Left External Carotid Research Articles

A Study on Position and Lumen Geometry at the Origin of External Carotid Artery in Human Adult Cadavers

Background: External carotid artery is the predominant source of blood supply to the structures in the head and neck region. Morphological anomalies in the external and internal carotid arteries may lead to severe complications, when radiographic evaluations and surgical proceedings are done in the neck without any prior knowledge. Normal arterial diameters of external carotid arteries were important in-patient selection, preoperative planning, and design of new endovascular devices for arterial reconstruction. Material and Methods: A descriptive study was performed on 60 formalin fixed male and female Human adult cadavers, aged between 45 to 75 yrs in the department of Anatomy, Dr.Pinnamaneni Siddhartha Institute of Medical Sciences and Research foundation, chinoutapalli and Mamatha academy of medical sciences, Hyderabad , during the academic years, 2018- 2023 during the academic years . Observations from both right and left external carotid arteries (total- 120 sides) were noted. Results: In the present study, positions of external carotid artery observed were, antero-medial in 90%, anterolateral in 6.66% and lateral position in 3.33% of cases. The mean ± standard deviation calculated for the diameter of lumen at the origin of external carotid artery on the right side was 0.623±0.048 cm and on the left side was 0.608±0.050cm. For both right and left sides was 0.616±0.049cm. Conclusion: Positional variations of external carotid artery observed in the present study were anterolateral and lateral positions. In such cases Carotid endarterectomy can be safely done, after transposing the internal carotid artery to normal location. Data on normal arterial diameters were helpful during reconstructive surgeries and manufacture of endovascular devices, respective to different ethnic groups. KEYWORDS: Common Carotid Artery, Carotid Artery External, Positional Variations, Lumen Geometry, Carotid Endarterectomy.

Abstract 333: Multiple Dural AV fistulas ‐ patient tailored approach and importance of vigilant monitoring

Introduction Dural AV fistulas (AVFs) are a type of heterogeneous vascular malformations accounting for 10‐15% of cerebral vascular malformations. They tend to bleed, grow and compress. The risk of neurological deficits is associated with their drainage. Cognard and Bogden grading uses such characteristics. Decision to treat is dependent on grading of AVF and symptomatology. The aetiology of the AV fistulas is likely secondary to thrombosis, trauma, inflammation or can be idiopathic. It occurs between 40‐60 years of age with no gender predisposition. Here we describe a patient who presented with multiple dural AVFs that required frequent monitoring and treatment. Patient course A 72 year old male patient with a past medical history of treated Renal Cancer, Myocardial infarction, Hepatic cysts, treated prostate cancer presents to the clinic with pulsatile tinnitus. Patient underwent MR angiogram that revealed left skull base dural AVF. A coil pack in the right ophthalmic artery was also found. He endorsed a history of protrusion and redness of the right eye which was treated at Barnes Jewish Hospital. Based on the records, concern was of a possible carotid‐cavernous fistula(CCF) on the right side. Patient opted for non‐invasive monitoring of the skull base AVF. 3 months later, patient presented with worsening tinnitus and proceeded with a diagnostic cerebral angiogram(DCA). DCA through the right internal carotid artery(ICA) revealed prominent meningohypophyseal arteries, pointing to remnants of the possible CCF. Right external carotid artery(ECA) revealed Cognard grade 1 grade AVF between the occipital and middle meningeal arteries with antegrade drainage into the transverse sinus. Left ICA was normal. Left ECA revealed a grade 1 AVF between the occipital artery and the inferior petrosal and cavernous sinuses with retrograde flow into the superior ophthalmic vein. Left vertebral artery was normal whereas the right vertebral artery revealed a subtle AVF from the posterior meningeal artery without any cortical vein involvement. 1 month later, symptoms worsened with throbbing, red and watery left eye with double vision. DCA was performed with plan to treat. Bilateral approach was planned due to concern for increasing the pressure on the right side. Patient underwent bilateral arterial embolization and was observed postoperatively overnight. Patient had some remnants of middle meningeal arteries feeding into the cavernous sinus, which were not treated. He endorsed no improvement in ophthalmological symptoms. In 6 weeks, he continued to have diplopia with injection. DCA was performed with the aim of endovenous embolization but was unsuccessful. Hence, endoarterial embolization of the cavernous branches of the MMA was performed, resulting in symptom resolution in 6 weeks. Conclusion Dural AV fistulas are vascular malformations that present themselves either incidentally or with occult and insidious progression of subtle symptoms which can also be fatal. Early acknowledgement of incidental findings, consideration for deeper investigation in case of incidental cases can help monitor the growth of the fistula and make planned decisions on their treatment whilst reducing the risk of sudden neurological injury that can lead to devastating disabilities and also death.

Turn-Over Technique for Inserting and Stabilizing Guiding Sheath without Straightening It during Carotid Artery Stenting via Trans-Brachial Approach in Cases with Severe Vascular Access Conditions

In cases of severe atherosclerosis or tortuous arteries, inserting the guiding sheath into the target vessel is challenging. Here, we present the turn-over technique for inserting and stabilizing the guiding sheath without straightening it during carotid artery stenting (CAS). Two patients with severe left internal carotid artery stenosis underwent CAS via the trans-brachial approach. Although inserting the guiding sheath into the common carotid artery using conventional techniques was challenging, we succeeded in inserting it into the target vessel using the "turn-over technique." At first, the guidewire was U-turned just above the aortic valve and inserted into the left external carotid artery. The inner catheter and guiding sheath were then followed along the guidewire to the left common carotid artery, and the guidewire and inner catheter were removed. The guiding sheath was stable in a U-turned position, and straightening the guiding sheath was difficult. Devices such as stents and balloons could be delivered without problems, and CAS was completed with the guiding sheath in a U-turned position. The turn-over technique for inserting and stabilizing the guiding sheath for CAS via the trans-brachial approach is an option in cases of difficult catheter access due to atherosclerosis or tortuous arteries.

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.

Mandibular swing approach for high parapharyngeal space schwannoma

Parapharyngeal space tumours are rare, comprising 0.5% of all head and neck neoplasms. Different surgical approaches to this space have been described based on various criteria. Here, we are presenting a case report of a 65-year-old woman with left vagal schwannoma splaying the left internal carotid artery and internal jugular vein superiorly and splaying the left internal carotid artery and external carotid artery inferiorly, with its upper edge about 0.7 cm caudal to skull base. Surgery by a combined trans-cervical and mandibular swing approach was adopted for this case. The tumour which was extending so close to the skull base was removed in toto with an intact capsule and the neurovascular structures like the carotids, internal jugular vein and the vagus were preserved through a trans-mandibular approach. Postoperatively patient had no neurovascular compromise. Histopathological examination revealed vagal schwannoma. Trans-mandibular approach may appear complex, but it offers excellent surgical field to keep the delicate surrounding structures intact, to reduce the risk of haemorrhagic and avoid neurological complications.

Emergency Stenting of Tandem Stenoses of the Internal Carotid Artery Using Proximal Protection Against Distal Embolism “MoMa”

Man, 61 years old. Admitted with complaints of severe weakness in the right limbs, which developed about 4 hours ago. Multispiral computed tomography with cerebral angiography: signs of ischemic stroke in the basin of the left middle cerebral artery. Angiography of the brachiocephalic arteries (BCA) was performed: angiographic signs of damage to the BCA: the left internal carotid artery (ICA) of the C2–C3 segments up to subocclusion, up to 75% in the mouth and right third. The circle of Willis is closed.A multidisciplinary council made a decision on emergency stenting of tandem ICA stenoses using proximal protection against distal embolism “MoMa”. The course of the operation: after angiography, the sheath introducer was replaced by a guidewire sheath with a 9F introducer. A proximal protection system “MoMa” was installed along the diagnostic conductor 260 cm at the mouth of the left external carotid artery (ECA) and the middle third of the left common carotid artery (OCA). Baloons in the ECA and OCA were inflated. The Promus element 4.0x12 mm (DES) ICA was brought into the affected area of C2–C3 segments, positioned and opened at a pressure of up to 14 atm. The balloon catheter has been removed. Aspiration from the ICA. On check angiography, residual stenosis of the ICA stenting zone was 0%. On the test angiography intracranial arteries without signs of embolism. A Protege (7x10x40) mm stent was placed, positioned and deployed in the affected area of the orifice and the right third of the ICA. The delivery system has been removed. Aspiration from the ICA. On the test angiography, the residual stenosis of the ICA stenting zone was up to 0%. The distal embolism protection system has been removed. On the control angiography intracranial arteries without signs of embolism.The postoperative period was uneventful. On the 10th day after stenting, the neurological deficit regressed completely, the patient was discharged for outpatient observation in a satisfactory condition.CONCLUSIONS When performing brain revascularization in the most acute period of ischemic stroke, it is necessary to take into account the recommendations of multicenter studies that report such conditions for a successful outcome of the operation as: the diameter of the ischemic focus in the brain, not exceeding 2.5 cm and the absence of severe neurological deficit (more than the Rankin scale score 2). Within the framework of this clinical example, these recommendations were taken into account, which, among other things, contributed to the optimal outcome of urgent revascularization. Emergency stenting of tandem stenosis of the internal carotid artery using the device for proximal protection “MoMa” is effective in the presence of a closed structure of the circle of Willis. The technical complexity of the operation is associated with the installation of a catheter guide and its diameter of 9 Fr (catheters up to 7 Fr are usually used), which requires additional manual skills.

Intraorbital Cavernous Hemangioma: Rare Cause of Exophthalmos

Nasopharyngeal angiofibroma refers to a locally aggressive benign vascular tumor composed of vasogenic and myofibroblastic elements, representing between 0.05% and 0.5% of all head and neck tumors. Here, we report a case of a 21-year-old patient with no particular personal or familial pathological history, who presented with recurrent epistaxis and anterior rhinorrhea and headaches for 1 year. Nasofibroscopy revealed a mass filling the entire left nasal cavity, streaked with blood. A face MRI revealed a highly vascularized and lytic nasopharyngeal tumor infiltrating the deep left lateral facial spaces with the beginning of endocranial infiltration, supplied by the homolateral maxillary artery, initially suggestive of a nasopharyngeal fibroma. Preoperative arteriography showed a voluminous vascular blush at the arterial time to the nasopharyngeal projection with branches arising from the left external and internal carotid arteries and multiple arterial shunts (between the left internal and maxillary carotid arteries), thus contradicting embolization. Early diagnosis is important as it is associated with a high risk of morbidity, but advances in imaging and surgical treatment methods have modified the sites associated with high morbidity risk.

Aggressive Tumor and Challenging Location: A Case Report of Nasopharyngeal Fibroma

Nasopharyngeal angiofibroma refers to a locally aggressive benign vascular tumor composed of vasogenic and myofibroblastic elements, representing between 0.05% and 0.5% of all head and neck tumors. Here, we report a case of a 21-year-old patient with no particular personal or familial pathological history, who presented with recurrent epistaxis and anterior rhinorrhea and headaches for 1 year. Nasofibroscopy revealed a mass filling the entire left nasal cavity, streaked with blood. A face MRI revealed a highly vascularized and lytic nasopharyngeal tumor infiltrating the deep left lateral facial spaces with the beginning of endocranial infiltration, supplied by the homolateral maxillary artery, initially suggestive of a nasopharyngeal fibroma. Preoperative arteriography showed a voluminous vascular blush at the arterial time to the nasopharyngeal projection with branches arising from the left external and internal carotid arteries and multiple arterial shunts (between the left internal and maxillary carotid arteries), thus contradicting embolization. Early diagnosis is important as it is associated with a high risk of morbidity, but advances in imaging and surgical treatment methods have modified the sites associated with high morbidity risk.

Abstract Number ‐ 220: Internal Carotid Artery Hypoplasia of Unique Anatomical Variance

Introduction Hypoplasia of the internal carotid artery (ICA) is incomplete development of the ICA with the presence of empty carotid canal. Despite anecdotal data reporting less than a 0.01% of developmental anomalies of ICA, the true incidence remains unknown. Many cases are asymptomatic and thus escape diagnostic detection or appropriate intervention. In 1968, Lie and Hage described collateral circulation in ICA developmental anomalies through the Circle of Willis, persistent embryonic vessels, or skull base arteries/anastomosis or rete mirabile. While collateral systems exist, subsequent cerebrovascular insufficiency and vascular malformations may occur as a result. To our knowledge, there is an incomplete body of literature surrounding the implications of ICA hypoplasia of varying anatomy. Methods We present a case report of left ICA hypoplasia and a comprehensive literature review. Results A 70‐year‐old woman with hypertension, nicotine dependence, and chronic obstructive pulmonary disease (COPD) presented with COPD exacerbation and disorientation. Computed tomography (CT) head angiography showing left cervical/petrous ICA aplasia with presence of a small carotid canal. The left external carotid and vertebral artery originate at the aortic arch. Majority of the blood supply to the left anterior cerebral artery (ACA) and middle cerebral artery (MCA) is suppliedby the right anterior communicating artery (AComA), posterior communicating artery (PComA). There is also a small left supraclinoid and carotid terminus that reconstitute predominantly by right A1 segment and PComA (Figure 1). Conclusions Although ICA hypoplasia may be an incidental finding, accurate and promptrecognition is essential for the consideration of endovascular implications, screening for vascular malformations, understanding cerebral vascular flow, managing cerebrovascular risk, and avoiding misinterpretation of clinical and imaging patterns.

Unusual Intracerebral Hemorrhage Secondary to Delayed Posttraumatic Middle Meningeal Artery Pseudoaneurysm, Successfully Treated by Endovascular N-Butyl Cyanoacrylate Embolization

AbstractPseudoaneurysm of the middle meningeal artery, presenting as a delayed sequela of trauma, being a rare entity, may sometimes present as an acute intraparenchymal hemorrhage, with a risk of rerupture and mortality. The optimal management in acute settings remains undetermined. We, hereby, report a case of elderly gentleman with a history of a road traffic accident. Noncontrast computed tomography (NCCT) brain was reported to have left parietal hemorrhagic contusion without any mass effect. The patient was managed conservatively without any major neurological deficits. After 7 months, the patient presented with severe headache, altered sensorium, and right hemiparesis. NCCT brain showed acute left thalamocapsular hemorrhage with minimal subarachnoid hemorrhage with associated mass effect and impending herniation. Considering the fall in patient's baseline Glasgow comma scale response, pupillary asymmetry, and CT findings, immediate decompression and hematoma evacuation were advised. In view of atypical morphology, the patient was planned for urgent digital subtraction angiography prior to the surgery to rule out the ruptured aneurysm or pial arterio-venous fistula. Selective angiography of the left external carotid artery demonstrated a dissecting pseudoaneurysm feeding from the middle meningeal artery (MMA), which was embolized using n-butyl cyanoacrylate (NBCA). Postprocedure DynaCT revealed the left temporal bone fracture, indicating this pseudoaneurysm to be most likely posttraumatic delayed sequelae. Postembolization, the patient underwent surgical decompression and excision of hematoma. Patient's neurological status gradually improved and was discharged with the minimal deficit. Our case highlights the importance of awareness of the posttraumatic MMA pseudoaneurysm as an uncommon but treatable entity, which can be easily diagnosed using cerebral angiography and amenable to safe and effective endovascular embolization using NBCA.

ANOMALOUS BRANCHING PATTERN OF UNILATERAL EXTERNAL CAROTID ARTERY: A CASE REPORT

Variations in the branching pattern of the external carotid artery (ECA) are well known and documented. The variation in the present case was compared with those reported before. An anomalous unilateral variation in the branching pattern of the left ECA was observed in a male embalmed cadaver. In this case, the ECA gives origin of linguofacial trunk as well as direct origin of glandular branch to the submandibular salivary gland, submental salivary gland and palatine glands from the external carotid artery instead of facial artery. The embryogenesis of such a combination of anomalies is not clear, but the anatomic consequences may have important clinical implications. Anatomical knowledge of the origin, course, and branching pattern of the external carotid artery will be useful to general, head & neck, ENT and oncosurgeons when ligating the vessels during head and neck surgeries to avoid unforeseen complication in the form of bleeding by injuring the abnormal arteries. It is also important for the vascular surgeons and radiologists while performing the procedures on the arteries

Simultaneous surgery for upper gastrointestinal cancer and cardiovascular diseases

To analyze the immediate and long-term results of simultaneous surgical treatment in patients with upper gastrointestinal cancer and cardiovascular diseases. There were 9 patients with upper gastrointestinal cancer and cardiovascular diseases who underwent simultaneous surgical treatment. We assessed safety and efficacy of this approach. Mean age of patients was 65.7±5.7 years. Coronary artery disease was diagnosed in 3 patients, aortic valve disease - 1 patient, abdominal aortic aneurysm - 2; 4 patients suffered from isolated mitral valve disease, stenosis of the left vertebral artery, internal and external carotid arteries and Leriche syndrome. Considering immediate and long-term postoperative results, we can emphasize advisability of simultaneous surgeries in appropriate patients.

Abstract 14484: Shockwave Lithotripsy as a Non Surgical Modality for Calcified Carotid Stenosis

An 80-year-old gentleman with significant bilateral carotid artery stenosis and previous right carotid endarterectomy underwent a CT Angiogram of the Head and Neck due to multiple episodes of syncope. The study revealed heavily calcified atherosclerotic disease at the left carotid bulb and bifurcation, causing high-grade luminal stenosis of 80 to 82% at the origin of the internal carotid artery. Hence, a decision was made to obtain a cerebral angiogram. Aortic arch angiogram revealed a type III arch, following which a cerebral catheter wire was engaged in the left carotid artery. A selective angiogram showed 80% calcified stenosis at the level of bifurcation, with the left external carotid artery being 100% occluded. Given the heavily calcified lesion, supra core guidewire was crossed across the lesion, followed by advancement of protection device into the distal segment of the left internal carotid artery. Balloon angioplasty was performed twice from the ostial to the proximal segment of the left internal carotid artery. An attempt was made to place a stent without any success. Subsequently, a decision was made to proceed with shockwave lithoplasty. We inserted a transvenous pacemaker with a backup rate of 40 bpm. A Shockwave catheter was inserted and shockwaves were delivered with multiple inflation techniques at 4 atmospheric pressure for 15 seconds each. Periodic neuro assessments were normal. This was followed by the placement of stents in the distal left common carotid and ostial to proximal left internal carotid artery reducing the calcified 80% stenosed lesion to 10% with excellent angiographic results. Subsequently, the filter and the catheter were removed and the femoral artery access site was secured. The patient tolerated the procedure very well without any immediate or delayed complications. The intracerebral vasculature remained intact as confirmed by a cerebral angiogram. TVP was removed and the patient was discharged in a stable condition after 2 days. Hence, Shockwave lithotripsy can be successfully used for critical carotid artery stenosis in patients that pose a high surgical risk. It helps soften the lesion for better dilatation of the vessel and achieve improved luminal gain for appropriate stent expansion.

PSUN382 Hold Still – A Large Neck Paraganglioma Limiting Head Movement

Abstract Background A head and neck paraganglioma is a rare diagnosis with most cases found incidentally or diagnosed due to mass effect symptoms. Only 3.5% of them are found to secrete catecholamines leading to episodic symptoms. Herein, we present a rare case of a functioning neck paraganglioma with head movement induced hyperadrenergic paroxysms. Clinical Case A 79-year-old Caucasian man, with previous left neck mass found incidentally on imaging after a motor vehicle accident, presented to the ER with syncope. While the mass had been growing for 10 years, he sought medical attention when he could no longer turn his head to the left due to worsening symptoms. He reported recurrent brief syncopal attacks along with intermittent episodes characterized by profuse sweating, headaches, palpitations, and flushed skin. Upon evaluation, he was afebrile, tachycardic and had labile blood pressure readings (high of 340/150 mmHg and a low of 70/40 mmHg). He was oriented to time and place but appeared lethargic and underweight. A solid non-tender neck mass, with an audible bruit, was apparent at the Level II of the left neck. A CT scan of the neck showed a 7.7cm left glomus vagale tumor with partial encasement of the left internal and external carotid artery. He was admitted to the intensive care unit for close blood pressure monitoring via an intra-arterial line. Due to high suspicion for a catecholamine driven process, he was started on Doxazosin 1 mg every 12 hours which stabilized his blood pressure and improved his symptoms. CT scan of the abdomen and pelvis showed a 1.1 cm left adrenal nodule with an intensity of 4 Hounsfield units. A trial of Hyoscyamine was done to help with hypotension and symptoms of dizziness and bradycardia. Labs showed plasma catecholamines that were significantly elevated to ten times the upper limit of normal. An MIBG scan showed uptake in the left carotid mass. He was a poor surgical candidate because of the proximity of the mass to the neuro-vascular bundle and was treated with radiation during hospitalization. The patient was discharged home on Doxazosin with improvement in his blood pressure. Genetic testing was negative for a pathogenic variant but detected a variant of uncertain significance (VUS) in CDKN2A, c.373G>C (p.Asp125His). Unfortunately, three months later the patient was admitted with an intracranial hemorrhage secondary to a fall and was transitioned to hospice care. There was no change in the tumor size noticed during that admission. Conclusion To our knowledge, this is the first case to describe hypertension paroxysms triggered by movements of the neck in the setting of a functional neck paraganglioma. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Sporadic occurrence of multiple paragangliomas causing carotid and coronary arterial encasement.

We describe a case of a 32-year-old man with a paraganglioma causing encasement of ostioproximal segments of the left internal carotid artery and left external carotid artery with concurrent presence of bilobulated mediastinal paraganglioma, with similar imaging characteristics, causing encasement of the coronary arteries.

Separate origin of left external and internal carotid arteries directly from aortic arch in a patient with double outlet right ventricle

We report a case of a 1-year-old boy with double outlet right ventricle where computed tomography(CT) angiography incidentally demonstrated the separate origin of the left external and internal carotid arteries directly from the left-sided aortic arch with absence of a left common carotid artery. The case highlights the underlying embryological hypothesis as well as the importance of CT angiography in identifying anomalies of the aortic arch and arch vessels in the setting of complex congenital heart defects.

Aumento da Espessura Médio-intimal Aórtica e sua Relação com Estresse Oxidativo Elevado em Pacientes com Talassemia Menor

ResumoFundamento A espessura médio-intimal (EMI) da artéria aorta abdominal (EMI-A) pode ser um marcador precoce de aterosclerose subclínica e um indicador objetivo de estresse oxidativo em pacientes com talassemia menor.Objetivo Avaliar se as EMIs da artéria aorta e da artéria carótida (EMI-C) se alteram com estresse oxidativo, e examinar a relação entre esses parâmetros em pacientes com talassemia menor.Métodos O estudo incluiu 80 pacientes diagnosticados com talassemia menor, e 50 indivíduos sadios com idade e sexo similares. Após procedimentos de rotina, as amostras de sangue foram coletadas dos grupos de estudo para a medida da homeostase tiol/dissulfeto e da albumina modificada pela isquemia (AMI). As medidas da EMI-C foram realizadas a partir de quatro regiões diferentes (artéria carótida externa direita e esquerda e artéria carótida interna direita e esquerda) por ultrassonografia, e a medida da EMI-A foi realizada por ultrassonografia abdominal. Um valor de p<0,05 foi definido como estatisticamente significativo.Resultados Nos pacientes com talassemia menor, os níveis de tiol nativo e tiol total, e a razão tiol nativo/tiol total foram mais baixos, e os valores de AMI, razão dissulfeto/tiol nativo, e razão dissulfeto/tiol total foram mais altos que no grupo controle. A EMI-A foi significativamente maior no grupo de pacientes com talassemia menor que nos controles (1,46±0,37 vs 1,23±0,22 e p<0,001). Quando os parâmetros associados com EMI-A na análise univariada foram avaliados por regressão linear multivariada, EMI-A apresentou uma relação positiva, e os níveis de tiol nativo e tiol total apresentaram uma forte relação negativa com AMI (p<0,01).Conclusão Nós demonstramos, pela primeira vez, um aumento no estresse oxidativo com a elevação da EMI-A, e valores inalterados da EMI-C em pacientes com talassemia menor.

Anatomical basis of intracranial meningiomas referred for preoperative embolisation: A retrospective chart review

Meningiomas are described as intracranial, extra-axial tumours arising from the arachnoid cap cells of the meninges. Due to the vast expanse of the meninges, the clinical presentation of meningiomas may vary. Treatment of this pathology involves surgical resection of the tumour. Preoperative tumour embolisation has proven to reduce blood loss during resection, however, misidentification of the vascular territory may lead to various post-operative complications such as cranial nerve palsies. The present study aimed to investigate the anatomy of intracranial meningiomas, referred for preoperative embolisation at a regional hospital. Patient demographics, histological reports, Magnetic Resonance Images and Digital Subtraction Angiography's of 98 patients were utilised to analyse the study's objectives. We report a high incidence of meningiomas in the female (67.3%; 81.3 cm 3 ) population with a smaller tumour volume in relation to males (32.7%; 102 cm 3 ). The Grade I meningioma (70.4%) was the most common with the meningothelial (48%) subtype being predominant. Regarding the blood supply, the internal carotid arteries were noted to be the primary feeders in the skull base region whilst the left external carotid artery was noted to be a primary feeder in the supratentorial region. The results from this investigation provided insight into the variable anatomy of intracranial meningiomas within a select South African population. Key outcomes from this study support the female predisposition for meningiomas along with the high incidences of meningiomas of the WHO Grade I and in the supratentorial region. Further research should be carried out as a comparative study in patients that were not referred for preoperative embolisation. • Meningiomas are mostly found in the supratentorial region. • MRI and DSA have proved to accurately quantify the meningioma vascularity. • The ICA system is a major feeder to skull base meningiomas.

Abstract 1122‐000081: Initial Experience Implementing the Transradial Approach for Diagnostic Cerebral Angiography

Introduction : The transradial approach (TRA) has gained acceptance among interventionists due to the lower operative complication rates, less operative time and better patient comfort. Our study aimed to analyze our experience in the implementation of the TRA for diagnostic cerebral angiographies. Methods : Between March 2020 and July 2021, consecutive patients who underwent TRA in two institutions were selected and data was retrospectively collected. Demographics, technical details of the procedure, duration of the procedure, fluoroscopy time and radiation exposure were analyzed. Results : A total of 76 angiographies using the TRA were done. The mean age was 47.5 ± 16.8 years (8 – 82 years). Women represented 57% of cases. Successful radial artery (RA) catheterization was done in 94% (85 patients/80 successful). A preoperative cocktail was used in all the cases. Subcutaneous lidocaine and a 5F sheath were used in 46% and 57% of cases, respectively. The Simmons 2 catheter was used in all the cases. Glidecath, followed by Merit were used in 40% and 32% of the cases, respectively. Right internal carotid artery (ICA), left ICA, right vertebral artery (VA), left VA, right external carotid artery (ECA) and left ECA were studied in 95%, 91%, 76%, 20%, 20% and 15% of the cases, respectively. Post‐operative vasospasm occurred in 29% of the cases, which resolved with intra‐arterial verapamil. Vasospasm was not associated with sheath diameter (p = 0.129) or local anesthesia (p = 0.065). The mean fluoroscopy time was 16 minutes. Conversion to TFA was done in 9 patients (10.6%), of which the RA was successfully catheterized in 4 patients: 1 patient had an atheroma in the brachial artery, 1 patient had a thrombus in the subclavian artery and 2 patients presented severe pain in the forearm. In the remaining 5 patients, there were 2 radial dissections and in 3 the RA could not be approached. Conclusions : The TRA is a safe and effective alternative to perform diagnostic cerebral angiographies with conversion rates according to the literature. The use of appropriate catheters is necessary in order to lower fluoroscopy times when this technique is chosen.

Incidental identification of the aberrant origin of left vertebral artery using magnetic resonance angiography: A case report

Background: The vertebral arteries originate from the root of the neck as the first branches of the subclavian arteries. Variations of vertebral arteries are congenital anomalies occurring during embryonic development. Anatomic variations of the left vertebral artery are clinically symptomless and recognized incidentally during angiographic assessments or imaging techniques so the diagnosis of these anomalies is a serious challenge. Anomalous origin of vertebral arteries may lead to neurologic disorders. It is, thus, important to identify variations of the large vessels of the aortic arch when planning neck and cervical spine interventions and diagnostic radiology. For this reason, we would like to present this rare case of left vertebral artery showing a different origin. Case report: In this work, we describe a 60-year-old female patient with headache, lethargy and blurred vision. We employed magnetic resonance angiography for both the brain and neck. There was no lesion in the brain. Incidentally, we found that the root of the left vertebral artery was anatomically aberrant. The left vertebral artery arose from the nearest section of the left external carotid artery, next to the bifurcation of the left common carotid artery, which is a rare variation. Conclusion: Understanding the state of anomalous variations of the origin of the vertebral artery might have crucial implications in angiographic and surgical procedures. It is beneficial to perform more screening with noninvasive studies like neck magnetic resonance angiography in clinical cases with potential symptoms coexisting with other diseases in order to predict possible future problems in intracranial and extracranial interventions. Keywords: Vertebral artery; external carotid artery; anatomic variation; magnetic resonance angiography.