Left Internal Carotid Artery Dissection Research Articles

The Silent Threat: Unraveling the Rare Catastrophic Complication after Elective Cranioplasty

AbstractAlthough cranioplasty seems to be a simple procedure, fatal complication of development of diffuse severe cerebral edema following cranioplasty although unusual have been reported in a few cases. The mechanism for this occurrence is still speculative. A 38-year-old male patient presented with a history of having undergone left decompressive hemicraniectomy following a road traffic accident with traumatic left intracranial internal carotid artery dissection leading to anterior cerebral artery and middle cerebral artery territory infarct and endovascular embolization of traumatic type 1 left caroticocavernous fistula. The preoperative computed tomography scan of the brain revealed left frontotemperoparietal craniectomy defect with sunken flap and diffuse encephalomalacia with gliosis of the entire left cerebral hemisphere. Immediately following an uneventful cranioplasty surgery with titanium mesh, the patient developed severe hypotension and dilated fixed pupils. Postoperative imaging revealed diffuse severe cerebral edema in bilateral hemispheres with a significant midline shift toward the ipsilateral (left) side, that is, toward the side of cranioplasty. The patient immediately underwent removal of the titanium mesh, and despite all efforts, the patient had a fatal outcome on postoperative day 5. Although this type of fatal complication of diffuse severe cerebral edema is rare in postcranioplasty patients, neurosurgeons must be aware of this complication and close monitoring postprocedure is important, especially in patients with a large craniectomy defect and sunken skin flap.

Surgical management of stylocarotid Eagle syndrome in a patient with bilateral internal carotid artery dissection: illustrative case.

Eagle syndrome is characterized by an elongated styloid process, which can cause acute neurological symptoms when the projection impinges on local structures. One method by which Eagle syndrome can cause acute stroke is via internal carotid artery dissection. A patient presented with acute aphasia and right-arm weakness. Imaging revealed a left internal carotid artery dissection, which was treated with stenting. Three years later, the patient presented with left-sided weakness, and imaging revealed a new right internal carotid artery dissection. Closer review of the patient's imaging revealed bilateral elongated styloid processes. The patient subsequently underwent staged bilateral styloidectomy and returned to his prior baseline postoperatively. This case report describes a patient with Eagle syndrome who had two internal carotid artery dissections separated by several years. A literature review revealed that styloidectomy is well tolerated in patients with carotid dissection due to Eagle syndrome. Patients with carotid dissection due to Eagle syndrome remain at risk for contralateral dissection, and prophylactic contralateral styloidectomy should be considered.

Paracentral acute middle maculopathy as the first sign of internal carotid artery dissection

Purpose: It is proposed to present a clinical case of a patient with a paracentral acute middle maculopathy (PAMM) as the first sign of presentation of severe internal carotid artery (ICA) dissection.Methods: An initial basic ophthalmologic examination of the patient was performed, followed by an optical coherence tomography (OCT) and an OCT‐angiography (OCT‐A) of each eye. Finally, the patient was evaluated by a neurologist, performing a cerebral and supra‐aortic trunks (SAT) computed tomography (CT) angiography.Results: We present a 54‐year‐old patient who came to the emergency room complaining of central blurred vision in his left eye (OS) during 24 h. On ophthalmological examination, it is remarkable a visual acuity (VA) of counting fingers at 1 m in OS. Eye fundus (EF) of OS showed small oval whitish macular lesions. Macular OCT of OS revealed hyperreflective bands in the internal nuclear layer (INL) and OCT‐A showed areas with low flow at deep capillary plexus (DCP) and macular vascular density (MVD) parameters decreased compared to the right eye (OD). During the examination, the patient began to feel a slight loss of strength in his right hemibody with dizziness, so he was explored by a neurologist and a cerebral and SAT CT angiography was performed, which reported severe left ICA dissection with an area of hypoperfusion in the territory of the left middle cerebral artery, but without intracranial vascular occlusion. Since there was no image of occlusion and given the mild neurological symptoms, endovascular treatment was rejected and anticoagulation with enoxaparin was established. Two months later, VA of OS improved to 1, with no significant lesions in the EF. The OCT of OS showed a slight thinning of the INL and the OCT‐A revealed a greater flow in the DCP with better MVD values.Conclusions: This entity should be considered in patients with visual disturbances. PAMM may be the first sign of ICA pathology.

Abstract 13325: Novel Heterozygous EFEMP2 Variant Detected in a Patient With Bilateral Internal Carotid Artery Dissection and Oligodontia

Cutis laxa is a rare connective tissue disorder characterized by sagging or inelastic skin. This phenotype is caused by multiple genotype variants. Biallelic variants in the EFEMP2 gene cause cutis laxa subtype IB characterized by aortic aneurysm, arterial tortuosity, arterial stenosis, joint laxity, arachnodactyly, emphysema, and retrognathia. EFEMP2 encodes fibulin-4, an extracellular matrix protein involved in elastogenesis and modulation of TGF-beta signaling. To date, monoallelic variants in EFEMP2 have not been described as pathogenic. Furthermore, oligodontia has not been associated previously with variants in EFEMP2 . We describe a 67-year-old male with a past medical history of left distal internal carotid artery (ICA) pseudoaneurysm and dissection, right distal ICA dissection, arterial tortuosity, and oligodontia who was found to have a heterozygous variant of uncertain significance in EFEMP2: c.1279_1289del11, p.Arg427CysfsX27. The variant has not been observed previously in large population cohorts and causes a shift in reading frame that substitutes the carboxyl terminal 17 amino acids with 26 alternative amino acids. This carboxyl terminal variant of EFEMP2 has been predicted to interact with PITX2 in yeast two-hybrid analyses. Furthermore, variants in PITX2 have been associated with dental agenesis, including oligodontia. We hypothesize that heterozygous variants in EFEMP2 represent a new syndrome characterized by arteriopathy and dental agenesis.

A case of Elschnig's spots observed using optical coherence tomography-angiography after stenting for internal carotid artery dissection.

We report the case of a 28-year-old man who developed Elschnig's spots after stenting for an internal carotid artery dissection using optical coherence tomography angiography (OCTA). A case report. The patient developed a visual field defect in the left eye immediately after endovascular stenting for left internal carotid artery dissection. Fundus examination revealed white lesions and numerous mottled orange-red lesions in the posterior pole and mid-periphery of the left eye. Indocyanine green angiography revealed mottled hypofluorescein areas in the early and late stages, coinciding with the orange-red lesions. OCTA showed flow void areas in the choriocapillaris layer, consistent with the orange-red lesions, which were diagnosed as Elschnig's spots associated with choroidal circulatory failure. The spots disappeared approximately 2 months after surgery, and the flow void on OCTA also disappeared. We report a case of Elschnig's spots associated with transient choroidal circulatory failure after stenting for internal carotid artery dissection. OCTA detected improved circulation at the level of the choriocapillaris with the disappearance of Elschnig's spots.

Ovarian hyperstimulation syndrome with carotid artery dissection and cerebral infarction: a case report

Background and purposeOvarian hyperstimulation syndrome (OHSS) is one of the most serious iatrogenic complications in assisted reproductive technology, which seem rarely associated with cerebrovascular diseases. We reported a patient diagnosed with OHSS combined with carotid artery dissection and massive cerebral infarction.Case presentationWe reported a unique case of a 31-year-old woman who experienced abdominal pain, blurred consciousness, and speech inability after 15-day continuous injection of human gonadotropin for infertility. Imaging examination showed hyperacute cerebral infarction in the left frontotemporal island parietal lobe and left internal carotid artery dissection. After therapeutic use of low-molecular-weight heparin calcium anticoagulation and other conventional cerebrovascular treatments, she eventually achieved a good prognosis.ConclusionsOHSS seemd rarely associated with cerebrovascular diseases, such as infarction and carotid artery dissection. Encountering abdominal symptoms combined with neurologic symptoms, a detailed history and a thorough examination are essential. It is necessary to comprehensively analyze the pathogenesis and formulate individualized therapy according to the specific conditions of patients.

P26 TRANSIENT GLOBAL AMNESIA AS A POSSIBLE CONSEQUENCE OF ICA DISSECTION: A CASE REPORT

Abstract Case Report A 42–year–old woman was carried to emergency room lamenting sudden memory loss. Her husband witnessed the onset of the episode. No recent head trauma was reported, blood pressure was under control. Anterograde and retrograde memory loss was present and confirmed by a neurologist. No other neurological signs were elicitable. Blood exams and toxicological analysis were negative. ECG, chest radiography, and cerebral TC showed no abnormalities. At physical examination a carotid bruit could be appreciated. The patient was asymptomatic. Subsequently an eco–colour–Doppler of carotid artery was performed showing a left common and internal carotid artery dissection. The diagnosis of ICA dissection was confirmed with a contrast CT furthermore excluding the coexistence of an aortic dissection. The anterograde amnesia resolved 15 h after the admission. A neurologist confirmed that the patient experimented an episode of transient global amnesia. After a vascular surgery consultation, a conservative treatment was deemed appropriate. After a 6 month follow up the patient didn’t complain of any other neurological symptom or sign. Transient global amnesia (TGA) is characterized by reversible anterograde and retrograde amnesia of sudden onset that resolves spontaneously within 24 h. The pathophysiological mechanisms underlying this puzzling neurological syndrome are yet not completely clarified. Some studies support an ischemic aetiology for TGA and cases of TGA following ICA–stenting or aortic dissection with involvement of the supra–aortic branches are reported in literature, thus supporting the hypothesis that a cause–effect relationship between ischemic pathologies of supra–aortic trunks and TGA might be present. In the case here presented, a Doppler ultrasound of carotid arteries performed in a patient presenting with TGA, asymptomatic for neck pain, led to a diagnosis of ICA dissection. In order to not miss a spontaneous ICA dissection as a rare ethology of TGA, we suggesto perform an eco–colour–Doppler of the epi–aortic vessels in patients affected by such amnesic syndrome.

Acute Tongue Swelling as a Still Unexpected Manifestation of Internal Carotid Artery Dissection: A Case Report

The diagnosis of internal carotid artery dissection (ICAD) at the stage of local signs is essential in the prevention of the life-treating cerebral complication; however, making this diagnosis has significant difficulties. We present the case of a 36-year-old female with left ICAD with asymmetric left-sided tongue swelling as an unusual and still unexpected symptom. The patient's complaints at admission were left-sided numbness of the tongue and swallowing difficulties but its movements were intact. Despite the provided treatment for suspected angioedema, no improvement was noted. Additional examination revealed left-sided tongue weakness, ipsilateral soft palate palsy, paralysis and reduced tension of the left vocal fold, and left-sided Horner's syndrome. Another suspected diagnosis was a dysfunction of the IX, X, and XII cranial nerves. A head MRI revealed an intramural hematoma of the left internal carotid artery. The radiologists suggested ICAD. The angio-MRI of the head arteries confirmed this diagnosis. The patient received dual antiplatelet therapy. The neuro-logopaedic therapy was also implemented. Currently, the patient's symptoms are gradually improving with significantly better results on follow-up neuroimaging. Among the possible local symptoms of ICAD, proper attention should be paid to asymmetric swelling of the tongue as an atypical manifestation of damage to the hypoglossal nerve.

564 AN UNUSUAL PRESENTATION OF ICA DISSECTION. A CASE OF TRANSIENT GLOBAL AMNESIA IN A PATIENT WITH PAINLESS SPONTANEOUS INTERNAL CAROTID ARTERY DISSECTION

Abstract Image focus A 42-year-old woman was carried to emergency room lamenting sudden memory loss. Her husband witnessed the onset of the episode. No recent head trauma was reported, blood pressure was under control. Anterograde and retrograde memory loss was present and confirmed by a neurologist. No other neurological signs were elicitable. Blood exams and toxicological analysis were negative. ECG, chest radiography, and cerebral TC showed no abnormalities. At physical examination a carotid bruit could be appreciated. We performed an eco-color-Doppler of carotid artery that showed a left common and internal carotid artery dissection (figure 1). The diagnosis of ICA dissection was confirmed with a contrast CT. The coexistence of an aortic dissection was excluded with the same imaging technique. The anterograde amnesia resolved 15 h after the admission. A neurologist confirmed that the patient experimented an episode of transient global amnesia (TGA). After a vascular surgery consultation, a conservative treatment was deemed appropriate. After a 6 month follow up the patient didn't complain of any other neurological symptom or sign. Transient global amnesia (TGA) is characterized by reversible anterograde and retrograde amnesia of sudden onset. This amnesic syndrome resolves spontaneously within 24 h. Annual incidence rate for all ages of spontaneous ICA dissection is approximately of 2.6 per 100 000 inhabitants, however data are extremely variable among different studies. TGA has never been associated with a spontaneous ICA dissection. In order to not miss a spontaneous ICA dissection as a rare ethology of TGA, we suggest performing an eco-color-Doppler of the epi-aortic vessels in patient affected by such amnesic syndrome.

Atypical Presentation of Traumatic Pediatric Carotid Artery Dissection: A Case Report.

IntroductionCarotid artery dissection is a rare but serious condition manifesting with signs and symptoms that closely overlap with other more benign medical diagnoses. This vascular injury, however, can result in debilitating sequelae, including thromboembolic cerebrovascular accidents.Case ReportWe describe the atypical presentation of a healthy eight-year-old male who presented to the emergency department (ED) with generalized abdominal pain and non-bloody, non-bilious emesis. These symptoms occurred nine days after he sustained blunt head trauma after a non-syncopal fall from standing while playing hockey. He was initially diagnosed with gastroesophageal reflux disease and constipation and was discharged home. The following day he developed an acute headache followed shortly by gait ataxia, prompting a return visit to the ED. Imaging of the head and neck revealed a left internal carotid artery dissection. The patient was started on intravenous unfractionated heparin and admitted to the hospital. He was later discharged symptom-free on therapeutic enoxaparin for eight weeks, followed by daily aspirin therapy.ConclusionPediatric trauma patients, especially those sustaining insult to the head and cervical spine, are at risk for craniocervical arterial injuries. This rare but dangerous pathology often manifests in a non-specific, delayed fashion making it a challenging diagnosis for physicians to make on the initial medical encounter.1,2 Maintaining a high clinical suspicion for carotid artery dissection is required to make this diagnosis and should guide a thorough history, physical examination, and appropriate imaging in order to improve patient morbidity and mortality. This case emphasizes key clinical features and risk factors of this disease that may help emergency clinicians promptly recognize and treat this entity.

Acute Ischemic Stroke Due to Spontaneous Internal Carotid Artery Dissection in a Human Leukocyte Antigen (HLA) B27 Young Male

Carotid artery dissection is a significant cause of stroke in young patients. Here, we report a 33-year-old male who presented with right homonymous hemianopia and paresthesia of the right side of the body. Magnetic resonance imaging (MRI) of the brain revealed an acute infarct in the left parieto-occipital region. Magnetic resonance angiography (MRA) and duplex ultrasonography (USG) of the neck vessels suggested the left internal carotid artery dissection as the underlying cause. The patient was a known human leukocyte antigen (HLA) B27 and had a history of a previous attack of uveitis. This case report will raise awareness regarding the possible association of HLA B27 with the dissection of neck vessels.

Ischemic Stroke Secondary to Dissection of the Internal Carotid Artery: A Case Report and a Brief Review

Background: Internal carotid artery (ICA) dissections generally occur when a tear occurs in the intima-media layer, either of traumatic or spontaneous origin. In this scenario, multifocal cerebral thrombosis may be a clear consequence of untreated ICA dissection. The incidence of internal carotid artery dissection in the US is estimated to be 1.72 per 100,000 population per year. Objective: To make a brief review of the literature and to explain, through a clinical case, the scenario of multiple ischemic cerebrovascular events is associated with the dissection of the internal carotid artery, in a young patient with no relevant history. Presentation of the Case: A 46-year-old female patient, with no significant history, who came to the emergency service presenting loss of strength in the right pelvic limb, disordered language, and difficulty walking for 3 hours, in the neurological examination evidence of decreased tendon reflexes and loss of strength of the right side of the body. Imaging studies show compromise of the M2 and M3 segments of the left middle cerebral artery, as well as multiple areas of associated ischemia in this hemisphere. Additional studies identify concomitant left ICA dissection. Based on the findings, it was decided to perform a thrombectomy of the affected area, as well as subsequent placement of a stent in the area of dissection. In the control angioTC study, revascularization of the M2 and M3 segments was observed, and in the follow-up of the patient, complete recovery of the symptoms was observed, with muscle strength, tendon reflexes, and preserved language functions. Conclusions: The ischemic cerebrovascular event is a frequent pathological entity in the emergency service; in the scenario of a young patient as mentioned above, it is important to take into consideration the different causes of this pathology. We are obliged to familiarize ourselves with the different imaging modalities for an adequate diagnostic approach, as well as the treatment methods according to the time of evolution.

Endovascular revascularization for internal carotid artery dissection during stroke‐like episode in MELAS: A case report

AbstractA 45‐year‐old woman was admitted to our hospital because of speech difficulties. Initial magnetic resonance imaging (MRI) suggested subacute ischemic infarction in the left parietal to temporal area. Neurological examination on admission showed motor aphasia without any other deficits, and her symptoms gradually worsened with severe headaches. Nine days after admission, brain MRI revealed the development of an ischemic lesion, and magnetic resonance angiography (MRA) showed left internal carotid artery dissection. Emergency carotid stent placement was then performed on the stenotic lesion, which improved her severe headache. Based on her symptoms, she was diagnosed with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke‐like episodes (MELAS) after revascularization therapy. This is the first case in which acute endovascular revascularization was performed for internal carotid artery dissection in MELAS.

Abstract 1122‐000020: Assessing Correlation Between Styloid Length and Internal Carotid Artery Dissection in EAGLE Syndrome Patients

Introduction : Eagle Syndrome (ES) also known as styloid–carotid artery syndrome is a caused by elongation of the styloid process or calcification of the stylohyoid ligament. Usually, normal stylohyoid process is 2.5 cm in length. However, it is classified as an elongated styloid process if its length is more than 2.5 cm. Carotid Artery dissection which is a significant cause of ischemic stroke in all age groups is a known rare complication of ES. Goal of our study is to assess for correlation between degree of styloid process lengthening and grades of Carotid and Vertebral Dissections in adult population. Methods : Retrospective database review of adult patients with known cervical dissections (traumatic and non‐traumatic) were analyzed from Level I Comprehensive Stroke Center. Patients in pediatric age group (less than age 18 years) were excluded. Deidentified patient information including patient’s age, demographics, past medical history, mechanism of injury (if applicable) prior to initial clinical presentation, initial clinical presentation, methodology for diagnosis of cervical dissection (Internal Carotid vs External Carotid vs Vertebral Arteries) along with measurements of stylohyoid ligaments and degrees of dissections bilaterally were retrieved and analyzed. Data analysis was performed by using IBM SPSS Statistics Software 28.0. Results : Total number of patients were 111 (N). Mean age of patients was 52.97 (±16 years). Demographic distribution: African Americans (47/111), Caucasians (62/111) and Others (2/111). Gender distribution: Males (55/111) and Females (56/111). Mechanisms of injury based on available data were as follows: Mechanical Fall (21); MVC (21) and other mechanisms (12). 43/111 patients did have a headache as compared to 68/111 who did not during initial clinical presentation. Imaging confirmation for arterial dissection was performed via MRA (6/111); CTA (98/111) and DSA (7/111). Average styloid length for patients with Eagle syndrome was 3.1 cm vs non‐Eagle group which was 2.38 cm. In Non‐Eagle Syndrome group (Styloid length <2.5 cm), average grades of arterial dissections were as follows: Left Vertebral Artery dissection‐2.1; Left Internal Carotid Artery‐2.1; Right Internal Carotid Artery‐0.40 and Right Vertebral Artery‐2.5. For Eagle Syndrome patients (Styloid length >2.5 cm), average grade of arterial dissections were as follows: Left Vertebral Artery‐2.6; Left Internal Carotid Artery‐3.38; Right Internal Carotid Artery dissection‐2.3 and Right vertebral artery dissection‐1. Based on statistical analysis (paired samples T‐test), styloid length of more than 2.5 cm was significantly correlated with left internal carotid artery dissection (p value 0.012; p<0.05***). For dissections in other arteries including Right Internal Carotid (p value 0.91), Right Vertebral (p value 0.12) and Left vertebral (p value 0.488) no statistical significance was found when both groups were compared. Conclusions : From our study we can conclude that in patients with EAGLE syndrome styloid length more than 2.5 cm is significantly correlated with higher risk of Left Internal Carotid Artery dissection.

Ischaemic stroke caused by spontaneous unilateral carotid artery dissection in patient with connective tissue disorder

Background: Spontaneous cervical artery dissection is a major cause of ischaemic stroke in young patients. It is supposed that genetic variants associated with connective tissue disorders often lead to neurovascular complications, the management of which remains a challenge. Case presentation: A 30-year-old female was admitted to the Department of Neurology with an episode of visual disturbances, speech problems, and concomitant headache. Computed tomography angiography revealed left internal carotid artery dissection. Magnetic resonance of the brain showed cortical and subcortical acute ischaemic lesions in the left cerebral hemisphere. The patient was diagnosed with vascular Ehlers–Danlos syndrome based on the clinical course of the disease. Conservative treatment was administered with full neurological recovery. Conclusion: It is very important for clinicians to consider the coexistence of genetically determined connective tissue disorders in young patients who develop arterial dissections.

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.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Penetran Travmaya Bağlı İnternal Karotis Arter Diseksiyonu ile İlişkili İskemik İnme Olgusu: Nedensellik Bağı İçin Adli Tıbbi Değerlendirme

İskemik inme, önemli bir morbidite ve mortalite nedenidir. Ancak travmatik internal karotis arter diseksiyonuna bağlı iskemik inme nadir görülen bir durumdur.
 Bu olgu sunumunda, 35 yaşında erkek hasta boynundan kesici-delici alet ile yaralanmış ve hastada total afazi ve sağ hemiparezi meydana gelmişti. Radyolojik incelemelerde sol parieto-temporal bölgede beyin enfarktüsü ve bıçaklama sonrası internal karotis arter diseksiyonu tanısı konuldu.
 Bu olgunun adli tıp anabilim dalında yapılan adli tıbbi değerlendirmesinde, başka travmatik veya patolojik bir durumun varlığını dışlamak ve “kesici-delici alet yaralanmasına bağlı internal karotis arter yaralanması” ile “iskeminin neden olduğu inme ve afazi” arasında nedensellik bağı kurulması için nöroşirürji anabilim dalı ile işbirliği yapıldı.
 Bu makalede sunulan olgu nedeniyle literatür gözden geçirilmiş, adli tıp uygulamalarında nedensellik kavramı ve prosedürü ele alınmış ve bu gibi durumlarda multidisipliner yaklaşımın önemini vurgulanmıştır.

Case Series of Adolescents With Stroke-Like Symptoms Following Head Trauma.

Studies cite the incidence of pediatric blunt cerebrovascular injuries (BCVI) ranges from 0.03% to 1.3%. While motor vehicle incidents are a known high-risk mechanism, we are the first to report on football injuries resulting in BCVI. Case 1 is a 14-year-old male football player who presented with slurred speech and facial droop 16h after injury that had resulted in unilateral stinger on the field. The patient had a negative brain computed tomography (CT) at the onset of symptoms. Given progression of symptoms over the next 24h, re-evaluation with CT angiography (CTA) of brain and neck showed left internal carotid artery (ICA) dissection, and magnetic resonance imaging of the brain showed left middle cerebral artery infarct. Case 2 is a 16-year-old male football player who presented with headache and right hemiparesis immediately following a tackle injury. CT brain and neck were negative at an outside hospital, but he was transferred to us for progressive symptoms, and then CTA showed a left ICA dissection with distal emboli, including occlusive involvement of the intracranial left ICA. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The diagnosis of BCVI requires a high level of suspicion. Focal neurologic deficits are consistently a risk factor across all screening criteria, including the Denver, Utah, Memphis, and Eastern Association for the Surgery of Trauma. These current screening criteria, however, may not be sufficient to diagnosis BCVI in children. The addition of the mechanism of injury and attention to the patient's clinical presentation and examination are important to prevent missed diagnosis and poor neurologic outcomes.