Internal Carotid Artery Stenosis Research Articles

Carotid atherosclerosis in a sample of Egyptian patients with or without ischemic vascular events

BackgroundEthnic-racial factors are related to the development of extra- and intracranial atherosclerosis. There are extensive data about carotid atherosclerosis from American, European and Asian population. However, data from Egyptian ethnics are extremely rare. We aimed to examine the frequency and determine the predictors of carotid atherosclerosis in a sample of Egyptian patients. In a cross-sectional observational study, we prospectively recruited consecutive patients, with or without ischemic vascular events, either ischemic stroke or transient ischemic attack, who received neurovascular ultrasound in a tertiary hospital. We assessed the presence of carotid plaques and the degree of stenosis according to the hemodynamic North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria.ResultsA total of 668 carotid arteries in 334 patients with a mean (IQR) age of 61 (55–70) years were examined; 69.5% presented with and 30.5% without ischemic vascular events. We found carotid plaques in 208 (31.1%) arteries among 147 (44%) patients; 32% of the patients showed non-hemodynamically significant plaques, whereas 3.6% showed 20–40% internal carotid artery (ICA) stenosis and 8.4% showed ≥ 50% ICA stenosis. In patients with ischemic vascular events and at least one risk factor, we detected carotid atherosclerosis, 20–40% ICA stenosis and ≥ 50% ICA stenosis in 40.4%, 3% and 9.1% among patients ≤ 60 years as well as in 64.8%, 5.5% and 13% among patients > 60 years, respectively. In an age and sex adjusted binary logistic regression model, the following factors predicted carotid atherosclerosis: age > 60 years (OR 3.33, 95% CI 1.99–5.57, p < 0.001), hypertension (OR 2.3, 95% CI 1.32–4.02, p = 0.003), current smoking (OR 2.27, 95% CI 1.13–4.55, p = 0.02), diabetes mellitus (OR 2.15, 95% CI 1.27–3.64, p = 0.004) and ischemic vascular events (OR 1.8, 95% CI 1.01–3.19, p = 0.046).ConclusionsAmong Egyptians, the frequency of carotid atherosclerosis seems to be low. Further multiethnic studies are warranted to compare the prevalence of carotid atherosclerosis among Egyptians with Whites and Chinese populations. Older age, hypertension, smoking, diabetes mellitus and ischemic vascular events are predictors of carotid atherosclerosis.

Natural history of internal carotid artery stenosis progression

ObjectiveThe aim of this study was to investigate the natural history of internal carotid artery (ICA) stenosis progression. MethodsThis single-institution retrospective cohort study analyzed patients diagnosed with ICA stenosis of 50% or greater on duplex ultrasound from 2015 to 2022. Subjects were drawn from our institutional Intersocietal Accreditation Commission-accredited noninterventional vascular laboratory database. Primary outcomes were incidences of disease progression, and stroke or revascularization after index study. Progression was defined as an increase in stenosis classification category. Imaging, demographic, and clinical data was obtained from our institutional electronic medical record via a database mining query. Cases were analyzed at the patient and artery levels, with severity corresponding to the greatest degree of ICA stenosis on index and follow-up studies. ResultsOf 577 arteries in 467 patients, mean cohort age was 73.5 ± 8.9 years at the time of the index study, and 45.0% (n = 210) were female. Patients were followed with duplex ultrasound for a mean of 42.2 ± 22.7 months. Of 577 arteries, 65.5% (n = 378) at the index imaging study had moderate (50%-69%) stenosis, 23.7% (n = 137) had severe (70%-99%) stenosis, and 10.7% (n = 62) were occluded. These three groups had significant differences in age, hypertension, hyperlipidemia prevalence, and proportion on best medical therapy. Of the 467-patient cohort, 56.5% (n = 264) were on best medical therapy, defined as smoking cessation, treatment with an antiplatelet agent, statin, and antihypertensive and glycemic agents as indicated. Mean time to progression for affected arteries was 28.0 ± 20.5 months. Of those arteries with nonocclusive disease at diagnosis, 21.3% (n = 123) progressed in their level of stenosis. Older age, diabetes, and a history of vasculitis were associated with stenosis progression, whereas antiplatelet agent use trended towards decreased progression rates. Of the 467 patients, 5.6% (n = 26) developed symptoms; of those, 38.5% (n = 10) had ischemic strokes, 26.9% (n = 7) had hemispheric transient ischemic attacks, 11.5% (n = 3) had amaurosis fugax, and 23.1% (n = 6) had other symptoms. A history of head and neck cancer was positively associated with symptom development. Of 577 affected arteries, 16.6% (n = 96) underwent intervention; 81% (n = 78) of interventions were for asymptomatic disease and 19% (n = 18) were for symptomatic disease. No patient-level factors were associated with risk of intervention. ConclusionsA significant number of carotid stenosis patients experience progression of disease. Physicians should consider long-term surveillance on all patients with carotid disease, with increased attention paid to those with risk factors for progression, particularly those with diabetes and a history of vasculitis.

Quantitative Assessment of Retinal and Choroidal Microvasculature in Asymptomatic Patients with Carotid Artery Stenosis.

Carotid disease contributes to 15-20% of all ischemic strokes, one of the leading causes of permanent disabilities and mortality globally. With its growing prevalence and the inflicted disability rates, screening for anomalies that precede the onset of its serious complications is of crucial global significance. To assess the relationship between retinal and choroidal perfusion changes with the degree of stenosis using quantitative Swept-source optical coherence tomography angiography (SS-OCTA) in patients with internal carotid artery stenosis. A retrospective cohort study was conducted in 72 eyes with carotid stenosis. According to the degree of stenosis, the participants were divided into a healthy group (Group 1: 34 eyes), a mild-moderate stenosis group (Group 2: 22 eyes), a severe stenosis group (Group3: 16 eyes). SS-OCTA was performed to scan macular fovea. Capillary density values in the different retinal and choroidal layers were the major measurements for our study. Mean vessel density in the mid-choroid layer was significantly higher in group 2 and 3 compared with group 1. Deep choroid disclosed significantly superior vascular density values in group 3 compared to groups 2 and 1. Superficial and deep capillary plexus showed decreased vascular density values when comparing group 3 with groups 1 and 2, although they were not significant. Our report provides the first evidence that choroidal microvascular changes were correlated with severity of carotid artery stenosis. OCTA can sensitively detect subtle, early changes in the ocular blood in carotid disease representing a useful, non-invasive and objective approach to the retinal microvasculature.

Abstract 126: Bilateral Limb Shaking TIA secondary to Severe Bilateral Carotid Stenosis

Introduction A case describing bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA. Methods '‐ Results CASE A 71‐year‐old male patient with a past medical history significant for type 2 diabetes mellitus and bilateral carpal tunnel syndrome is being followed for symptomatic management of known axonal sensorimotor diabetic polyneuropathy in the neuromuscular clinic. He reported on one of his follow‐up visits that he had been experiencing an eight‐month history of presyncopal to syncopal events occurring solely in the standing position, not followed by postictal state but amnesia to the syncope itself, and resulting in falls with mild injuries. He was experiencing new‐onset dry eyes and mouth but denied anhidrosis or early satiety, and cardiac event monitoring during one of these events was unremarkable for rhythmic causes. Examination was unchanged from previously and was significant for findings consistent with length‐dependent sensory loss with hyporeflexia/areflexia. The constellation of symptoms was suggestive of autonomic dysfunction, and while this may be seen with diabetic polyneuropathy, workup for alternative autonomic neuropathies (including SSA/SSB antibodies, paraneoplastic antibody panel, serum protein electrophoresis with immunofixation, serum free light chains, transthyretin amyloid) was obtained with plan for follow‐up. A few months later, he presented to the ED with intermittent upper extremity shaking (more pronounced on the right than on the left) preceding the syncopal events, which only occurred in the standing position or during physical activity and resolved with rest. There were no (transient) focal neurological deficits, including monocular vision loss or hemispheric syndrome. CTA of the head/neck was obtained and was notable for severe to critical stenoses of the bilateral internal carotid arteries (see figure 1). Duplex US revealed 80‐99% stenosis of both right and left proximal internal carotid arteries. The constellation of findings was most suggestive of bilateral limb‐shaking TIA secondary to bilateral carotid stenosis. He was started on secondary stroke prevention and referred to vascular surgery for evaluation of revascularization. The patient underwent left carotid endarterectomy briefly afterward and experienced resolution of the events – he later also underwent carotid endarterectomy of the right side and remains asymptomatic. DISCUSSION: Limb‐shaking TIA is a well‐described yet underrecognized manifestation of severe carotid disease reported by C.M. Fisher in 1962. The “limb shaking” episodes are typically unilateral, affecting the arm or leg, and are often mistaken for seizures [1]. Pathogenesis involves hemodynamic impairment related to extracranial/intracranial carotid stenosis or occlusion resulting in stereotypical recurrent contralateral limb shaking episodes precipitated by physical activity [2], [3]. The constellation of “limb shaking” spells precipitated upon standing or physical activity with resolution after activity cessation should raise suspicion for limb‐shaking TIA and warrant vascular imaging. Treatment includes medical secondary stroke prevention and revascularization procedures [4], which can alleviate or even resolve the transient symptoms [2]. Conclusion Limb‐shaking TIA is an important yet underrecognized manifestation of relative cerebral hypoperfusion related to severe cerebrovascular disease. This case describes bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA.

Abstract 115: Carotid Intraluminal Thrombus Obscuring Underlying Carotid Web: Case Report

Introduction Carotid webs (CaW) have been increasingly recognized as a unique cause of recurrent ischemic strokes.1 They are defined as thin, intraluminal, shelf‐like lesions along the posterior aspect of the carotid bulb.1,2 Despite more awareness and ongoing studies into their pathogenesis, diagnosis, and management,3 they are still overlooked in clinical practice as a primary carotid ischemic etiology. Our case describes a patient with right extracranial internal carotid artery (ICA) thrombus secondary to later‐diagnosed CaW on close follow‐up imaging. Methods We report a 55‐year‐old African American man with history of hypertension, type 2 diabetes mellitus and hyperlipidemia presented with acute onset slurred speech and left facial droop (FP). His last known well was 24 hours prior to presentation, and NIHSS upon arrival was 3 (FP 2, dysarthria 1). CT angiography (CTA) of the head and neck demonstrated a nearly occlusive thrombus of the distal right M2 segment MCA as well as non‐hemodynamic stenosis of the proximal right ICA with possible underlying sidewall filling defect‐appearing lesion concerning for a posterior wall thrombus without underlying atherosclerosis at the bulb or otherwise. The patient was admitted to the neurovascular intensive care unit and started on aspirin and high‐risk heparin drip. His MRI Brain demonstrated multiple acute/subacute right MCA territory strokes, predominately in the right posterior insula, right frontal lobe, and right posterior corona radiata. His stroke workup was otherwise unrevealing, and he was discharged on apixaban 5mg BID. Results Close surveillance follow‐up imaging with CTA head and neck was planned and obtained one month later, which demonstrated resolution of the filling defect that was obscuring the currently visualized underlying right CaW pocket (Figure‐1). The prevalence of CaWs has been reported to be between 1.2% and 2.5% of patients with acute ischemic stroke. CaWs are most frequently seen in younger, female patients, and patients with these lesions are at increased risk of recurrent stroke.4,5 Determining the optimal management for these lesions remains essential, but the available data thus far have not been conclusive. Most patients are treated with antiplatelet therapy, but some elect to treat with anticoagulation due to the focal hemostasis caused by CaWs.6 However, multiple studies have suggested that medical management alone is likely not sufficient in reducing the recurrent stroke risk caused by CaWs.5,7 Neuro‐interventional procedures including carotid artery stenting have been reported as secondary prevention strategies in patients with recurrent strokes.5,7,8 Although data regarding the rate of recurrence of strokes secondary to these lesions remains unclear, the current data does suggest benefit and safety in pursuing carotid stenting to prevent recurrent strokes.5‐8 Conclusion In young patients with proximal ICA thrombosis without underlying atherosclerosis or other conventional stroke risk factors, CaW should be considered among other differentials including hypercoagulable status. Following acute medical management, short‐term surveillance imaging is essential to confirm or rule out the diagnosis. In our case, the patient’s proximal ICA thrombus resolved after short course of anticoagulation and was determined to be secondary to the obscured underlying CaW.

Abstract 059: The Tenzing‐Dotter Technique for Endovascular Management of Atherosclerotic Cervical ICA Tandem Large Vessel Occlusions

Introduction The endovascular treatment of acute ischemic stroke due to atherosclerotic occlusion/near‐occlusion of the cervical internal carotid artery (ICA) and a concurrent intracranial large vessel occlusion (LVO) remains challenging, and the optimal approach remains unclear. Options include initial angioplasty and/or stenting of the cervical lesion followed by intracranial thrombectomy versus Dotter navigation of catheters through the cervical lesion to first target the intracranial LVO. We describe a novel Tenzing‐Dotter technique which utilizes a Tenzing device for the Dotter delivery of large bore (0.070”) and super‐large bore (0.088”) catheters through cervical atherosclerotic lesions to gain access to the intracranial circulation in tandem LVO patients. Methods We performed a retrospective review our single center experience of atherosclerotic tandem occlusion patients in which the Route 92 Medical Tenzing ® 7 (T7®) and Tenzing ® 8 (T8®) delivery catheters were used to Dotter‐deliver large bore or super‐large bore catheters, respectively, through the cervical ICA lesion to gain access to the intracranial circulation. We reviewed clinical, radiographic and procedural data to describe the safety and efficacy of this approach. Results Twenty patients were identified that that atherosclerotic occlusion/near‐occlusion of the cervical ICA and a single symptomatic intracranial LVO. The mean age was 65 (44 – 89), and 40% were female. The mean NIHSS was 14 (7‐25) and 40% were treated initially with intravenous thrombolytics. The ipsilateral cervical ICA was occluded in 11 of 20 patients (55%) and nearly‐occluded (degree of stenosis 90‐99%) in 9 of 20 patients (45%). The intracranial occlusions were carotid terminus (5), M1 middle cerebral artery (14) and M2 middle cerebral artery (1). Seven patients were treated with Tenzing 7 paired with a large bore catheter (6 with Medtronic React 71 and 1 with Route 92 Medical Hipoint 70), while 13 were treated with Tenzing 8 paired with a super‐large bore catheter (11 with Route 92 Medical Hipoint 88 catheter and 2 with Route 92 Medical Freeclimb 88 catheter). In all cases, successful navigation of the paired catheter through the cervical lesion was achieved in 100% of patient using the Tenzing‐Dotter delivery technique. The mean time from groin puncture to successful Tenzing‐Dotter delivery was 11 minutes, and the mean time from groin puncture to device delivery to the intracranial occlusion was 15 minutes. TICI 2B or greater reperfusion (self‐adjudicated) as achieved in 100% of patients, with a mean time to best TICI of 21 minutes. The degree of cervical ICA stenosis following thrombectomy improved from 96.5% to 67.4%. No symptomatic intracranial hemorrhage or cervical arterial dissections were noted. Conclusion The Tenzing‐Dotter technique, in which a Route 92 Medical Tenzing ® delivery catheter is utilized to Dotter navigate a large or super‐large bore catheter through an occluded or nearly‐occluded cervical atherosclertotic lesion, may be a promising technique for safe and fast access to the intracranial circulation in patients presenting with tandem large vessel occlusion acute ischemic strokes.

Abstract 049: Effect of the ICA Lesion Severity in Outcomes after Endovascular Treatment of Acute Tandem LVO

Introduction Tandem Lesions (TLs) pose unique challenges in the endovascular management of acute ischemic stroke.(1) The absence of anterograde blood flow in the carotid occluded segment may limit the effectiveness of endovascular interventions, resulting in delayed reperfusion or suboptimal recanalization.(2,3) Thus, the presence of unpaired blood flow through the ICA in the context of TLs is believed to exacerbate the extension of ischemic lesions. (4,5) This study compared the clinical and procedural outcomes of patients with TLs and extracranial internal carotid artery occlusion versus those with stenosis. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups: those with extracranial ICA stenosis and those with occlusion. Clinical outcomes, including functional independence, hemorrhagic events, and procedural time metrics including puncture to reperfusion time were assessed. Sensitivity analyses were conducted to evaluate these differences segregating patients according to varying degrees of stenosis, and in pre‐specified subgroups. Results A total of 513 patients with TLs were included in the study. 281 (54.8%) presented with ICA occlusion, and 232 (45.2%) presented stenosis &gt;=70% (Table 1). The comparison between the stenosis and occlusion groups revealed no significant differences in the main outcomes, including mTICI 2c‐3 (47.5% vs. 50.6%, aOR 1.07, 95% CI 0.70‐1.64, p=.751) (Figure 1), mRS 0‐2 at 90 days (43.6% vs. 48.9%, aOR 0.79, 95% CI 0.52‐1.20, p=.271), sICH rates (4.7% vs. 5.6%, aOR 0.72, 95% CI 0.31‐1.71, p=.458), and puncture to reperfusion time (58 [40‐80.5] vs. 52.5 [35.2‐80], ratio 1.04, 95% CI 0.88‐1.23, p=.64). Similar analyses performed comparing different degrees of stenosis and occlusion, and in patients treated with the antegrade approach only, did not show significant differences either. Conclusion Our findings indicate that although more severe degrees of stenosis or occlusion of the ICA prolong the time from puncture to reperfusion, no significant differences in clinical outcomes exist. The clinical implications of these findings need to be further evaluated to fully comprehend the specific needs of patients affected by TLs.

Abstract 109: Endonasal Endoscopic Approach Associated Cerebral Vasospasm and Management: A Case Report

Introduction Endoscopic endonasal approach(EEA) techniques have been increasingly utilized and have been associated with development of cerebrospinal fluid(CSF) leak, meningitis, diabetes insipidus post‐operatively. Cerebral vasospasm following EEA has rarely been described. Here, we describe the clinical course and management of a patient who underwent EEA for encephalocele repair whose course was complicated by postoperative subarachnoid hemorrhage(SAH) and cerebral vasospasm. Methods n/a Results Case Presentation: 40 year old female with past medical history significant for cerebral venous sinus stent on aspirin, CSF rhinorrhea secondary to right nasal encephalocele s/p endoscopic transnasal transethmoidal repair with nasoseptal flap reconstruction and lumbar drain placement eleven days prior presented with speech difficulties and right sided weakness. On exam, patient was noted to have mild right hemiparesis and expressive aphasia. MRI brain showed subacute infarcts in left greater than right frontal lobes, corpus collosum and right anterior perforated substance. MRA head demonstrated multifocal arterial stenosis. In light of postoperative CT head showing SAH in the basilar, perimesencephalic, prepontine cisterns, interhemispheric fissure and right frontal sulci as well as intraventricular hemorrhage in fourth ventricle, her presentation was thought to be secondary to cerebral vasospasm in the setting of postoperative SAH. She was treated with intravenous hydration, permissive hypertension with head of bed in flat position and transferred for further evaluation. On arrival, she continued have mild right hemiparesis and aphasia. Repeat CTA head/neck and CT perfusion showed severe stenosis of bilateral M1 segments and left greater than right A1 segments as well as ischemic penumbra in left ACA/MCA watershed territory. Diagnostic cerebral angiogram showed bilateral severe A1 stenosis and mild to moderate bilateral M1 and supraclinoid ICA stenosis which improved with intra‐arterial verapamil. She was started on nimodipine. Systolic blood pressure was augmented with vasopressors for goal of 150‐180mmHg. Daily TCDs were followed. She developed worsening right leg weakness following day, thus she was taken for repeat diagnostic cerebral angiogram during which time she was re‐administered intra‐arterial verapamil with improvement in vasospasm. After the second treatment, she had improvement in speech and motor strength. Systolic blood pressure goal was gradually normalized. She was noted to have incidental left internal jugular (IJ) vein thrombosis for which anticoagulation was held in the setting of recent neurosurgical procedure and SAH. Workup for vasculitis and hypercoagulability was unrevealing. Lumbar puncture demonstrated 13 WBC/cu mm with lymphocytic predominance(90%), 23 RBC/cu mm, glucose 89mg/dl, protein 30mg/dl. CSF cultures were negative. Pleocytosis in CSF was attributed to recent neurosurgical procedure. Her neurological exam improved to baseline on hospital day(HD) 9.On HD12, she was found to have left common femoral deep venous thrombus in addition to the left IJ thrombus. Anticoagulation with low dose heparin infusion was started which was transitioned to apixaban on discharge. She was discharged home on HD20. Conclusion We report a case of EEA associated with severe multifocal cerebral vasospasm secondary to postoperative SAH that was successfully treated with induced hypertension, oral nimodipine and intra‐arterial verapamil as an adjunct therapy with an excellent outcome.

Stenting for Severe C7 Stenosis of Internal Carotid Artery (ICA) and Related Literature Review

Intracranial Atherosclerosis (ICAS) is a common cerebrovascular lesion worldwide and an important cause of stroke [1]. Nonmodifiable risk factors include age, gender, and genetics, with age being a key factor and atherosclerosis usually progressive, with no clinical manifestations until middle age. Ischemic Heart Disease (IHD) has increased fivefold among people aged 40 to 60. Before menopause, women are less prone to atherosclerosis than men, and the incidence of atherosclerosis is increased in postmenopausal women [2,3]. The inheritance of various genetic polymorphisms and the accumulation of family risk factors (such as diabetes and hypertension) create multiple conditions for the formation of atherosclerosis [4]. On the other hand, modifiable risk factors, such as smoking, hyperlipidemia, diabetes, and high blood pressure, can be improved by adjusting daily life. Studies have analyzed that white people are prone to extracranial arterial occlusive disease, while Asian, black and Hispanic people have a higher risk of intracranial atherosclerotic disease [1]. Therefore, the prevention of atherosclerotic disease, has been very urgent, to increase publicity, from the source to solve the problem.

X-RAY-GUIDED ENDOVASCULAR TREATMENT FOR CRITICAL STENOSIS OF A SOLITARY INTERNAL CAROTID ARTERY: A CLINICAL CASE

In this work, the authors present a clinical case of a 65 year-old man with a history of three acute cerebrovascular accidents similar to a transient ischemic attack and/or ischemic stroke with a minor neurological deficit with short-term weakness in the left or right limbs and loss of coordination. Carotid angiography showed that the blood supply to the brain was provided by a single internal carotid artery on the left and a potent collateral network on the same side. The patient underwent stenting of the internal carotid artery on the left. As a result, blood supply was restored through the stented artery and pronounced collateralization on the right. This clinical case demonstrated that even in complex clinical situations associated with multifocal lesions of the carotid arteries, the use of x-ray endovascular technologies can achieve good clinical results, and x-ray-guided endovascular treatment of critical stenosis of the solitary internal carotid artery will allow achieving significant regression of neurological deficit and designating prognosis optima.

Upregulated Cytoskeletal Proteins Promote Pathological Angiogenesis in Moyamoya Disease.

Moyamoya disease (MMD) is a rare progressive vascular disease that leads to intracranial internal carotid artery stenosis and eventual occlusion. However, its pathogenesis remains unclear. The purpose of this study is to explore the role of abnormally expressed proteins in the pathogenesis of MMD. Data-independent acquisition mass spectrometry identifies the differentially expressed proteins in MMD serum by detecting the serum from 60 patients with MMD and 20 health controls. The differentially expressed proteins were validated using enzyme linked immunosorbent assays. Immunofluorescence for superficial temporal artery and middle cerebral artery specimens was used to explore the morphological changes of vascular wall in MMD. In vitro experiments were used to explore the changes and mechanisms of differentially expressed proteins on endothelial cells. Proteomic analysis showed that a total of 14 726 peptides and 1555 proteins were quantified by mass spectrometry data. FLNA (filamin A) and ZYX (zyxin) proteins were significantly higher in MMD serum compared with those in health controls (Log2FC >2.9 and >2.8, respectively). Immunofluorescence revealed an intimal hyperplasia in superficial temporal artery and middle cerebral artery specimens of MMD. FLNA and ZYX proteins increased the proportion of endothelial cells in S phase and promoted their proliferation, angiogenesis, and cytoskeleton enlargement. Mechanistic studies revealed that AKT (serine/threonine kinase)/GSK-3β (glycogen synthase kinase 3β)/β-catenin signaling pathway plays a major role in these FLNA- and ZYX-induced changes in endothelial cells. This study provides proteomic data on a large sample size of MMD. The differential expression of FLNA and ZYX in patient with MMD and following in vitro experiments suggest that these upregulated proteins are related to the pathology of cerebrovascular intimal hyperplasia in MMD and are involved in MMD pathogenesis, with diagnostic and therapeutic ramifications.

Ischemic stroke secondary to radiation-induced carotid artery stenosis

Large vessel vasculopathy, such as carotid stenosis, has been shown to be a side effect of radiotherapy (RT) and has received increasing attention especially in recent decades with the improvement of RT technology. These injuries can lead to a higher risk of cerebrovascular events such as ischemic stroke. The management of these lesions may be performed with surgical repair but also with endovascular technique. A 61-year-old man was admitted to the emergency department for an acute ischemic stroke. He was treated 16years prior for laryngeal tumor for which he had received 23 sessions of radiation therapy at the dose of 60Gy per session. The CT scan showed a radiation-induced stenosis of the right internal carotid artery with thrombosis of the right anterior cerebral artery and the right middle cerebral artery. The patient was treated with angioplasty of the right internal carotid artery with good outcome. Radiation-induced vasculopathy of the carotid artery has gained relevance in patients with head and neck neoplasms. These vascular lesions are associated with the risk of late cerebrovascular events.

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case.

Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature. A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient's blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0. This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

Percutaneous transluminal angioplasty for persistent primitive hypoglossal artery stenosis: illustrative case.

We report a case of symptomatic, progressive stenosis of a persistent primitive hypoglossal artery (PPHA), which was successfully treated with percutaneous transluminal angioplasty (PTA) of the origin of the PPHA. The PPHA is a type of carotid-basilar anastomosis with an incidence of 0.02% to 0.10%. It originates from the internal carotid artery (ICA), passes through the hypoglossal canal, and merges with the basilar artery. In many cases, the ipsilateral vertebral artery is hypoplastic; therefore, PPHA stenosis causes cerebral infarction in the posterior circulation territory, as in this case. The patient's right PPHA had severe and progressive stenosis; therefore, he experienced cerebral infarction despite medical treatment. Therefore, PTA for the stenosis was performed, which ceased the recurrence of cerebral infarction and dizziness by improving blood flow in the posterior circulation. Several reports have described ICA stenosis accompanied by PPHA or PPHA stenosis in patients receiving endovascular treatments. Almost all cases were nonprogressive, and the treatment procedure was stenting. However, in our case, the PPHA stenosis was progressive, and we performed PTA because the patient experienced resistance to antiplatelet drugs and had poor collateral flow.

Numerical study of hemodynamic changes in the Circle of Willis after stenosis of the internal carotid artery

Background and objectivesIn clinical practice a large number of patients with ischemic stroke have internal carotid artery (ICA) stenosis accompanied by Circle of Willis (CoW) stenosis. In the presence of carotid artery stenosis, CoW atherosclerosis may cause cerebral blood flow decompensation and may promote the development of ischemic stroke. The reason for the concomitant stenosis at both sites is unknown. This study investigated the hemodynamic effects of ICA stenosis on the CoW. MethodsWe developed a three-dimensional/zero-dimensional (3D/0D) closed-loop geometric multiscale model of the cerebral artery to quantify the hemodynamic indicators, including time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI). Mild (<50 %), moderate (50–69 %) and severe (>69 %) ICA stenoses were established based on 3D models of cerebral arteries in two volunteers. Geometric multiscale computing models were numerically evaluated to obtain local hemodynamic changes in the CoW in order to assess the risk of stenosis in the CoW. ResultsModel calculations showed that for all 3D models the A1 segment of the anterior cerebral artery (ACA) or the posterior communicating artery (PCA) within the CoW exhibited a hemodynamic environment with high OSI (>0.2) and low TAWSS (<1 Pa) when the ICA had a moderate stenosis. While in the case of mild and severe stenosis in ICA, there is no such phenomenon. The proportion of the surface area possessing high OSI and low TAWSS in the A1 segment of the ACA or in the PCA was mostly greater than 60 %, which might potentially cause the formation and development of atherosclerosis in CoW and finally lead to CoW stenosis. ConclusionsTherefore, although moderate carotid artery stenosis may not cause ischemic stroke, it may cause hemodynamic changes in the CoW, which in turn may promote CoW stenosis and cause CoW decompensation. In clinical treatment attention should be paid not only to stenosis of the carotid arteries but also to changes in the hemodynamic environment within the CoW, in order to prevent the adverse effects of CoW stenosis.

Prevalence of intracranial artery stenosis in a general population using 3D-time of flight magnetic resonance angiography

BackgroundData on prevalence of intracranial artery stenosis (ICAS) in Western populations is sparse. The aim of the study was to assess the prevalence and risk factors for ICAS in a mainly Caucasian general population. MethodsWe assessed the prevalence of ICAS in 1847 men and women aged 40 to 84 years who participated in a cross-sectional population-based study, using 3-dimensional time-of-flight 3 Tesla magnetic resonance angiography. ICAS was defined as a focal luminal flow diameter reduction of ≥50 %. The association between cardiovascular risk factor levels and ICAS was assessed by multivariable regression analysis. ResultsThe overall prevalence of ICAS was 6.0 % (95 % confidence interval (CI) 5.0–7.2), 4.3 % (95 % CI 3.1–5.7) in women and 8.0 % (95 % CI 6.3–10.0) in men. The prevalence increased by age from 0.8 % in 40-54 years age group to 15.2 % in the 75-84 years age group. The majority of stenoses was located to the internal carotid artery (52.2 %), followed by the posterior circulation (33.1 %), the middle cerebral artery (10.8 %) and the anterior cerebral artery (3.8 %). The risk of ICAS was independently associated with higher age, male sex, hypertension, hyperlipidemia, diabetes mellitus, current smoking and higher BMI. ConclusionsThe prevalence of ICAS in a general population of Caucasians was relatively high and similar to the prevalence of extracranial internal carotid artery stenosis in previous population-based studies.

Experience in surgical treatment of extra-intracranial tandem ICA stenosis at the National Medical Research Center for High Medical Technologies named after A. A. Vishnevsky of the Ministry of Defense of the Russian Federation

To date, the effectiveness and safety of reconstructive surgery for steno-occlusive lesions of the internal carotid artery (ICA) have been proven by multicenter cooperative studies Despite this, the indications and tactics of surgical treatment of patients with extra-intracranial tandem stenotic lesions of the ICA remain controversial. In the period 2010-2020, 32 patients with symptomatic (15 cases) and asymptomatic tandem ICA lesions were hospitalized for surgical treatment. The distribution of tandem lesions was as follows: 10 patients had bicarotid hemodynamically significant stenotic and occlusive lesions of the ICA ostium in combination with stenosis of more than 50% of the petrous (4 cases), cavernous (8 cases), and clinoid segments (5 cases), of these, four had bilateral intracranial stenosis; 22 patients with hemodynamically significant lesions of the ICA and vertebral artery (VA) in combination with stenosis of more than 50% of the petrous (10 cases), foramen lacerum (2 cases), cavernous (16 cases), clinoid (14 cases), and ophthalmic segments (1 cases), of these, six had bilateral intracranial stenosis of the ICA. All patients underwent staged surgical interventions on the arteries of the carotid and vertebrobasilar systems. In the postoperative period, there was one case of repeated ischemic stroke in the territory of the reconstructed artery after the application of extra-intracranial microanastomosis (EICMA). There were no relapses of restenosis or acute cerebrovascular accident (CVA) in the follow-up. Staged reconstructive and revascularization treatment is safe and effective for tandem extra-intracranial lesions of the ICA. It is necessaryto continue further study of this issue in order to develop unified tactics and methods of surgical treatment.

FLAIR vascular hyperintensity combined with asymmetrical prominent veins in acute anterior circulation ischemic stroke: prediction of collateral circulation and clinical outcome

BackgroundTo investigate the value of fluid-attenuated inversion recovery vascular hyperintensity (FVH) within asymmetrical prominent veins sign (APVS) on susceptibility-weighted imaging predicting collateral circulation and prognosis in patients with acute anterior circulation ischemic stroke.MethodPatients with severe stenosis or occlusion of ICA or MCA M1, who underwent MRI within 72 h from stroke onset were reviewed. The Alberta Stroke Program Early CT Score was used to evaluate the volume of infarction on DWI, the degree of FVH and APVS. Spearman correlation analysis was used to evaluate the correlation between FVH and APVS. All patients were divided into the good prognosis group and the poor prognosis group according to the score of the modified ranking scale (mRS) 90 days after the stroke. Logistic regression analysis was used to explore the relationship between FVH and APVS and functional prognosis, while receiver operating characteristic (ROC) curves were plotted to assess the value of FVH and APVS in predicting prognosis.ResultsSpearman correlation analysis revealed moderate positive correlations between FVH and APVS (r = 0.586, P < 0.001). The poor prognosis group had a higher rate of a history of atrial fibrillation, a larger cerebral infarction volume, a higher NIHSS score at admission, and a higher FVH and APVS score compared with the good prognosis group (all P < 0.05). A further logistic regression indicated that the NIHSS score, cerebral infarction volume, FVH and APVS were independent risk factors for a poor functional prognosis. In terms of FVH, APVS, alone and their combination for the diagnosis of poor prognosis, the sensitivity, specificity, area under the ROC curve (AUC), and 95% confidence interval (CI) were 86.8%, 83.3%, 0.899 (95% CI 0.830–0.968); 60.5%, 93.7%, 0.818 (95% CI 0.723–0.912); 86.8%, 89.6%, 0.921 (95% CI 0.860–0.981), respectively.ConclusionThe presence of FVH and APVS can provide a comprehensive assessment of collateral circulation from the perspective of veins and arteries, and the correlation between the two is positively correlated. Both of them were independent risk factors for poor prognosis, their combination is complementary and can improve the predictive value.

Stenting for Severe C7 Stenosis of Internal Carotid Artery (ICA) and Related Literature Review

Intracranial Atherosclerosis (ICAS) is a common cerebrovascular lesion worldwide and an important cause of stroke [1]. Non-modifiable risk factors include age, gender, and genetics, with age being a key factor and atherosclerosis usually progressive, with no clinical manifestations until middle age. Ischemic Heart Disease (IHD) has increased fivefold among people aged 40 to 60. Before menopause, women are less prone to atherosclerosis than men, and the incidence of atherosclerosis is increased in postmenopausal women [2,3]. The inheritance of various genetic polymorphisms and the accumulation of family risk factors (such as diabetes and hypertension) create multiple conditions for the formation of atherosclerosis [4]. On the other hand, modifiable risk factors, such as smoking, hyperlipidemia, diabetes, and high blood pressure, can be improved by adjusting daily life. Studies have analyzed that white people are prone to extracranial arterial occlusive disease, while Asian, black and Hispanic people have a higher risk of intracranial atherosclerotic disease [1]. Therefore, the prevention of atherosclerotic disease, has been very urgent, to increase publicity, from the source to solve the problem.

Transradial intra-aortic catheter looping in the angioplasty of severe intracranial symptomatic arteriosclerotic diseases.

This study aims to investigate the effect and feasibility of intra-aortic catheter looping via transradial access in angioplasty for symptomatic intracranial severe (>70%) atherosclerotic stenosis or occlusion of large arteries (SISOLAs). Patients with SISOLAs who underwent transradial endovascular angioplasty using the catheter looping technique in the ascending aorta were retrospectively enrolled. The clinical data and treatment outcomes were analyzed. Fifteen patients aged 48-71 years were enrolled in this study. Left vertebrobasilar artery occlusion was present in 1 (6.7%) patient, severe left middle cerebral artery stenosis in 7 (46.7%) patients, severe left internal carotid artery (ICA) stenosis of the ophthalmic segment in 4 (26.7%) patients, severe left ICA stenosis of the cavernous segment in 2 (13.3%) patients, and severe right middle cerebral artery stenosis in 2 (13.3%) patients. The arterial stenosis ranged from 70 to 92% (mean 86%) before stenting. The looping of a guiding catheter in the ascending aorta via transradial access for angioplasty was successful in all patients (100%). The vertebral artery intracranial segment occlusion was successfully recanalized, while severe stenosis in the remaining 14 patients was successfully eliminated. After endovascular recanalization, the residual stenosis was reduced by 12-26% (median 18%). No puncture-related complications or surgical-related neurological complications occurred in these patients. In the follow-up angiography conducted on 10 (66.7%) patients after 6-25 months, no in-stent restenosis was detected. Intra-aortic guiding catheter looping via transradial access for endovascular angioplasty of SISOLAs is technically safe, feasible, and effective, especially when the transfemoral artery approach is difficult or impossible to undertake.