Left Cervical Internal Carotid Artery Research Articles

Another cause of treatable dementia: rapid cognitive improvement after carotid endarterectomy. Illustrative case.

Revascularization techniques in cervical internal carotid artery (ICA) stenosis are indicated to prevent the onset or recurrence of ischemic events in the setting of atherosclerotic carotid artery disease. Recent reports, case series, and comparative studies have suggested that revascularization techniques may also improve cognitive outcome in both symptomatic and asymptomatic patients, thus raising the question of whether another surgically treatable dementia has presented itself. A 70-year-old right-handed female with a history of hypertension, diabetes, and bilateral silent cerebral infarcts was evaluated for progressive cognitive impairment over a 1-year period, which was associated with a severe left cervical ICA stenosis. Carotid endarterectomy (CEA) was indicated as a revascularization technique, and the patient showed significant neurocognitive improvement as early as one month postoperatively, consistent with blood flow restoration to the left hemisphere on control imaging. This case serves as a reminder that CEA may improve the cognitive outcome of patients previously impaired by uncomplicated severe cervical ICA atherosclerotic disease, which can be another cause of treatable dementia. Further prospective studies may help to assess this potential benefit.

Acute bilateral middle cerebral artery occlusion treated with thrombectomy via the anterior communicating artery in a patient with chronic left cervical internal carotid artery occlusion: a case report

Acute bilateral middle cerebral artery occlusion treated with thrombectomy via the anterior communicating artery in a patient with chronic left cervical internal carotid artery occlusion: a case report

Abstract 018: External carotid artery Pseudo aneurysm induced Internal Carotid Artery compression causing acute ischemic stroke

Introduction Here, we describe a patient in whom ischemic stroke was caused by compression of the Internal Carotid Artery (ICA) by a Pseudoaneurysm (PSA) of the External Carotid Artery (ECA) after Gun Shot injury. Eventually, the PSA of the Internal maxillary artery (IMAX) was embolized, resulting in resolution of the patient's symptoms. Methods Case Report Results A 75‐year‐old male with a history of atrial fibrillation on Eliquis presented to the emergency department after sustaining a gunshot wound to the left face. He had extensive injuries through the left masticator and submandibular space with an inferior orbital wall fracture. A Computed Tomography Angiography (CTA) neck showed injuries to the left proximal IMAX with a small PSA. As the PSA was asymptomatic it was managed with observation. On HOD day 13, CTA was done for a brief period of unresponsiveness, which showed high‐grade narrowing of left cervical ICA due to extrinsic compression from PSA which was supplied by a branch of the left ECA with distal re‐constitution (image A). The next day, patient developed right sided plegia and aphasia with NIHSS of 17. A CT head showed no acute intracranial abnormality. The patient underwent emergent Digital Subtraction Angiography (DSA), which demonstrated occlusion of the left cervical ICA from compression from a left IMAX PSA which was treated with n‐butyl‐cyanoacrylate TRUFILL embolization with resolution of flow limitation in the left cervical ICA (Image B1,B2). After embolization, the patient was oriented and able to lift right arm and leg anti‐gravity. Magnetic Resonance Imaging (MRI) was contraindicated due to retained bullet fragments. Repeat CT head did not show stroke. Conclusion A Pseudo aneurysm is characterized by a rupture of the arterial wall and the formation of an aneurysmal sac by the adjacent structures while the sustaining artery remains intact. The most prevalent causes are penetrating or acute blunt neck trauma, hyperextension injury, and injury to the base of the skull (1). Predisposing factors for PSA include carotid endarterectomy or a late complication of carotid artery dissection, infection, radiotherapy, and malignancy (1‐2). Cox et al. reported 124 patients with significant neck and head penetrating injuries. Eleven patients were found to have thirteen head and neck PSA: two in the ICA, one in the vertebral artery, and ten involving branches of the ECA. Two of seven symptomatic PSAs manifested with episodes of massive hemorrhage (3). There have been case reports describing the consequences of an elongated styloid process causing an ischemic stroke due to subsequent dissection and PSA formation (4). According to our knowledge, this case report is one of the first to describe acute ischemic symptoms resulting from ECA PSA‐induced ICA compression, with resolution of symptoms following PSA embolization. The educational value of our case lies not only in the rarity of the condition but also in the uniqueness of its presentation. This case is a fundamental addition to the existing literature on rare neuro‐vascular anomalies leading to potential catastrophic outcomes.

Abstract 098: Symphony of Risk: A Case Report of Carotid Artery Dissection Associated with Violin Playing

Introduction Carotid artery dissection (CAD) is an uncommon and potentially life‐threatening condition that can have a delayed presentation. More commonly associated with blunt cervical trauma, CAD due to repetitive stress to the neck goes under‐recognized, making it challenging to diagnose. Herein, we aim to shed light on a unique instance of CAD after continuous microtrauma, as well as highlight diagnostic challenges associated with CAD. Methods We present a case of a 57‐year‐old man who presented with a one‐week course of unequal pupils, left‐sided headaches, left sided ptosis, and intermittent blurry vision. Exam revealed a callous where he held a violin against his left neck, having endorsed playing for several years with repeated contortion of his head to the left (Figure 1A). Magnetic resonance angiogram (MRA) of the head and neck revealed an acute dissection of the left internal carotid artery (ICA) (Figure 1B). A diagnosis of Horner’s syndrome secondary to acute dissection of the left cervical ICA was made. Consent to share this information was obtained from the patient and witnessed by another physician. Results MRA head and neck showed a 2.5 cm irregularity of the distal left ICA with high signal on fat saturated T1‐weighted images consistent with an acute dissection (Figure 1B). The patient underwent an apraclonidine test and was positive for left sided Horner’s syndrome with reversal of anisocoria after application of drops (Figure 1C). Given no evidence of stroke or thrombus on imaging, he was placed on dual antiplatelet therapy (DAPT) for three months. He was advised not to play violin for a month and to restart cautiously with a pad between his neck and the instrument. Follow‐up imaging showed eventual resolution of the CAD, while physical exam revealed improvement in ptosis and miosis. Conclusion While playing the violin involves repetitive stress on the neck, there is limited research on this specific activity as a cause of carotid artery dissection, making it a rare occurrence. Common clinical manifestations of CAD include neck pain, headache, Horner’s syndrome, tinnitus, stroke, and lower cranial nerve palsies, occurring suddenly or over time. Diagnosing CAD typically involves a combination of thorough history, physical examination, and diagnostic imaging. Ongoing research in the optimal management of CAD focuses on minimizing the risk of stroke, after factoring in variables such as location of dissection and whether it is symptomatic or not.

SAT058 Diabetes Complicated By DKA, Mucormycosis And Covid-19

Abstract Disclosure: A. Gordon: None. Background: Mucormycosis is an invasive opportunistic fungal infection, that although rare, has an estimated all-cause mortality of 54%. Even with aggressive treatment, significant tissue necrosis and bone destruction can occur. Risk factors include diabetes, acidosis (as in diabetic ketoacidosis), excess iron, transplant, malignancy, kidney and liver disease, immunosuppressant and corticosteroid use - and in more recent times, the Covid-19 infection. We present a case of invasive rhino-orbital cerebral mucormycosis in the setting of DKA, uncontrolled diabetes and Covid-19. Case: A 60-year-old female with history of uncontrolled type 2 diabetes (HbA1c 14.3%) presented after being found unresponsive. Her exam was significant for encephalopathy, complete left eye ophthalmoplegia and right-sided hemiparesis. She was hemodynamically stable without fever. Initial labs showed significant hyperglycemia with an elevated anion gap and beta-hydroxybutyrate indicative of diabetic ketoacidosis (DKA). She had a lumbar puncture which showed leukocytosis with neutrophilia (146 WBC, 39% neutrophils), elevated glucose and normal protein; CSF culture was negative for growth. She also tested positive for Covid-19 although CXR was unremarkable and she did not require treatment. Initial CT/CTA head/neck showed complete occlusion of the left cervical internal carotid artery with associated acute/subacute infarcts in the left frontal, parietal, temporal and occipital lobes. CT sinuses showed severe frontal, maxillary and ethmoid sinus mucosal wall thickening with left premaxillary soft tissue swelling and leftward nasal septum deviation. Finally, orbital imaging showed left cavernous sinus thrombosis, left superior ophthalmic vein thrombosis, and necrosis vs devascularization of the extraocular muscles. She was initially treated with fluids, an insulin infusion and broad-spectrum antibiotics and was evaluated by neurology, ophthalmology, infectious disease and otolaryngology. She underwent surgical debridement with left maxillary antrostomy, left total ethmoidectomies and septoplasty. Sinus cultures were positive for MSSA (methicillin sensitive staph aureus) and tissue pathology showed angioinvasive fungal disease compatible with Mucor/Rhizomucor species. Antimicrobial coverage was changed to intravenous Nafcillin and Amphotericin B, and she underwent further surgical debridement twice more. Repeat brain imaging to evaluate for disease progression is pending. Discussion: Early detection and aggressive treatment of Mucormycosis with surgical debridement and Amphotericin B can improve patient outcomes, however the mortality rate is still significant. Therefore, tight glycemic control in high risk groups is imperative, particularly in those with uncontrolled diabetes complicated by DKA and Covid-19 infection (with or without steroid treatment). Presentation: Saturday, June 17, 2023

Concurrence of multiple aneurysms, extreme coiling of the extracranial internal carotid artery and ipsilateral persistent primitive hypoglossal artery: A case report and literature review.

The primitive hypoglossal artery (PHA) is an anastomotic vessel of the carotid-basilar artery system that is prevalent only transiently during the embryonic period. Persistent primitive hypoglossal artery (PPHA) is a rare vessel variation in which PHA exists persistently in adulthood and occurs in approximately 0.02-0.1% of the population. Tortuosity of the extracranial internal carotid artery (ICA) is relatively common, impacting 10-43% of the population, and is caused by either congenital or acquired factors. It is still unknown whether PPHA and tortuosity of extracranial ICA are associated. Here, we present a case report of the concurrence of three types of pathologies of the carotid artery: extreme coiling of the extracranial internal carotid artery, multiple aneurysms and persistent primitive hypoglossal artery. A 66-year-old woman suffered intermittent headaches, dizziness and numbness of the right eyelid for 5 years. Magnetic resonance angiography performed in a local hospital reported an aneurysm of the posterior communicating artery segment of the left ICA and a left PPHA. Digital subtraction angiography conducted after admission showed a PPHA originating from the left cervical ICA and an extremely coiling segment of the ICA distal to the beginning of PPHA. Except for the aneurysm of the posterior communicating artery segment of the left ICA, multiple aneurysms were found at the coiling segment of the ICA. To the best of our knowledge, this is the first report of PPHA accompanied by an adjacent, extremely coiling ICA. There are no reports of similar tortuous ICAs to this extent or at this position. Including aneurysms, three types of pathologies suggest their congenital origin, and a review of the literature infers the probable association of these lesions.

Young Male with Bilateral ICA Dissection: Beyond CADISS Trial

Objective: To report a case of young male with stroke and bilateral internal carotid artery (ICA) dissection. Background: Cervical Artery Dissection in Stroke Study trial has provided some insight on management of patients with ICA dissection. However, there is a need to modify the management strategies as per specific clinical scenario. Design/Methods: Case report and literature review. Results: A 45-year-old male presented with 1 month old history of acute onset numbness of right half of the body with slurring of speech. Computed tomography angiography showed complete occlusion of left cervical ICA just beyond origin with presence of fusiform dilatation and spiral flap in right extracranial cervical ICA. The patient was started on antiplatelets and taken for endovascular procedure using 2-mesh-based carotid stents. Patient was discharged after 3 days on antiplatelet therapy. At 1-year follow-up, there were no fresh symptoms. Conclusion: This case emphasizes the role of successful endovascular management of carotid dissection in a young male. These clinical situations may not be fully represented in trials, and a case-based approach is required.

Bilateral carotid artery dissection due to Eagle syndrome in a patient with vascular Ehlers-Danlos syndrome: a case report

BackgroundPatients with vascular Ehlers-Danlos syndrome (EDS) occasionally suffer from arterial dissection. Eagle syndrome, which is caused by an elongated styloid process and also causes arterial dissection, is difficult to diagnose and could sometimes be overlooked. Little is known of the coexistence of these two diseases, and treatment strategy is not established. Here, we present a case of bilateral internal carotid artery (ICA) dissection due to Eagle syndrome in a patient with vascular EDS.Case presentationA 30-year-old man was admitted to our hospital because of sudden onset of mild sensory disturbance in his left limbs. He had a history of Ehlers-Danlos syndrome (EDS) and also had left cervical internal carotid artery (ICA) dissection 3 years before. Diffusion-weighted imaging showed acute cerebral infarcts in the right hemisphere. Cervical computed tomography angiography (CTA) revealed the right ICA narrowing at the cervical portion in addition to the previous left cervical ICA dissection. Cervical magnetic resonance imaging (MRI) revealed double-lumen and intramural hematoma at the narrowing portion of the right cervical ICA, which indicates arterial dissection. CT also revealed bilateral elongated styloid processes which are close to each side of cervical ICA. We diagnosed him as bilateral ICA dissection due to bilateral Eagle syndrome. Considering vascular complications due to vascular EDS, we performed closer follow-up with transoral carotid ultrasonography (TOCU). In 4 months, his right ICA dissection gradually improved without stroke recurrence or deterioration of dissection.ConclusionsSince patients with vascular EDS easily develop arterial dissection, Eagle syndrome may be overlooked. Clinicians should consider Eagle syndrome in the case of vascular EDS with extracranial ICA dissection and close follow-up should be prioritized in cases of Eagle syndrome with vascular EDS.

Utility of Coaxial Angioplasty-thrombectomy for Acute Tandem Occlusion of Intracranial and Extracranial Arteries.

We report a novel technique for acute occlusion of both intracranial and extracranial arteries (tandem lesions [TL]). A 67-year-old male was transferred to our hospital because of right hemiparesis and aphasia. MRA revealed occlusion of the left cervical internal carotid artery (ICA) and middle cerebral artery (MCA). A balloon guide catheter (BGC) was advanced into the left common carotid artery (CCA). A microcatheter was advanced over a microwire through the intracranial thrombus. A stent retriever (SR) was deployed from the MCA to the ICA through the microcatheter. Next, with the SR anchored to the thrombus, the microcatheter was withdrawn. The extracranial percutaneous transluminal angioplasty (PTA) balloon was coaxially advanced over the SR's delivery wire and angioplasty was performed. Then, an aspiration catheter was coaxially advanced to the proximal aspect of the intracranial thrombus over the delivery wire by pump aspiration. We removed the SR and the aspiration catheter as a single unit into the BGC, resulting in sufficient recanalization. The puncture to recanalization time was 29 minutes. This technique can lead to faster recanalization in cases of TL.

A case of pipeline migration in the cervical carotid

Since its emergence in 2011, the pipeline flow diversion (PFD) has gained recognition in the treatment of certain intracranial aneurysms. However, early or delayed pipeline migration (PM) and micro-catheter/guidewire retention have been infrequently reported. We report a case of PM and shortening in the treatment of a left cervical internal carotid artery (LICA) aneurysm. A middle-aged African-American patient presents for an off-label PFD treatment of an incidental 21 × 23 mm aneurysm at the sub-petrous segment of the left ICA. While the patient remained completely neuro-intact, a 6 months follow-up angiogram revealed a persisting filling of the cervical aneurysm with a foreshortening of the pipeline by 1/3 of its original 30 mm size and proximal migration into the aneurysmal sac. We opted to watch the aneurysm within 6 months especially that the aneurysm was extra-cranial and because of the potential risks involved in trying to re-access the device.

Cerebral infarct with idiopathic cervical internal carotid artery vasospasm: A case report and literature review

Abstract Intracranial vasospasm that results from subarachnoid hemorrhage mostly leads to cerebral infarct. On the other hand, cervical internal carotid artery (CICA) vasospasm is caused by various factors such as cervical surgery, taking ergotamine, or is of unknown origin. We report here a rare case of cerebral infarct due to repeated idiopathic bilateral CICA vasospasm, and present a review of the literature. A 38-year-old man, who had a medical history of cerebral infarcts at the ages of 27 and 35, was admitted complaining of disturbance of consciousness and aphasia. MRI and MRA revealed cerebral infarct of the left middle cerebral artery (MCA) area due to occlusion of the left cervical internal carotid artery. Cerebral angiography at 9 days after onset, we demonstrated that the right CICA was occluded, whereas the left CICA was recanalized. On the 32nd day after onset, MRA showed the bilateral CICA to be recanalized. Idiopathic CICA vasospasm should be considered as a cause of juvenile-onset cerebral infarct. Regular follow-up is therefore needed because idiopathic CICA vasospasm is prone to recurrence.

Left Cervical Internal Carotid Artery Stenting via the Left Brachial Artery in Which a Simmons-type Guiding Sheath Was Combined with a Guiding Catheter

Left Cervical Internal Carotid Artery Stenting via the Left Brachial Artery in Which a Simmons-type Guiding Sheath Was Combined with a Guiding Catheter

Surgical Revascularization During the Acute Phase of Stroke Caused by Near Occlusion of the Cervical Internal Carotid Artery

An 83-year-old woman was admitted with a diagnosis of transient symptoms with a left hemisphere infarction due to atherosclerosis. Despite the best medical treatments, her neurological symptoms gradually deteriorated. The color Doppler ultrasound (CDUS) and digital subtraction angiography (DSA) demonstrated a near occlusion of the left cervical internal carotid artery. Because the intracranial internal carotid artery (ICA) seemed patent on DSA, although CDUS also suggested that the intracranial ICA was also occluded, carotid endarterectomy was performed. However, magnetic resonance angiography performed immediately after the operation showed distal occlusion of the ICA. A superficial temporal artery-middle cerebral artery (MCA) bypass was performed immediately to rescue the region that was perfused by the MCA. The neurological symptoms stabilized after the operation. It is often difficult to assess the patency of the intracranial ICA by DSA if distal ICA flow is slow and faint. Although the pulsed Doppler waveform can be affected by the site of the distal occlusion, CDUS would be a good addition to the preoperative evaluation. And if the patency of the ICA distal to the stenosis cannot be confirmed, especially in emergent settings, a superficial temporal artery-MCA bypass can be a good treatment option.

Elongated Styloid Process as a Cause of Transient Ischemic Attacks

A 49-year-old man had been experiencing transient right-sided weakness during neck rotation and flexion to the left for 1 year. On hospital admission, a neurological examination revealed no deficits. Initialmagnetic resonance imaging of the brainwas unremarkable. The first computed tomographic (CT) angiographyof thebrain and neck revealed no abnormal findings. Catheter cerebral angiography,performedwiththepatient’sheadturnedtothe left (Figure1), demonstrated a filling defect fromwhat appears to be an extrinsic compression.ThesecondCTangiographyof thebrainandneckperformed with the patient’s head turned to the left (Figure 2 and Figure 3) revealed a left cervical internal carotid artery (ICA) compression due to an elongated styloid process. The elongated styloidprocesswasremovedduringsurgery,afterwhichthepatienthad a satisfactory recovery. Postoperative CT angiography of the brain and neck (Figure 4) revealed that the left cervical ICA was free of compression. This case suggests the usefulness of dynamic catheter and CT angiography for the diagnosis of an elongated styloid process as a cause of transient ischemic attack.

Le modafinil améliore les performances de conduite simulée des malades souffrant d’hypersomnie : étude randomisée placebo-verum

To report a novel technique for temporary and permanent vessel occlusion with a single microcatheter and investigate its efficacy in endovascular management of cerebral aneurysms and invasive head and neck tumors.A 58-year-old woman with a history of T3N0 squamous cell carcinoma of the tongue with extensive surgical resections and radiotherapy presented to the emergency department with further wound dehiscence and exposure of the left cervical internal carotid artery (ICA). Digital subtraction angiography (DSA) was performed with the patient under conscious sedation. An Ascent balloon, 4 mm × 15 mm, was prepared and introduced into the proximal ICA. While the patient was fully awake, temporary balloon occlusion (TBO) was performed for 30 minutes. The Ascent balloon was kept inflated. Through the inflated Ascent balloon, coil embolization of the proximal ICA was initiated. The interstices of the coils were filled with Onyx 18 and Onyx 34 liquid embolic agents (ev3 Neurovascular, Inc, Irvine, California, USA).The Ascent balloon can be used as a temporary balloon device and as a coil or Onyx embolization device. As a result, fewer catheters, guidewires, and balloon inflations and deflations are required for the procedure, which is both cost-effective and time-efficient. The combination of initial coiling to create a framework for the deconstruction with a liquid embolic agent (Onyx) is a safe and efficient technique for vessel deconstruction. Flow arrest with proximal balloon occlusion minimizes the risks of distal thromboembolic events during embolization.This novel technique for temporary and permanent vessel occlusion with a single microcatheter is both cost-effective and time-efficient.

Drip, Ship, and Grip, then Slice and Dice: Comprehensive Stroke Center Management of Cervical and Intracranial Emboli

Background and Purpose: Tandem acute thrombotic emboli in the cervical and intracranial arteries are an unusual cause of stroke presenting unique management challenges. In regional systems of acute stroke care anchored by Comprehensive Stroke Centers (CSC), combined fibrinolytic, endovascular, and open surgical intervention is a new therapeutic option.Summary of Case: A 28-year-old male underwent retinal surgery, including post-operative neck compression and the next day presented to a primary stroke center with aphasia and right hemiplegia. Intravenous tissue plasminogen activator therapy was initiated and the patient was transferred to a CSC for higher level of care (drip and ship). Imaging at the CSC demonstrated tandem thrombi: a near occlusive lesion at the origin of the left cervical internal carotid artery and a total occlusion of the M1 segment of the left middle cerebral artery. Endovascular thrombectomy with the Solitaire stent retriever resulted in intracranial recanalization (grip). Immediately after the endovascular procedure, open carotid thrombectomy was performed to achieve cervical carotid revascularization without systemic heparinization (slice). Both cervical carotid and intracranial thrombi were processed for proteomic analysis via mass spectrometry (dice).Conclusion: Combined fibrinolytic, endovascular, and open surgical intervention can yield revascularization and good clinical outcome in cases of tandem lesions.

Blunt carotid artery injury after minor facial trauma

A healthy young man presented three days after suffering a punch to the face resulting in minimally displaced mandibular fractures. History revealed an episode of anterograde amnesia and a delayed episode of dysphonia. Apart from the fractured mandible, the physical examination was otherwise noncontributory. Imaging revealed severe luminal narrowing of the left cervical internal carotid artery distal to the carotid bifurcation, consistent with carotid dissection; and two focal hypodensities in the left frontal and parietal cortices, highly suggestive of acute secondary embolic infarcts. The patient was treated with systemic anticoagulation for three months and experienced no further neurological symptoms. His mandibular fractures, treated conservatively, healed without any complications. Blunt carotid artery injuries are uncommon and diverse. Neurological symptoms may develop in a delayed fashion, thus, a high index of suspicion based on knowledge of the injury mechanisms and patterns of associated injuries may enable earlier diagnosis and treatment. Angiographic imaging is essential for the diagnosis and classification of injury characteristics (eg, type, location, etc). Treatment must be considered on an individual patient basis depending on the presentation, grade and morphology of the lesion. Although no level I clinical trials exist on the topic, anticoagulation seems to be the treatment of choice in most cases and surgical intervention is not commonly indicated. Carotid artery dissection without complete thrombosis may be effectively treated with systemic anticoagulation or antiplatelet therapy in the majority of cases.

Ischemic Events Due to Intraoperative Microemboli Developing in the Cerebral Hemisphere Contralateral to Carotid Endarterectomy in a Patient With Preoperative Cerebral Hemodynamic Impairment

A 74-year-old man with a history of asymptomatic right internal carotid artery (ICA) occlusion experienced amaurosis fugax in the left eye. Angiography showed left cervical ICA stenosis in addition to right cervical ICA occlusion. The right anterior and middle cerebral artery (MCA) territories were perfused from the left ICA via the anterior communicating artery. Brain perfusion single-photon emission computed tomography revealed reduced cerebral blood flow and reduced cerebrovascular reactivity to acetazolamide only in the right cerebral hemisphere. The patient underwent left carotid endarterectomy (CEA). Transcranial Doppler monitoring showed microembolic signals in the left MCA during dissection of the left ICA, but intraoperative monitoring suggested absence of global hypoperfusion or ischemia in the bilateral cerebral hemispheres during left ICA clamping. Transient and slight motor weakness of the left upper extremity was noted on recovery from anesthesia. Diffusion-weighted magnetic resonance imaging demonstrated the development of new spotty ischemic lesions only in the right cerebral hemisphere. The present case suggests that intraoperative cerebral embolism causing postoperative neurological deficits can develop exclusively in the cerebral hemisphere contralateral to CEA if the hemisphere has preoperative hemodynamic impairment and collateral circulation via the anterior communicating artery from the ICA ipsilateral to CEA.

Unilateral Macroglossia as Sole Presenting Manifestation of Internal Carotid Artery Dissection

A patient presented with acute-onset, painless, unilateral enlargement of the tongue. Steroid treatment for angioedema was ineffective, and a biopsy of an apparent mass of the tongue base showed normal tissue. Subsequent magnetic resonance imaging showed enlargement, enhancement, asymmetric T2 hyperintensity of the left half of the tongue, and dissection of the left cervical internal carotid artery (ICA) at the skull base. Unilateral enlargement of the tongue due to acute neurogenic denervation may be the sole clinical presentation of a spontaneous arterial dissection at the skull base. The hypoglossal neuropathy resulted from compression by the pseudoaneurysmal ICA dilatation or ischemia from interruption of the vasa nervorum.

RESOLUTION OF MYDRIATIC PUPIL AFTER ANGIOPLASTY AND STENTING OF CERVICAL INTERNAL CAROTID ARTERY DISSECTION

A patient with cervical internal carotid artery (ICA) dissection presented with visual loss and a mydriatic pupil that resolved after angioplasty and stenting. A 49-year-old woman presented with a unilateral dilated tonic pupil and transient monocular visual loss and subsequently developed speech disturbance. Angiography revealed a left cervical ICA dissection with significant luminal narrowing. The ophthalmic artery filled retrograde through external carotid artery branches and reconstituted the supraclinoid ICA. Computed tomographic perfusion showed significant hypoperfusion of the left hemisphere. Magnetic resonance imaging showed punctate boundary zone infarcts. The patient experienced pressure-dependent left hemispheric transient ischemic attacks and pressure-dependent ocular findings despite anticoagulation. She underwent uncomplicated left ICA angioplasty and stenting. The flow through the ophthalmic artery became anterograde. The tonic pupil returned to symmetry with the contralateral pupil, and the patient's symptoms resolved completely. Cervical ICA dissection can manifest with a tonic mydriatic pupil. Treatment with angioplasty and stenting of the dissected segment can restore flow and resolve the pupillary abnormality. A pathophysiological mechanism for the mydriasis is proposed.