Ipsilateral Internal Carotid Artery Occlusion Research Articles

Carotid Stump Syndrome: Rare Cause of Recurrent Stroke Post-Ipsilateral Carotid Occlusion - A Case Report.

Carotid stump is blind remnant of occluded proximal segment of the internal carotid artery (ICA) that can become the potential source of embolism. Carotid stump syndrome is a potentially treatable cause of recurrent ischemic events in the carotid territory in the setting of occlusion of the ipsilateral ICA. It is thought to be caused by turbulent blood flow in the patent stump of the occluded ICA causing microemboli migrating in the brain through external carotid-ophthalmic anastomotic channels and retrograde flow. Here, we report a patient with known ipsilateral chronic ICA occlusion, who was on best medical management, presented on two separate occasions with recurrent embolic infarctions in ipsilateral carotid territory. She was diagnosed with carotid stump syndrome and treated through endovascular route with clinical and angiographic follow-up.

Abstract WP208: Infarction Size Affects Clinical Outcomes in Emergent Carotid Artery Stenting With Mechanical Thrombectomy

Background: Management of large vessel occlusion with extensive ipsilateral internal carotid artery (ICA) occlusion is unknown. We evaluated patients who underwent emergent carotid artery stenting (CAS) of the ICA with mechanical thrombectomy (MT). Methods: We retrospectively collected baseline demographic, clinical, and radiographic data on 27 patients who presented as a stroke alert within 24 hours of symptoms and had extensive (from bifurcation to distal ICA) occlusion by computerized tomography angiography from 2019-2023 at our institution. All patients underwent CAS with MT and received dual antiplatelet therapy. We measured outcomes by: (1) development of symptomatic ICH at 24 hours, (2) mortality, (3) Modified Rankin Scale (mRS) at 90 days, and (4) change in NIHSS at 24 hours. Baseline characteristics were reported by descriptive statistics. Statistical analyses were completed using Fisher’s exact test, Wilcoxon rank sum test, and logistic regression. Differences were statistically significant at p < 0.05. Results: The mean age for our cohort was 64.5 ± 10.62 and nine patients were females (33.3%). Sixteen had M1 (59.3%) while 10 had M2 occlusion (37%), 14 patients received IV tPA (51.9%), and mean NIHSS at presentation was 15.6 ± 5.99. All patients achieved TICI 2b or TICI 3 recanalization. In our cohort, patients with lower ASPECT score 7.4 ± 1.8 compared to those with higher ASPECT score 9.0 ± 1.0 were more likely to have symptomatic ICH ( p = 0.032), and higher odds of mortality OR = 0.496, 95% CI (0.261-0.945). The development of symptomatic ICH at 24 hours following procedure was associated with severe disability (mRS 4-6) at 90 days ( p = 0.032). Administration of intravenous tPA was significantly associated with improvement of 4 or more points on NIHSS at 24 hours ( p = 0.032), but not with symptomatic ICH ( p = 0.419). Age, NIHSS at presentation, systolic blood pressure, and diabetes mellitus were not associated with mortality or symptomatic ICH. Conclusion: The area of infarction at the time of presentation (ASPECT score) is an essential factor in stratifying patient selection for emergent CAS during MT in extensive internal carotid artery occlusion. Further studies are needed to evaluate infarction size for safe interventions.

A Case of Ruptured Middle Portion Posterior Communicating Artery Aneurysm with Ipsilateral Internal Carotid Artery Occlusion Treated by Superficial Temporal Artery-Middle Cerebral Artery Anastomosis and Endovascular Treatment

A Case of Ruptured Middle Portion Posterior Communicating Artery Aneurysm with Ipsilateral Internal Carotid Artery Occlusion Treated by Superficial Temporal Artery-Middle Cerebral Artery Anastomosis and Endovascular Treatment

Abstract 093: Carotid Stump Syndrome: an Insidious Source of Recurrent Ischemic Strokes

Introduction Carotid stump syndrome (CSS) is a paradoxical phenomenon that occurs when there are repeated ischemic events in the carotid vascular territory despite demonstrated occlusion of the ipsilateral internal carotid artery (ICA). It is thought to be caused by turbulent blood flow in the patent stump of the occluded ICA creating microemboli which reach the brain through anastomotic channels and retrograde flow. We present a case of recurrent infarctions in setting of known ipsilateral ICA occlusion, who was diagnosed with carotid stump syndrome. Methods A male veteran in his 60s with a medical history of DVTs on apixaban, PVD, and ischemic stroke with residual right‐sided weakness, presented with worsening right‐sided weakness and difficulty with ambulation. Two months prior to the presentation he was diagnosed with acute infarcts in left frontal, parietal, and temporal lobes due to thromboembolism from left ICA occlusion. On presentation his neurological exam revealed right‐sided hemiparesis. MRI brain showed multiple acute and chronic cortical and subcortical infarcts in the left frontotemporoparietal lobes and lack of flow void in the left distal ICA. To further evaluate the dynamics of blood flow patient underwent a cerebral angiogram which confirmed the diagnosis of complete occlusion of left ICA and demonstrated reconstitution of the intracranial ICA through retrograde filling via the ophthalmic artery and anastomotic branches with the internal maxillary artery (IMax). For secondary prevention he was started on statin and aspirin while his home Apixaban was continued. Surgical and endovascular treatment approaches were discussed but the patient declined any intervention. In his four months follow up clinic visit he had no further concerns of recurrent strokes or new symptoms. Results Carotid stump syndrome is a rare cause of cerebral and retinal ischemia; however, it must be considered in patients with recurrent ischemic strokes and chronic ipsilateral ICA occlusion. Due to the patent proximal, or perhaps in some cases distal, carotid stump, there’s turbulent flow and hence the thrombus formation can occur. Hemodynamic and embolic factors attribute towards the microembolization from the proximal carotid stump through the external carotid artery (ECA), into the facial artery and IMax and their distal branches which anastomose with the ophthalmic artery, causing the emboli to end up in the major branches of the carotid terminus. If a distal stump is symptomatic, then the microemboli can readily end up in the distal ICA branches. In addition to medical management with DAPT or anticoagulation and high intensity statin, our literature review supports endovascular or surgical interventions due to reportedly good outcomes. Interventional approaches may include ECA‐ICA stenting with a covered stent or stent‐assisted coil embolization of the proximal stump. Surgical procedures include an endarterectomy on the ipsilateral ECA or contralateral ICA to increase collateral circulation. ECA‐ICA bypass is another option. Conclusion Carotid stump syndrome is a rare and underrecognized cause of recurrent ischemic strokes, though it is a potentially treatable entity. The therapeutic goals include medical management along with endovascular or surgical treatment whenever possible.

Spontaneous complete resolution of a giant cavernous carotid aneurysm in the setting of ipsilateral ICA occlusion

Background. Cavernous carotid aneurysms (CCA) are rare aneurysms with a relatively benign natural history. The association between CCA aneurysm and ipsilateral Internal carotid artery (ICA) thrombosis or occlusion has not been described previously. The management of patients with these dual lesions is a challenging problem. Case description. In this report, we describe an 18-year-old man who presented with left abducent nerve palsy of 3 weeks duration, and imaging revealed left CCA with left ICA occlusion. The patient was managed conservatively with clinical and imaging follow-up. The patient recovered well with complete resolution of clinical symptoms and disappearance of left CCA. Conclusions. The association of giant CCA and ICA occlusion on the same side is a rare phenomenon with no current consensus on the appropriate follow-up and management strategy. In this report, we described the first case of spontaneous complete disappearance of a giant CCA in the setting of ipsilateral ICA occlusion with complete resolution of symptoms at nine months of follow-up.

Abstract Number ‐ 148: Emergent Carotid Artery Stenting On Acute Stroke Patients With Carotid Occlusion: Benefit Or Harm?

Introduction Almost one out of four patients with acute middle cerebral artery occlusion also have ipsilateral internal carotid artery occlusion (ICAO). The interventions for acute stroke due to extracranial ICAO with or without intracranial occlusions are still a challenge. Case series reported early revascularization reduced stroke recurrence and improved outcomes. The benefits of this intervention on hyperacute ischemic strokes (within 6 hours) were much less known. We reported here two hyperacute stroke patients who emergent CAS on ICAO. Methods Electronic medical charts were reviewed, assessing intracranial hemorrhage (ICH) in two hyperacute stroke patients resulting from emergent carotid artery stenting (CAS) on the occluded internal carotid artery (ICA). Results Case description:The first patient was a 60‐year‐old male who had acute right hemiparesis, aphasia, and left gaze deviation with NIHSS12. The last known normal was five hours ago. Head and neck CT angiography (CTA) showed left anterior M2 branch artery occlusion and left ICAO. Head CT perfusion (CTP) showed a small core infarct with a large perfusion mismatch. Emergent CAS was performed without distal embolic protection (DEP) and followed by distal mechanical thrombectomy (MT). TICI 2B recanalization was achieved. After CAS, aspirin and clopidogrel were administrated. He had a large left MCA and PCA stroke from fetal PCA. A few days later, the patient developed large intraparenchymal hemorrhage (IPH) and intraventricular hemorrhage (IVH). He expired shortly. The second was a 52‐year‐old male had acute right facial droop, aphasia, dysarthria, and decreased consciousness (NIHSS 8). CTA showed left ICAO but patent intracranial arteries. CT perfusion showed a large mismatch without core infarction. He received intravenous tPA and had emergent CAS with a DEP. Aspirin 600 mg was administrated afterward. A few hours later, he had worsened weakness. Head CT showed left IPH, IVH, and subarachnoid hemorrhages with cerebral edema, and midline shift. He was medically managed for a prolonged stay and was discharged to a rehabilitation facility. Conclusions We presented two consecutive cases of emergent revascularization of ICAO in hyperacute stroke carried a high risk of ICH with poor outcome. Our online database search found that only a few case series of emergent CAS on ICAO were reported. Overall, emergent CAS carried about 20% risk of ICH and high mortality. Other series reported angioplasty on stenotic or occluded cervical ICA lesions with MT on distal occlusions had less hemorrhagic risk because there was no need fordual antiplatelet treatment. Most emergent CAS cases were performed on tandem occlusions for faster direct access and better efficacy of distal recanalization. A futurestudy comparing hemorrhagic risk betweenemergent CAS versus angioplasty of ICAO in patients with tandem occlusions can help to establish a standard MT protocol. For isolated ICAO with patent intracranial arteries from good collaterals, CTP may not be a good guidance tool for decision‐making of emergent CAS as it can falsely show mismatch from existing collaterals due to occlusion. A randomized clinical trial of comparison of medical management versus emergent CAS on those patients is warranted.

Impact of Patency of the Carotid Terminus and Middle Cerebral Artery on Early Clinical Outcomes in Patients with Acute Internal Carotid Artery Occlusion and Mild Symptoms

Introduction: Both collateral flow via the internal carotid artery (ICA) terminus (ICT) and initial mild symptoms might be associated with favorable outcomes in patients with acute ICA occlusion (ICAO). This study aimed to address the association between early clinical outcomes and patency of the ICT and middle cerebral artery (MCA) in patients with acute ICAO with mild symptoms. Methods: Of 1,214 consecutive patients with acute ischemic stroke or transient ischemic attack due to large vessel occlusion, patients with ipsilateral ICAO and initial National Institutes of Health Stroke Scale (NIHSS) score ≤5 were retrospectively enrolled. We examined the associations between clinical factors including patency of the ICT and MCA and recurrence of stroke or early neurological deterioration (REND). Significant early neurological deterioration was defined as increment in NIHSS score ≥1 during hospital stay. Results: Thirteen of the 35 patients who were finally enrolled had REND (37%), and median modified Rankin scale (mRS) score at discharge was 1 (interquartile range, 0–4). Initial NIHSS score (4 vs. 1, p < 0.001) and rates of diabetes mellitus (61.5% vs. 13.6%, p = 0.007), intravenous thrombolysis (IVT) (30.9% vs. 0%, p = 0.014), and mechanical thrombectomy (MT) (23.1% vs. 0%, p = 0.044) were significantly higher in patients with REND rather than in those without. The rate of patent ICT and MCA was comparable between groups. Except for 1 patient who underwent MT promptly after IVT immediately after REND, 3 patients initially treated with IVT deteriorated after the procedure. One patient without patent ICT and MCA did not meet the indications for MT. In 2 other patients with patent ICT and MCA, MT was not initially performed, but was eventually performed because of REND due to thrombus migration, and both were discharged with an mRS score of 5. Conclusion: The overall clinical outcomes of patients with acute ICAO with mild symptoms were not depending on the patency of the ICT and MCA, but initial treatment with IVT alone might risk unfavorable outcomes due to thrombus migration in patients with patent ICT and MCA.

Pediatric Case of Completely Thrombosed Giant Cavernous Carotid Aneurysm with Ipsilateral ICA Occlusion Mimicking an Intra-Axial Cystic Lesion: A Case Report and Review of the Literature

There have been a few cases where completely thrombosed cavernous carotid artery (CCA) aneurysms have resembled neoplasms based on neuroimaging data, but no reports have been documented in children. Here, we report an unusual pediatric case of a completely thrombosed giant CCA aneurysm with ipsilateral internal carotid artery (ICA) occlusion which imitates an intra-axial cystic lesion on magnetic resonance image (MRI). Therefore, we performed the surgery on suspicion of a cystic mass but it revealed a huge completely thrombosed CCA aneurysm with thrombosis of the ipsilateral ICA.

External carotid artery stenting in patients with ipsilateral internal carotid artery occlusion: Peri-operative and 12-month follow-up.

This study aimed to evaluate the safety and clinical efficacy of external carotid artery (ECA) stenting in patients with ipsilateral internal carotid artery (ICA) occlusion. In patients with ICA occlusion, severe ipsilateral ECA stenosis may exacerbate pre-existing cerebral ischemia and cognitive impairment. It remains unclear whether ECA stenting to normalize ECA collaterals to the cerebralis alleviates cerebral ischemia and improves cognitive function. From January 2008 to June 2019, we retrospectively collected clinical data of 36 consecutive patients with ipsilateral ICA occlusion who had undergone ECA stenting (mean age, 66.7 ± 8.3 years; males, n = 26 [72.2%]). Neurocognitive test results, including Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MOCA) tests, symptom assessment, and adverse events were recorded. ECA stenting was successful in all 36 patients. Intra-operatively, six (16.7%) patients experienced hemodynamic depression during balloon dilation and recovered completely within 2 days. Within a 12-month follow-up period, two patients experienced a transient ischemic attack, one patient had a contralateral minor stroke, and 33 patients remained asymptomatic. No other adverse events occurred in the peri-operative or follow-up periods. Compared with baseline, significant MMSE (25.3 ± 1.3 vs. 23.6 ± 1.7; p < .05) and MOCA (24.1 ± 1.3 vs. 22.8 ± 1.7; p < .05) test score improvements were observed 3 months post-operatively and were maintained throughout follow-up. ECA stenting may improve cerebral ischemia and cognitive function in patients with severe ECA stenosis and ipsilateral ICA occlusion; however, further research is required to support our findings.

An Autopsic Study on Bilateral Hypoplasiaof the Posterior Communicating Arteriesin Cerebrovascular Diseases

Objective: To identify the clinical consequences of bilateral hypoplasia of the posterior communicating arteries (PCoAs) in order to provide a clue to neurosurgeons and neurologists in their work to diagnose and treat patients with stroke symptoms. Material and methods: We performed an anatomical retrospective study on gross morphology of 98 circles of Willis (CW) that were identified at the time of the autopsies made on patients who have died in the Prof. dr. N. Oblu” Emergency Clinical Hospital Iasi, Romania, the main neurological and neuro-surgical healthcare Centre in the region of North-Eastern Romania, for a period of three years. Demographical and autopsic data, as well as photographic images were taken from the registers and archives of the Pathology Department. Only CWs with bilateral hypoplasia of PCoA without any other associated anatomical abnormalities were studied. Results: In 5 cases (5.12%) we identified bilateral hypoplasia of PCoAs. Male: Female ratio was 3: 2. The average age was 63.5 years. 80% of cases died of ischemic or haemorrhagic stroke, but 10% died of heart disease. In 2 (40%) cases, one of the two PCoAs presented aplasia and the other was hypoplastic, an event related to frontal lobe strokes on the same side. In the other two (40%) cases in which both arteries were hypoplastic, the cause of death was ischemic stroke located in the brainstem. In only one case (20%), even in the presence of bilateral hypoplasia of PCoAs, the cause of death was non-neurological. Conclusion: Even if literature claims that PCoA hypoplasia becomes a risk factor for ischemic stroke only in the presence of ipsilateral internal carotid artery (ICA) occlusion, in our study we found that aplasia of one of the two PCoAs associated with hypoplasia of the controlateral artery caused ischemic stroke in the brainstem, thus revealing the role of PCoAs in ensuring the posterior circulation in case of occlusion of the vertebro-basilar system.

Facing a Feared Situation: Endoscopic Endonasal Approach for Petroclival Lesions With Internal Carotid Artery Encasement: 2-Dimensional Operative Video.

A 33-yr-old woman presented with diplopia due to partial III and VI cranial nerve palsies, and an magnetic resonance imaging (MRI) showed a left petroclival lesion with cavernous sinus invasion. The ipsilateral internal carotid artery (ICA) was displaced and encased by the tumor. Chondroid tumors such as this are known to be high risk for ICA injury1; however, given the patient's young age a radical resection was desirable,2 depending on the risk of such a strategy. Therefore, a preoperative balloon test occlusion (BTO) was performed to estimate the risk of stroke in case of ICA sacrifice.3 Clinical and single-photon emission computed tomography testing predicted low risk of stroke, allowing for aggressive resection. A preoperative ICA occlusion was not performed as intraoperative control was believed to be adequate and preservation is always preferable when possible due to rare inaccuracies in BTO and long term risks of occlusion. An endoscopic endonasal and right contralateral transmaxillary approach with intraoperative neurophysiology were performed to remove this lesion.4,5 During surgery, the ICA proved dehiscent, and was therefore clip sacrificed.6 An immediate postoperative digital subtraction angiography showed minimally delayed, but adequate, blood flow to the left cerebral hemisphere. Postoperative MRI showed complete removal and no significant infarct. The patient was discharged in stable neurological condition, with only a slightly worsened CN III palsy. Experience with management of ICA injury is of uttermost importance in endoscopic endonasal surgery,1,2 and requires adequate training and an experienced 2-surgeon team.7 The patient provided consent to the submission and publication of the related surgical video.

External carotid artery stenting in symptomatic internal carotid artery occlusion

We report the case of a patient with an anterior ischemic stroke due to tandem occlusion of the left M2 segment and ipsilateral internal carotid artery (ICA), with concomitant severe stenosis of the ipsilateral external carotid artery (ECA) and contralateral ICA, and moderate stenosis of the left vertebral artery (VA); as thrombectomy was not possible, stenting of the right ICA was performed. Two days after significant recovery, the patient showed neurological deterioration when in upright position, and brain magnetic resonance imaging confirmed decreased cerebral blood flow on the left hemisphere. Stenting of the left ECA and balloon angioplasty of the ipsilateral VA were performed in order to increase collateral flow, with an almost complete resolution of symptoms. This case highlights the importance of assessing the collateralization pattern when an ICA occlusion is present, and the potential need to revascularize an ipsilateral stenotic ECA.

Acquired Hemicerebral Atrophy Secondary to Chronic Internal Carotid Steno-Occlusive Disease: A Case Series.

Cerebral atrophy is a common finding in elderly patients; however, cerebrovascular disease causing progressive focal cerebral atrophy and dysfunction is unusual. In this report, we present 3 cases of hemicerebral atrophy due to ipsilateral internal carotid artery (ICA) stenosis or occlusion mimicking neurodegenerative conditions. Patient 1 had a frontal dysexecutive syndrome potentially consistent with a diagnosis of behavioral variant frontotemporal dementia; however, neuroimaging revealed a chronically occluded left ICA and a pattern of atrophy restricted to the left middle cerebral artery territory, suggestive of a vascular etiology. Patient 2 presented with progressively worsening seizures and right-sided weakness consistent with left hemispheric dysfunction, with radiographic evidence of left hemicerebral atrophy. Angiography revealed a chronic dissection of the left ICA leading to left cerebral hypoperfusion. Patient 3 had asymmetric parkinsonism, alien limb, and cognitive impairment consistent with a diagnosis of corticobasal syndrome. His imaging, however, revealed atrophy and encephalomalacia within the anterior circulation watershed territories with chronic, severe stenosis of the left ICA suggestive of a chronic hypoperfused state. In this case series, we report 3 examples of hemicerebral atrophy secondary to chronic ipsilateral ICA vascular disease with diverse progressive clinical symptoms mimicking primary neurodegenerative conditions. This case series highlights the importance of considering chronic hypoperfusion and large-vessel severe stenosis or occlusion in patients with cognitive impairment and evidence of asymmetric brain atrophy. In addition to symptomatic treatment, the management of vascular risk factors including treatment with antiplatelet agents, statins, and revascularization procedures can be considered.

Balanced single-vector co-delivery of VEGF/PDGF-BB improves functional collateralization in chronic cerebral ischemia

The myoblast-mediated delivery of angiogenic genes represents a cell-based approach for targeted induction of therapeutic collateralization. Here, we tested the superiority of myoblast-mediated co-delivery of vascular endothelial growth factor-A (VEGF) together with platelet-derived growth factor-BB (PDGF-BB) on transpial collateralization of an indirect encephalomyosynangiosis (EMS) in a model of chronic cerebral ischemia. Mouse myoblasts expressing a reporter gene alone (empty vector), VEGF, PDGF-BB or VEGF and PDGF-BB through a single bi-cistronic vector (VIP) were implanted into the temporalis muscle of an EMS following permanent ipsilateral internal carotid artery occlusion in adult, male C57BL/6N mice. Over 84 days, myoblast engraftment and gene product expression, hemodynamic impairment, transpial collateralization, angiogenesis, pericyte recruitment and post-ischemic neuroprotection were assessed. By day 42, animals that received PDGF-BB in combination with VEGF (VIP) showed superior hemodynamic recovery, EMS collateralization and ischemic protection with improved pericyte recruitment around the parenchymal vessels and EMS collaterals. Also, supplementation of PDGF-BB resulted in a striking astrocytic activation with intrinsic VEGF mobilization in the cortex below the EMS. Our findings suggest that EMS surgery together with myoblast-mediated co-delivery of VEGF/PDGF-BB may have the potential to serve as a novel treatment strategy for augmentation of collateral flow in the chronically hypoperfused brain.

Reperfusion therapy in patients with minor or mild ischemic stroke

A significant number of patients with minor or mild stroke symptoms on initial presentation subsequently develop neurological deterioration and poor clinical outcomes at hospital discharge. The presence of an underlying large vessel occlusion is a strong predictor of both clinical worsening and poor outcome. Although patients with a low baseline National Institutes of Health Stroke Scale (NIHSS) could have been included in some randomized controlled trials, the benefits of the mechanical thrombectomy for patients with a low NIHSS score are unknown. The causes of neurological deterioration in patients with underlying large vessel occlusion are heterogeneous, but include collateral failure, and no straightforward mechanisms are found in the majority of cases. Patients with internal carotid artery occlusion, but with a patent middle cerebral artery (MCA), can occasionally have good collateral circulation and develop only minor or mild stroke. These patients exhibit collateral MCA flow via the circle of Willis despite ipsilateral internal carotid artery occlusion. However, thrombus migration may cause occlusion of collateral MCA flow, leading to dramatic neurological deterioration. Careful observation and detailed assessment are required for the management of these patients. Recent studies have examined the efficacy and optimal timing of thrombolysis or mechanical thrombectomy for patients with minor or mild stroke. Herein, we review the mechanisms of neurological deterioration, and the efficacy of reperfusion therapy, for patients with minor or mild stroke.

Association Between Stroke Severity and 5-Year Mortality in Ischemic Stroke Patients with High-Grade Stenosis of Internal Carotid Artery

BackgroundThe clinical presentations and outcomes of patients with high-grade stenosis of internal carotid artery (ICA) are highly variable. We investigate the influence of different stroke severity on outcomes of ischemic stroke patients with high-grade stenosis of ipsilateral ICA. Methods372 acute first-ever ischemic stroke patients with high-grade stenosis (70%-99%) or occlusion of ipsilateral ICA were enrolled and followed up for 5years. Stroke severities of the enrolled patients were grouped according to the Oxfordshire Community Stroke Project classification system as total anterior circulation infarcts (TACI) or non-TACI. Demographic features, vascular risk factors, comorbidities, and outcomes were compared between the 2 groups. ResultsA total of 71 patients (19.1%) were presented with TACI. Of laboratory data, the values of white blood cell count and high-sensitivity C-reactive protein were significantly higher in patients with TACI (P = .008 and P = .003, respectively). Of clinical course, the occurrence of initial impaired conscious, stroke-in-evolution, pneumonia, gastrointestinal bleeding, and urinary tract infection were significantly higher in patients with TACI. The prevalence of dependent functional status was higher in patients with TACI. Multivariate Cox regression revealed that TACI is a significant predictor of 5-year all-cause mortality in first-ever ischemic stroke patients with high-grade stenosis of ipsilateral ICA (HR [hazard ratio] = 3.66, 95% confidence interval = 2.23-6.00, P < .001). ConclusionsTACI is associated with increased risk of 5-year mortality in ischemic stroke patients with high-grade stenosis of ipsilateral ICA. Intensive medical treatment for stroke prevention in patients with severe carotid artery stenosis is warranted.

Blood pressure and collateral circulation in acute ischemic stroke

This study aimed to evaluate the effect of different blood pressure (BP) parameters on the collateral circulation in aretrospective cohort of patients with acute ischemic stroke and ipsilateral internal carotid artery (ICA) occlusion. The degree of intracranial collaterals was graded according to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System. At 12-72 h after stroke onset, six BP measurements were obtained in 124 patients with ICA occlusion. Baseline clinical and imaging characteristics were collected. Group comparisons were performed, and the collateral score (CS) was assessed and entered into alogistic regression analysis. In all, 80 (64.5%) patients displayed good collateral filling (CS ≥ 2). Good intracranial collaterals were more frequently associated with the development of collaterals in the anterior communicating artery, posterior communicating artery, and leptomeningeal artery. The systolic blood pressure (SBP; p = 0.018), diastolic blood pressure (DBP; p = 0.013), and mean arterial pressure (MAP; p = 0.016) were significantly associated with good CS. Median CS was highest when SBP was 120-130 mm Hg (p = 0.034). Logistic regression analysis showed that hypertension (p = 0.026, OR: 0.380, 95% CI: 0.163-0.890) was asignificant predictor of poor CS. The development of collateral circulation in patients with acute ischemic stroke with ICA occlusion may be influenced by BP. Amoderately decreased SBP is associated with good integrity of the collateral circulation in patients with acute ischemic stroke with occlusion of the ICA.

The effect of interventional thrombolytic therapy for central retinal artery occlusion with ipsilateral internal carotid artery occlusion via supratrochlear artery retrogradely or external carotid artery anterogradely

Objective To observe the effect of interventional thrombolytic therapy for central retinal artery occlusion (CRAO) with ipsilateral internal carotid artery occlusion via supratrochlear artery retrogradely or external carotid artery anterogradely. Methods Nine CRAO patients (9 eyes) were enrolled in this study, including 5 males and 4 females. The mean age was (45.2±18.1) years. The mean onset duration was 24 hours. There were 4 eyes with vision of no light perception, 3 eyes with light perception and 2 eyes with hand movement. Fundus fluorescein angiography (FFA) examination showed that the retinal artery was filled with delayed fluorescence. The peak of fluorescence was seen in the anterior part of the artery, and some of the eyes showed retrograde filling. The arm-retinal circulation time (A-Rct) was ≥35 s in 4 eyes, ≥35 s - <25 s in 5 eyes. The filling time of retinal artery and its branches (FT) was ≥ 15 s in 2 eyes, ≥12 s - <15 s in 3 eyes, ≥9 s -<12 s in 4 eyes. All the patients received the treatment of interventional thrombolytic therapy via supratrochlear artery retrogradely (8 eyes) or external carotid artery anterogradely (1 eye) according to the indications and contraindications of thrombolytic therapy in acute cerebral infraction patients. Urokinase (0.4 million U in total) was intermittently injected into the arteries. After artery thrombolysis, the changes of digital subtraction angiography (DSA), filling time of retinal artery and its branches on FFA within 24 hours and the visual acuity were observed. According to the A-Rct and FT on FFA, the therapeutic effects on retinal circulation were defined as effective markedly (A-Rct≤15 s, FT≤2 s) , effective (A-Rct was improved but in the range of 16 - 20 s, FT was in 3 - 8 s) and no effect (A-Rct was improved but ≥21 s, FT≥9 s). The related local or systemic complications were recorded. Results After the injection of urokinase into the catheter, the ophthalmic artery and its branches were increased in 6 eyes (66.7%), and the development of the eye ring was significantly more than that of the eyes before thrombolysis. The circulation time in ophthalmic artery was speeded up for 2 s before thrombolysis in 3 eyes, 3 s in 3 eyes, and 4 s in 2 eyes. Within 24 hours after thrombolysis treatment, the A-Rct was significantly decreased than that of before interventional therapy. The retinal circulation was effective markedly in 4 eyes (44.4%), effective in 4 eyes (44.4%) and no effect in 1 eyes (11.2%) . The vision was improved 3 lines in 4 eyes (44.4%), 2 lines in 3 eyes (33.3%), 1 line in 1 eye (11.2%) and no change in 1 eye (11.2%). There were no abnormal eye movements, vitreous hemorrhage and incision hematoma, intracranial hemorrhage, cerebral embolism, and other local and systemic adverse effectives during the follow-up. Conclusions The interventional thrombolytic therapy via supratrochlear artery retrogradely or external carotid artery anterogradely for CRAO with the ipsilateral internal carotid artery occlusion can improve retinal circulation and vision. There are no related local or systemic complications. Key words: Retinal artery occlusion/drug therapy; Carotid stenosis/drug therapy; Thrombolytic therapy; Radiography, interventional; Angiography, digital subtraction; Fluorescein angiography

頭蓋内内頸動脈閉塞症による血行力学的ストレスにて生じたと考えられる後大脳動脈近傍のtrue posterior communicating artery aneurysm の1 例

頭蓋内内頸動脈閉塞症による血行力学的ストレスにて生じたと考えられる後大脳動脈近傍のtrue posterior communicating artery aneurysm の1 例

Successful Cross-circulation Stent-Retriever Embolectomy Through Posterior Communicating Artery for Acute MCA Occlusion by Using Trevo XP ProVue.

Acute ischemic stroke due to embolic occlusion of the middle cerebral artery (MCA) in patients with chronic ipsilateral internal carotid artery (ICA) occlusion is quite rare. Several previous reports demonstrated that intra-arterial (IA) thrombolytic therapy or aspiration thrombectomy using the cross-circulation technique via an alternative collateral pathway is feasible in acute stroke patients with an unfavorable direct route to the occluded sites. However, stent-retriever embolectomy via the cross-circulation approach has not been reported in the literature. The present paper reports the first case of successful stent-retriever embolectomy for acute MCA occlusion via the patent posterior communicating artery (PComA) by using Trevo XP ProVue stent-retriever in a patient with acute MCA stroke and chronic occlusion at the origin site of the ipsilateral ICA.