immune-inflammation index predicts short-term mortality in acute ischemic stroke with severe stenosis of internal carotid artery associated pneumonia.

We aimed to investigate the relationship between systemic immune-inflammation index (SII) and short-term mortality in acute ischemic stroke (AIS) with internal carotid artery (ICA) severe stenosis and stroke associated pneumonia (SAP) patients. Information on general demographic, laboratory data, CT angiography, magnetic resonance angiography, or digital subtraction angiography were obtained. The predictive power was evaluated by assessing the area under the receiver operating characteristic (ROC) curve. The logistic regression was performed to assess the association of SII and short-term mortality in severe stenosis ICA-AIS and SAP patients. Among 342 patients with severe stenosis ICA-AIS and SAP, death occurred in 66 patients during 120 days follow-up. Multivariate regression analyses indicated that increased SII predicts higher mortality in 120 days follow-up, and the risk of short-term mortality in SII>666.31 × 109/L group is increased 4.671-fold. Patients with SII>666.31 × 109/L had higher proportion of male, hypertension, smoking, higher admission NIHSS score, higher systolic blood pressure, and higher proportion of 120 days mortality. Higher SII predicted a worse 120 days mortality was worked out by Kaplan-Meier methods. An elevated SII was remarkably associated with 120 days mortality in severe stenosis ICA-AIS and SAP patients.

Soluble Glycoprotein VI Levels Assessed Locally within the Extra- and Intracerebral Circulation in Hyper-Acute Thromboembolic Stroke: A Pilot Study.

Background: Severe acute ischemic stroke (AIS) is mainly caused by thromboembolism originating from symptomatic carotid artery (ICA) stenosis or in the heart due to atrial fibrillation. Glycoprotein VI (GPVI), a principal platelet receptor, facilitates platelet adherence and thrombus formation at sites of vascular injury such as symptomatic ICA stenosis. The shedding of GPVI from the platelet surface releases soluble GPVI (sGPVI) into the circulation. Here, we aimed to determine whether sGPVI can serve as a local biomarker to differentiate between local atherosclerotic and systemic cardiac thromboembolism in AIS. Methods: We conducted a cohort study involving 105 patients undergoing emergency endovascular thrombectomy (EVT) for anterior circulation stroke. First, sGPVI concentrations were measured in systemic arterial plasma samples collected at the ipsilateral ICA level, including groups with significantly (≥50%) stenotic and non-stenotic arteries. A second sample, taken from the intracerebral pial circulation, was used to assess GPVI shedding locally within the ischemic brain. Results: Our analysis revealed no significant increase in systemic sGPVI levels in patients with symptomatic ≥ 50% ICA stenosis (3.2 [95% CI 1.5-5.0] ng/mL; n = 33) compared with stroke patients without significant ICA stenosis (3.2 [95% CI 2.3-4.2] ng/mL; n = 72). Additionally, pial blood samples, reflecting intravascular molecular conditions during collateral flow, showed similar sGPVI levels when compared to the systemic ICA samples in both groups. Conclusions: Our findings indicate that GPVI is not locally cleaved and shed into the bloodstream in significant amounts during hyper-acute ischemic stroke, neither at the level of symptomatic ICA nor intracranially during collateral blood supply. Therefore, sGPVI does not appear to be suitable as a local stroke biomarker despite strong evidence of a major role for GPVI-signaling in stroke pathophysiology.

Non-contrast-enhanced MR-angiography of Extracranial Arteries in Acute Ischemic Stroke at 1.5 Tesla Using Relaxation-Enhanced Angiography Without Contrast and Triggering (REACT).

To evaluate anovel flow-independent sequence (Relaxation-Enhanced Angiography without Contrast and Triggering (REACT)) for imaging of the extracranial arteries in acute ischemic stroke (AIS) at 1.5 T. This retrospective single-center study included 47AIS patients who received REACT (scan time: 3:01 min) and contrast-enhanced MRA (CE-MRA) of the extracranial arteries at 1.5 T in clinical routine. Two radiologists assessed scans for proximal internal carotid artery (ICA) stenosis, stated their diagnostic confidence and rated the image quality of cervical arteries, impact of artifacts and image noise. Apparent signal- and contrast-to-noise ratios (aSNR/aCNR) were measured for the common carotid artery and ICA. REACT achieved asensitivity of 95.0% and aspecificity of 97.3% for ICA stenoses in high agreement with CE-MRA (κ = 0.83) with equal diagnostic confidence (p = 0.22). Image quality was rated higher for CE-MRA at the aortic arch (p = 0.002) and vertebral arteries (p < 0.001), whereas REACT provided superior results for the extracranial ICA (p = 0.008). Both sequences were only slightly affected by artifacts (p = 0.60), while image noise was more pronounced in CE-MRA (p < 0.001) in line with higher aSNR (p < 0.001) and aCNR (p < 0.001) values in REACT for all vessels. Given its good diagnostic performance while yielding comparable image quality and scan time to CE-MRA, REACT may be suitable for the imaging of the extracranial arteries in acute ischemic stroke at 1.5 T.

Артериальное и венозное кровообращение у пациентов с выраженным стенозом внутренних сонных артерий до и в разные сроки после проведения каротидной эндартерэктомии

In continuation of earlier studies of the features of venous outflow from the head and neck in patients with varying degrees of stenosis of the internal carotid arteries (ICA), in this article the authors present data on the features of arterial inflow and venous outflow in patients with a high degree of stenosis before and at different periods after carotid endarterectomy. Material and methods 30 patients with stenosis ˃ 60%, were examined before and after surgery at 10-14 days, 6 months and 1 year. The control group consisted of 30 patients without ICA stenosis and signs of systemic and regional phlebohypertension. The results were compared with the control and between the groups. Results The study has shown that venous outflow through the PV in orthostasis at different times after CEAE prevailed over venous outflow in clinostasis. The average values of the total volumetric blood flow through the PV statistically significantly increase after surgery in both clinostasis and orthostasis. Conclusions The presence of phlebohypertension with severe stenosis of the ICA may indicate a relationship between atherosclerotic lesions of the ICA and changes in venous outflow and the formation of systemic or regional phlebohypertension. When restoring blood flow through the ICA with stenosis ˃ 60% after CEAE, the predominance of venous outflow remains in the horizontal position along the IJV system.

&lt;i&gt;CDKN2B-AS1&lt;/i&gt; polymorphism rs1333049 is associated with advanced carotid artery atherosclerosis in a Slovenian population

Several studies have reported an association between the 9p21 region in the human genome and atherosclerosis. The rs1333049 polymorphism is a single nucleotide polymorphism (SNP) in CDKN2B-AS1, located in the 9p21 region. The aim of our study was to investigate the association between the rs1333049 polymorphism and advanced carotid atherosclerosis, as well as its effect on CDKN2B expression in endarterectomy sequesters. In our case-control study, we included 881 participants, divided into two groups. The case group comprised 308 participants with advanced atherosclerosis of the internal or common carotid artery (stenosis &gt; 75 %) who underwent a revascularization procedure. The control group included 573 participants without hemodynamically significant carotid atherosclerosis. We analyzed the rs1333049 polymorphism using the StepOne real-time polymerase chain reaction (PCR) and TaqMan SNP genotyping assay. We found a statistically significant association according to the co-dominant (P=0.014, OR=3.29, 95% CI: 1.32-8.91, and P=0.015, OR=2.50, 95% CI: 1.22-5.37) and dominant (P=0.006, OR=2.74, 95% CI: 1.36-5.71) models. We performed immunohistochemical analysis of CDKN2B expression on 26 endarterectomy sequesters. The C allele of rs1333049 was associated with a lower numerical area density of CDKN2B-positive cells in atherosclerotic plaques. In conclusion, the C allele of the rs1333049 SNP is associated with an increased risk of developing advanced carotid atherosclerosis and lower CDKN2B expression in the plaques.

Bow Hunter Phenomenon From Advanced Cerebrovascular Disease Treated With Subclavian Artery Stenting and Carotid Endarterectomy.

Bow Hunter syndrome (BHS) is a rare disorder characterized by mechanical occlusion of the vertebral artery (VA) during neck rotation, resulting in symptomatic, transient, and positional vertebrobasilar insufficiency. We describe a case of a 76-year-old female who presented with dizziness and right ear tinnitus triggered by right head rotation. Her symptoms would immediately resolve upon returning her head to the neutral position. CT angiogram showed 80% stenosis of the left subclavian artery origin, 50%-70% stenosis of the proximal right internal carotid artery (ICA), and near occlusive stenoses of the origins of the bilateral VAs. After failing conservative management, the patient was treated with left subclavian artery stenting, followed by a right carotid endarterectomy (CEA) 6weeks later. Follow-up at 1month showed resolution of paroxysmal symptoms and no neurological sequelae. To our knowledge, there have not yet been reported cases of patients with concurrent BHS, subclavian artery stenosis, and carotid artery stenosis. We suggest that global revascularization via subclavian artery stenting and CEA may be considered as treatment for patients with BHS complicated by other cerebrovascular disease secondary to stenoses of the ICA and subclavian artery. This approach obviates the need for more complex surgery or endovascular intervention of the VA.

Stroke after heart valve surgery: a single center institution report

IntroductionStroke is a potentially debilitating complication of heart valve replacement surgery, with rates ranging from 1 to 10%. Despite advancements in surgical techniques, the incidence of postoperative stroke remains a significant concern, impacting patient outcomes and healthcare resources. This study aims to investigate the incidence, risk factors, and outcomes of in-hospital adverse neurologic events, particularly stroke, following valve replacement. The analysis focuses on identifying patient characteristics and procedural factors associated with increased stroke risk.MethodsThis retrospective study involves a review of 417 consecutive patients who underwent SVR between January 2004 and December 2022. The study cohort was extracted from a prospectively recorded cardiac intensive care unit database. Preoperative and perioperative data were collected, and subjects with specific exclusion criteria were omitted from the analysis. The analysis includes demographic information, preoperative risk factors, and perioperative variables.ResultsThe study identified a 4.3% incidence of postoperative stroke among SVR patients. Risk factors associated with increased stroke susceptibility included prolonged cardiopulmonary bypass time, aortic cross-clamp duration exceeding 90 min, prior stroke history, diabetes mellitus, and mitral valve annulus calcification. Patients undergoing combined procedures, such as aortic valve replacement with mitral valve replacement or coronary artery bypass grafting with AVR and MVR, (OR = 10.74, CI:2.65–43.44, p-value = < 0.001) and (OR = 11.66, CI:1.02–132.70, p-value = 0.048) respectively, exhibited elevated risks. Internal carotid artery stenosis (< 75%) and requiring prolonged inotropic support were also associated with increased stroke risk(OR = 3.04, CI:1.13–8.12, P-value = 0.026). The occurrence of stroke correlated with extended intensive care unit stay (OR = 1.12, CI: 1.04–1.20, P-value = 0.002) and heightened in-hospital mortality.ConclusionIn conclusion, our study identifies key risk factors and underscores the importance of proactive measures to reduce postoperative stroke incidence in surgical valve replacement patients.