Internal Carotid Occlusion Research Articles

Improved outcome prediction using CT angiography in addition to standard ischemic stroke assessment: results from the STOPStroke study.

PurposeTo improve ischemic stroke outcome prediction using imaging information from a prospective cohort who received admission CT angiography (CTA).MethodsIn a prospectively designed study, 649 stroke patients diagnosed with acute ischemic stroke had admission NIH stroke scale scores, noncontrast CT (NCCT), CTA, and 6-month outcome assessed using the modified Rankin scale (mRS) scores. Poor outcome was defined as mRS>2. Strokes were classified as “major” by the (1) Alberta Stroke Program Early CT Score (ASPECTS+) if NCCT ASPECTS was≤7; (2) Boston Acute Stroke Imaging Scale (BASIS+) if they were ASPECTS+ or CTA showed occlusion of the distal internal carotid, proximal middle cerebral, or basilar arteries; and (3) NIHSS for scores>10.ResultsOf 649 patients, 253 (39.0%) had poor outcomes. NIHSS, BASIS, and age, but not ASPECTS, were independent predictors of outcome. BASIS and NIHSS had similar sensitivities, both superior to ASPECTS (p<0.0001). Combining NIHSS with BASIS was highly predictive: 77.6% (114/147) classified as NIHSS>10/BASIS+ had poor outcomes, versus 21.5% (77/358) with NIHSS≤10/BASIS− (p<0.0001), regardless of treatment. The odds ratios for poor outcome is 12.6 (95% CI: 7.9 to 20.0) in patients who are NIHSS>10/BASIS+ compared to patients who are NIHSS≤10/BASIS−; the odds ratio is 5.4 (95% CI: 3.5 to 8.5) when compared to patients who are only NIHSS>10 or BASIS+.ConclusionsBASIS and NIHSS are independent outcome predictors. Their combination is stronger than either instrument alone in predicting outcomes. The findings suggest that CTA is a significant clinical tool in routine acute stroke assessment.

Transient Global Amnesia as the First Symptom of Primary Antiphospholipid Syndrome: A Case Report

We describe the case of a 45-year-old woman who had drawn our attention for some recent episodes of transient global amnesia that, upon further examination, resulted from ischemic events caused by multiple arterial thrombosis (bilateral internal carotid occlusion, significant stenosis of the right external carotid, mild stenosis of the right vertebral artery, right anterior cerebral artery occlusion and severe stenosis of the anterior descending coronary artery) due to primary antiphospholipid syndrome. Revascularisation of either carotid was not attempted. A percutaneous intervention in the anterior descending coronary artery stenosis was performed successfully. Due to severe arterial thrombosis, the patient was discharged with only duplex antiplatelet treatment and subcutaneous anticoagulant therapy, since immunotherapy is not indicated in primary APS. The occurrence of transient global amnesia should raise the suspicion of APS.

P Com–P1 Aneurysm Formation in a Patient with Bilateral Internal Carotid Occlusion

P Com–P1 Aneurysm Formation in a Patient with Bilateral Internal Carotid Occlusion

′Susceptibility sign′ on susceptibility-weighted imaging in acute ischemic stroke

Acute intra-arterial thrombus produces susceptibility artifact on gradient echo images (susceptibility sign). Our aim was to study the sensitivity and specificity of the susceptibility sign in various major intracranial arteries on susceptibility-weighted imaging (SWI) in patients with acute stroke. We also compared it with the 'hyperintensity sign' on fluid-attenuated inversion recovery (FLAIR) and 'hyperdense artery sign' on computed tomography (CT) for middle cerebral artery (MCA) occlusion. We have retrospectively studied 48 patients with ischemic stroke in various stages, due to intracranial arterial occlusions, for presence of 'hyperdense artery sign' (CT), 'hyperintense arterial sign' (FLAIR sequence) and 'susceptibility sign' (SWI). The sensitivity and specificity of each sign to detect intracranial arterial occlusion were calculated using the contrast-enhanced magnetic resonance (MR) angiogram as reference standard. The sensitivity and specificity of the 'susceptibility sign' for detecting the MCA occlusion were 77% and 100% respectively (10 of 13).The sensitivity of the 'susceptibility sign' for detecting anterior cerebral artery (ACA) occlusion was 50% (1 of 2), 66.6% for posterior cerebral artery (2 of 3) and 75% for basilar artery (3 of 4). All the vertebral artery occlusions showed 'susceptibility sign' (6 of 6). Overall sensitivity and specificity of the 'susceptibility sign' for all acute major intracranial arterial occlusions were 82% and 100% respectively. Only one of the two cases of subacute infarcts studied showed a positive susceptibility sign. None of the 11 chronic intracranial occlusions and seven internal carotid occlusions showed the sign intracranially. 'Susceptibility sign' is more sensitive in detecting the acute MCA thrombus as compared to 'hyperdense MCA sign' on CT and 'hyperintense artery' sign on FLAIR images. It also has high sensitivity and specificity for other intracranial acute arterial occlusions.

Access to the ophthalmic artery by retrograde approach through the posterior communicating artery for intra-arterial chemotherapy of retinoblastoma

Intra-arterial infusion of chemotherapy into the ophthalmic artery for treatment of retinoblastoma has been realized after catheterization of the internal carotid and temporary balloon occlusion beyond the orifice of the ophthalmic artery, or more recently after superselective canulation of the ophthalmic artery by a microcatheter. The superselective catheterization of the ophthalmic artery could be cumbersome because of the implantation of the ostium on the carotid siphon or because of the tortuosity of the carotid siphon. We report our experience of using a retrograde approach through the posterior communicating artery that allows a more direct angle of access to the origin of the ophthalmic artery.

P Com - P1 Aneurysm Formation in a Patient with Bilateral Internal Carotid Occlusion

P Com - P1 Aneurysm Formation in a Patient with Bilateral Internal Carotid Occlusion

Bilateral spontaneous internal carotid artery dissection with both early and very late recanalization: A case report

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened.

Is Intravenous Thrombolysis Useful in Carotid Artery Dissection With Tandem Occlusion?

Cervical artery dissection no longer represents an obstacle for performing intravenous (IV) thrombolysis. This treatment can be used safely for patients with cervical artery dissection, but tandem lesions may be related to poor outcome. We report a patient with an occlusive internal carotid artery (ICA) dissection and middle cerebral artery (MCA) embolus, with collateral circulation through the ophthalmic artery and communicating anterior artery. He underwent IV thrombolysis, with subsequent MCA recanalization and good outcome. In cases of tandem lesions in cervical artery dissection with MCA occlusion, IV thrombolysis is indicated despite the presence of ICA occlusion. Due to the presence of collateral circulation and the composition of the embolus, recanalization of MCA might be possible.

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

Conclusion: Carotid artery angioplasty and stenting can be successfully performed in patients with internal carotid artery pseudo-occlusion or string sign. Summary: This report focuses on carotid angioplasty and stenting in a series of patients in whom the internal carotid artery (ICA) was thought occluded by conventional ultrasound but who actually had string signs. The authors treated 16 patients. Contrast computed tomography (CT) showed a patent distal ICA in 14 of the 16 patients treated. Contrast-enhanced ultrasound imaging also showed patent distal ICAs in 13 cases. This is actually a series of very high-grade ICA stenosis and/or string signs treated with angioplasty and stenting. The authors performed the angioplasty and stent placement under cerebral protection. Duplex imaging was performed at 14 days, 3 months, and every 6 months thereafter. CT scans were obtained at 2 to 9 months, and the mean follow-up period was 9.9 months. Most patients had nonhemispheric symptoms as the indication for treatment. Patients were treated with clopidogrel and aspirin before the procedure and were maintained on clopidogrel 90 days after treatment and on aspirin indefinitely. A 6F sheath was placed in the common carotid artery and the ICA accessed with a 5F diagnostic vertebral catheter. A 0.035-inch hydrophilic guide wire was then passed into the ICA, followed by the catheter. An interceptor filter (Medtronic, Minneapolis, MN) was passed through the catheter and opened in the lumen, and then the catheter was withdrawn. Predilation was performed with a 3-mm balloon through the filter wire, and then a self-expanding stent was placed in the proximal ICA and dilated with a 5-mm balloon. If necessary, a second distal stent was placed. Stent placement was successful in 13 of 16 patients. There were no deaths, conversions, or cardiac complications. One patient had paresis in the upper limb with recovery in 3 months. At follow-up, all 13 patients remained with patent arterial lumens and were symptom free. After 2 to 9 months, so-called string signs had calibers close or equal to those of normal arteries. Comment: The title of this article is misleading. Although conventional duplex ultrasound imaging showed the patients had occluded ICAs, all in fact had patent distal ICAs either by contrast-enhanced ultrasound or contrast CT scanning. The authors of the article, the Journal of Vascular and Interventional Radiology reviewers, and the editors should be ashamed for permitting such a misleading title. What the authors have shown us is that in their institution, conventional duplex ultrasound imaging is likely below standard in distinguishing high-grade carotid stenosis from occlusion. They have shown us that CT angiography and contrast-enhanced ultrasound imaging can detect carotid string signs, something we already knew. They have also shown us that if you can get a wire across a high-grade stenosis, then you can perform angioplasty and stenting, again something we already knew. They have demonstrated that such procedures can be performed, but whether they should be performed is an entirely different question.

Safety of coronary artery bypass grafting in patients with bilateral total carotid occlusions

The presence of bilateral carotid artery occlusions in patients that require coronary artery bypass surgery is rare. Here, we report the successful coronary revascularization of two patients with cardiopulmonary bypass under moderate hypothermia. Routine preoperative carotid artery duplex sonographies revealed bilateral total internal carotid occlusions. However, no neurological deficits or abnormalities were found on clinical examination or brain computed tomography, respectively. The vertebral blood flows of both patients were also found to be highly increased. Following successful surgery, the postoperative courses were uneventful and patients were discharged from the hospital on the seventh postoperative day.

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

To report a series of patients with symptomatic internal carotid artery (ICA) occlusion treated with angioplasty and stents. From a consecutive series of 50 patients experiencing neurologic ischemic symptoms and shown by conventional ultrasonography (US) to have a total ICA occlusion, 16 patients (ages 45-79 years; mean, 63 y; 10 men) were selected between August 2006 to September 2008 to be treated with angioplasty based on discovery of an open ICA distal to the occlusion through contrast-enhanced echo Doppler imaging and/or multislice contrast computed tomography (CT). Angioplasty and stent placement were performed under cerebral protection. Follow-up duplex imaging was performed at 14 days and 3 months and every 6 months thereafter and CT follow-up was performed at 2-9 months; the mean follow-up period was 9.9 months. Lesion crossing and stent placement was successful in 13 of 16 patients. There were no deaths, conversions, cardiac complications, or major strokes. One patient had a transient mild hemiparesis in the upper limb, with total recovery in 3 months. At follow-up, all 13 patients with a good initial result remained with patent arterial lumens and resolution of neurologic ischemic symptoms. After 2-9 months, ICAs with a "string sign" had calibers close or equal to those of normal arteries. Angioplasty with stent placement is an effective treatment with a low morbidity rate for selected patients who continue to experience neurologic ischemic symptoms despite US findings of total occlusion of the ICA.

Presumed perinatal stroke in a child with Down syndrome and moyamoya disease

Moyamoya disease describes a cerebral arteriopathy characterized by stenosis or occlusion of the terminal internal carotid and/or the proximal middle cerebral arteries. We report a female child with trisomy 21 and bilateral moyamoya disease who presented, unusually, with a presumed perinatal cerebral infarct. The clinical, radiological, and angiographic features of moyamoya disease in children with Down syndrome are similar to those with other aetiologies or idiopathic cases. Early recognition is important as moyamoya disease presenting in childhood is associated with a high rate of recurrent stroke and there is evidence that surgical revascularization can prevent further events. An important practical lesson arising from this case is that although the evaluation of children with presumed perinatal stroke tends to be limited relative to the evaluation of arterial ischaemic stroke in older children, this may need to be more comprehensive in infants at high risk of arteriopathy. The parents of the child gave informed consent to the publication of this report.

Spontaneous recanalization of complete internal carotid artery: A clinical reminder

Spontaneous recanalization of atherothrombotic extracranial cerebral arteries is rare vis-à-vis recanalization of intracranial vessels. The time course is unknown. The question is the advisability and timing of surgery in a recanalized vessel. We describe a patient with spontaneous recanalization of a totally occluded left Internal Carotid Artery (ICA) who was monitored with periodic imaging and in time had partial recanalization of the ICA. We believe patients with total ICA occlusion with return of function should be followed up with periodic carotid ultrasound, Magnetic Resonance Angiography (MRA) or CT angiography, and when appropriate, be candidates for carotid vascular interventions.

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

Occlusion of Internal Carotid Artery in Kimura's Disease

We describe a unique case of Kimura's disease in which cerebral infarction was caused by occlusion of the right internal carotid artery. A 25-year-old man with Kimura's disease was admitted to our hospital because of left hemiparesis. Computed tomography and magnetic resonance imaging of the head showed infarction in the right frontal and temporal lobes. Cerebral angiography demonstrated right internal carotid artery occlusion affecting the C1 segment, with moyamoya-like collateral vessels arising from the right opthalamic artery. Kimura's disease is a chronic disease characterized by the clinical triad of slowly enlarging subcutaneous masses with lymphoid hyperplasia in the head and neck. It often occurs in young Asian men. In our patient, the pathogenesis of internal carotid artery occlusion was unknown. There have only been a few case reports in which occlusion of the internal carotid artery was associated with autoimmune disease, and no previous cases of internal carotid occlusion associated with Kimura's disease have been reported. We suspected that occlusion of this patient's internal carotid artery may be caused by the autoimmune mechanism that underlies Kimura's disease.

Eversion Carotid Endarterectomy Versus Best Medical Treatment in Symptomatic Patients with Near Total Internal Carotid Occlusion: A Prospective Nonrandomized Trial

We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion. From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months. There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B. Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Treatment of Transiently Symptomatic Acute Internal Carotid Artery Occlusion: Learning from the Interventional Field

A 69-year-old man experienced left hemiparesis and confusion of sudden onset, followed by complete spontaneous recovery after about 20 minutes. When carotid ultrasound was performed in the neurovascular unit 12 hours later, an occluded right internal carotid artery was found. Transcranial ultrasound showed normal flow in the right middle and anterior cerebral arteries. How should he be treated?

Safe Treatment of Pulmonary Hypertension With Bosentan in a Patient With Moyamoya Disease and Cerebral Ischemia

A 7-year-old girl with Down syndrome and moderately severe pulmonary hypertension experienced a stroke while being treated with a calcium channel blocker. Angiography identified bilateral stenosis of the supraclinoid internal carotid arteries, stenosis or occlusion of the proximal anterior and middle cerebral arteries, and occlusion of the left posterior cerebral artery. She underwent surgery to enhance collateral blood flow to vulnerable areas of the brain. Her pulmonary hypertension therapy was changed to an oral endothelin receptor antagonist. She developed excellent collateral blood flow through external carotid arteries to each cerebral hemisphere and an improvement in blood flow through the right internal carotid artery. This case suggests that bosentan can be used safely in children with moyamoya disease. Additional studies are needed to determine whether endothelin receptor antagonists may influence the progression of moyamoya disease or the development of collateral cerebral blood flow following surgery.

Embolic stroke associated with injection of buprenorphine tablets

Drug users who crush, dissolve, and inject buprenorphine tablets parenterally may be at risk of severe thromboembolic complications or death. We describe patients with neurologic complications after injecting buprenorphine tablets. Brain MRI including diffusion-weighted imaging (DWI) in patients admitted to the neurologic department after injecting buprenorphine tablets were reviewed. Seven men had neurologic complications after buprenorphine tablet injection. In 5 patients, multiple small scattered hyperintense lesions were detected on DWI in the cortex, white matter, and basal ganglia of the cerebral hemisphere; one patient had a single small lesion. The side of MRI abnormality corresponded to the side of needle marks on the neck except in one patient who had bilateral injections. One patient, who denied injecting into the neck, had DWI abnormalities in the middle cerebral artery territory on one side and occlusion of the ipsilateral internal carotid artery. Buprenorphine tablets can be intentionally or inadvertently injected into the carotid artery, causing a characteristic appearance on diffusion-weighted imaging, consistent with embolic cerebral infarction.

Immediate and 30-Day Clinical Outcome of Patients Treated with the TwinOne Cerebral Protection System: Multicenter Experience in 217 Cases

There are several cerebral protection devices used for carotid artery stenting (CAS). All of them require manipulation and exchange of two separate materials (cerebral protection device ? dilatation balloon), making the procedure longer and posing possible complications such as vasospasm and embolism. The new system described here is an evolution of the cerebral protection concept and allows temporary occlusion of the distal internal carotid during CAS procedures with both materials in one device. We present our experience using this new device. Between January 2007 and March 2008, consecutive patients sent for CAS (symptomatic, with stenosis C50%, or asymptomatic, with stenosis C70%) were treated using TwinOne as a cerebral protection system. All patients were treated using the "simplified" CAS technique, limiting cerebral protection to the poststenting angioplasty phase. Two hundred nine patients have been treated at our institutions; eight underwent bilateral CAS, for a total of 217 CAS procedures performed using the TwinOne for cerebral protection. There have been four periprocedural (within 3 h of procedure) cases of complications (1.8%): three disabling strokes (one in-stent thrombosis, one presumed clotting, one ipsilateral stroke with uncertain root cause) and one transient ischemic attack attributable to heart failure. There have been two in-hospital complications (0.92%): one disabling stroke of unclear origin and one contralateral transient ischemic attack. No additional adverse event has been reported at 30 days after the CAS procedure. In conclusion, this cerebral protection system is simple to use, allows a quick intervention and short occlusion time, and has a low rate of complications.