Internal Carotid Artery Lesions Research Articles

Carotid endarterectomy for treatment of tandem carotid stenosis in the presence of the anomalous origin of the occipital artery arising from the cervical internal carotid artery: a case report

IntroductionBranches from the cervical portion of the internal carotid artery are rare. In most cases, atherosclerotic stenosis is found at the bifurcation of the internal and external carotid arteries. However, when associated with atherosclerotic carotid artery disease, the origin of the rare branches arising from the internal carotid artery can be another site of stenosis. This report describes a rare case of such tandem carotid stenosis treated by carotid endarterectomy and the importance of the possibility of stenosis at the origin of the anomalous branch from the internal carotid artery.Case presentationA 73-year-old Japanese woman presented with transient left hemiparesis and vertigo. Magnetic resonance angiography seemed to indicate two stenotic lesions distal to the right internal carotid artery in addition to the origin of the right internal carotid artery, and angiography indicated tandem stenotic lesions of the internal carotid artery. The patient was successfully treated with right carotid endarterectomy, including the distal stenotic lesion of internal carotid artery, and postoperative angiography indicated that the occipital artery arose from the internal carotid artery.ConclusionIt is important to recognize rare cases of the anomalous origin of the occipital artery from the internal carotid artery and the possibility that the origin of such an anomalous occipital artery may be the cause of stenosis.

Effective coil embolization of intracavernous carotid artery pseudoaneurysm with parental artery preservation following severe head trauma in a pediatric patient

Intracranial traumatic pseudoaneurysms are rare in children. If left untreated, mortality rate can be as high as 50% due to delayed rupture and disastrous bleeding. Endovascular embolization is considered the preferred treatment option because of its minimal invasiveness and negligible mortality. However, exclusion of the pseudoaneurysm with preservation of the parental vessel is not always possible. In comparison with peripheral aneurysms, intracavernous internal carotid artery lesions are technically more challenging with both open surgery and endovascular techniques. We report the case of a successful two-stage coil embolization of a traumatic intracavernous carotid artery pseudoaneurysm with preservation of parental vessel in a 6-year-old boy. Endovascular embolization with parental vessel preservation should be considered the first treatment option for traumatic intracavernous internal carotid artery pseudoaneurysms in children. Although treatment of pseudoaneurysms in this location may be technically difficult, it is feasible in experienced hands.

Emergency Cervical Internal Carotid Artery Stenting in Combination with Intracranial Thrombectomy in Acute Stroke

In past years, thrombectomy has become a widely used procedure in interventional neuroradiology for the treatment of acute intracranial occlusions. However, in 10-20% of patients, there are additional occlusions or stenotic lesions of the ipsilateral cervical internal carotid artery. The purpose of this study was to evaluate the feasibility of emergency carotid artery stent placement in combination with intracranial thrombectomy and the clinical outcome of the treated patients. We analyzed clinical and angiographic data of patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent-retriever devices in our institution between November 2009 and July 2012. Recanalization was assessed according to the Thrombolysis in Cerebral-Infarction score. Clinical outcome was evaluated at discharge (NIHSS) and after 3 months (mRS). Overall, 24 patients were treated. The mean age was 67.2 years; mean occlusion time, 230.2 minutes. On admission, the median NIHSS score was 18. In all patients, the Thrombolysis in Cerebral Infarction score was zero before the procedure. Stent implantation was feasible in all cases. In 15 patients (62.5%), a Thrombolysis in Cerebral Infarction score ≥ 2b could be achieved. Six patients (25%) improved ≥10 NIHSS points between admission and discharge. After 90 days, the median mRS score was 3.0. Seven patients (29.2%) had a good clinical outcome (mRS 0-2), and 4 patients (16.6%) died, 1 due to fatal intracranial hemorrhage. Overall, symptomatic intracranial hemorrhage occurred in 4 patients (16.6%). Emergency ICA stent implantation was technically feasible in all patients, and the intracranial recanalization Thrombolysis in Cerebral Infarction score of ≥2b was reached in a high number of patients. Clinical outcome and mortality seem to be acceptable for a cohort with severe stroke. However, a high rate of symptomatic intracranial hemorrhage occurred in our study.

Features of Patients with Transient Monocular Blindness: A Multicenter Retrospective Study in Japan

Transient monocular blindness (TMB) is associated with a transient ischemic attack (TIA). The purpose of this study was to investigate the features of TMB in the Japanese population using data from a multicenter retrospective study of TIA. The subjects were consecutive TIA patients admitted to 13 stroke centers within 7 days after symptom onset. We compared clinical characteristics of patients with TMB and those without TMB who had other symptoms of cerebral TIA. A total of 464 patients were registered between January 2008 and December 2009, and 444 patients (283 men, mean age: 68.5 years) were included in the analysis. Thirteen patients (2.9%) presented with TMB. Patients with TMB were less likely to arrive at the specialized stroke center quickly than those without TMB (P = .013). Stenotic lesions in the extracranial internal carotid artery were more common in patients with TMB (33.3% versus 9.1%, P = .022). TMB was not common in our TIA inpatients. This study suggests that patients with TMB should immediately undergo a diagnostic workup, including brain and vessel imaging, and cardiac evaluation, as is performed in patients with other cerebral TIA symptoms. A larger, prospective cohort is needed to confirm the risks and outcomes of patients with TMB in the Japanese population.

Mandibular Subluxation as an Adjunct in Very Distal Carotid Arterial Reconstruction: Incidence of Peripheral and Cerebral Neurologic Sequelae in a Single-Center Experience

The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24). MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.

Assessment of the difference in posterior circulation involvement between pediatric and adult patients with moyamoya disease

There is no description of the change in the posterior cerebral artery (PCA) in the diagnostic criteria of moyamoya disease (MMD). However, PCAs are often involved in the clinical setting, and an understanding of the significance of PCA lesions is therefore of great importance when evaluating the disease progression and predicting prognosis. The aim of this study was to assess the difference in posterior circulation involvement in pediatric and adult patients with MMD. The records of 120 consecutive patients with MMD were reviewed. The clinical manifestations at diagnosis were evaluated on the basis of symptoms and CT and MRI findings. The degree of steno-occlusive internal carotid artery (ICA) lesions and the existence of steno-occlusive PCA lesions were evaluated by observing a total of 240 ICAs and PCAs on angiography. Angiographic correlation between anterior and posterior circulation was assessed in pediatric and adult patients with MMD. Seventeen (26%) of 66 pediatric patients and 18 (33%) of 54 adult patients exhibited steno-occlusive PCA lesions. There was no significant difference in the prevalence of PCA lesions between pediatric and adult patients with MMD (p = 0.36). The prevalence of infarction in pediatric and adult patients with PCA involvement was significantly higher than that in pediatric and adult patients without PCA involvement (p = 0.0003 and p = 0.003, respectively). There was no significant difference in the distribution of infarction areas between pediatric and adult patients with PCA involvement (p = 0.62). On the basis of the staging system used, steno-occlusive lesions in ICAs ipsilateral to PCAs with lesions were in significantly advanced stages compared with lesions in ICAs ipsilateral to PCAs without lesions in both pediatric and adult cases (p < 0.0001 and p = 0.0008, respectively). Pediatric patients had less advanced steno-occlusive lesions in ICAs ipsilateral to PCAs with lesions compared with adults (p < 0.05). The clinical significance of posterior circulation involvement in MMD was similar between pediatric and adult patients. The only significant difference was that less advanced ICA lesions could complicate posterior circulation involvement in pediatric patients.

Transient ischemic attack after hot bath in a patient with Moyamoya disease

Hot bath has not yet been reported as a precipitating factor in patients with Moyamoya disease. Here, we report an adult patient with Moyamoya disease presenting transient ischemic attack (TIA) characteristically precipitated by hot bath. A 38-year-old housewife presented with recurrent transient right hemiparesis and difficulty in speech for the past 3 months. These symptoms were developed only during hot bath, especially around the end of bath, and lasted about 5 min and then relieved spontaneously. Her past medical history and neurologic examination were unremarkable. Laboratory tests for associated conditions with vasculopathy were normal. Brain MRI revealed increased cortical vascular markings on the right hemisphere without parenchymal lesion. Brain magnetic resonance angiography revealed bilateral steno-occlusive lesions of the distal internal carotid arteries (ICAs) and the proximal part of the middle cerebral arteries (MCAs) and anterior cerebral arteries (ACAs) (Fig. 1a). Digital subtraction angiography (DSA) demonstrated that extensive collateral flows to the right hemisphere were from basal collaterals, posterior circulation system (Fig. 1b), the external carotid artery via transdural anastomosis, and ethmoidal arteries via ophthalmic artery. However, DSA of left ICA showed only small basal collaterals with delayed filling of the dilated distal left MCA branches (Fig. 1c). Perfusion CT demonstrated increased cerebral blood volume (CBV) in the right hemisphere (Fig. 1d). After acetazolamide challenge, increased CBV in the right hemisphere was more prominent and cerebral blood flow (CBF) was mildly increased (Fig. 1e). However, CBV and CBF changes after acetazolamide were not remarkable in the left hemisphere. Baseline transcranial Doppler showed the increased mean flow velocity (MFV) in both MCAs. Hyperventilation did not cause any changes, but breath holding decreased MFV paradoxically only in the left MCA. After taking hot bath, baseline MFVs of both MCAs were decreased. Breath holding after taking hot bath caused marked drop in MFV of the left MCA (Fig. 1f). The evoked potential (EP) studies were unremarkable at both room temperature (25 C) and heated room temperature (30 C). Breath holding and hyperventilation did not cause any changes in EP studies. However, during hyperventilation for 3 min in electroencephalography (EEG) study, transient right hand shaking movements were developed without EEG changes. She was on antiplatelet agent and educated to avoid hot bath for a long time. After discharge, she experienced TIA after hot bath only once in recent 6 months. Most of precipitating factors of TIA in Moyamoya disease are associated with hyperventilation [1]. The main underlying mechanism is presumed to be hyperventilationinduced vasoconstriction in hemodynamic-compromised cerebral region and subsequent CBF reduction [2]. In our case, hyperventilation during EEG study also induced transient right limb shaking, reflecting decreased vascular reserve in left hemisphere [3]. Interestingly, hot bath in this case was a distinct precipitating factor that affected cerebral hemodynamic status. Electronic supplementary material The online version of this article (doi:10.1007/s10072-013-1468-8) contains supplementary material, which is available to authorized users.

Carotid Artery Plaque and Progression of Coronary Artery Calcium: The Multi-Ethnic Study of Atherosclerosis

Carotid and coronary atherosclerosis are associated with each other in imaging and autopsy studies. The aim of this study was to evaluate whether carotid artery plaque seen on carotid ultrasound can predict incident coronary artery calcification (CAC). Agatston calcium score measurements were repeated in 5,445 participants of the Multi-Ethnic Study of Atherosclerosis (MESA; mean age, 57.9 years; 62.9% women). Internal carotid artery lesions were graded as 0%, 1% to 24%, or >25% diameter narrowing, and intima-media thickness (IMT) was measured. Plaque was present for any stenosis >0%. CAC progression was evaluated with multivariate relative risk regression for CAC scores of 0 at baseline and with multivariate linear regression for CAC score > 0, adjusting for cardiovascular risk factors, body mass index, ethnicity, and common carotid IMT. CAC was positive at baseline in 2,708 of 5,445 participants (49.7%) and became positive in 458 of 2,837 (16.1%) at a mean interval of 2.4 years between repeat examinations. Plaque and internal carotid artery IMT were both strongly associated with the presence of CAC. After statistical adjustment, the presence of carotid artery plaque significantly predicted incident CAC with a relative risk of 1.37 (95% confidence interval, 1.12-1.67). Incident CAC was associated with internal carotid artery IMT, with a relative risk of 1.13 (95% confidence interval, 1.03-1.25) for each 1-mm increase. Progression of CAC was also significantly associated (P < .001) with plaque and internal carotid artery IMT. In individuals free of cardiovascular disease, subjective and quantitative measures of carotid artery plaques by ultrasound imaging are associated with CAC incidence and progression.

Part Two: Against the Motion. Completion Angiography is Unnecessary Following Carotid Endarterectomy

Part Two: Against the Motion. Completion Angiography is Unnecessary Following Carotid Endarterectomy

Disappeared Pulsatile Tinnitus Related to Petrous Segment Stenosis of the ICA after Relief of the Stenosis by Stenting

Pulsatile tinnitus may result from turbulent flow within the internal carotid artery (ICA). Atherosclerotic carotid stenosis is a rare but well-known cause of pulsatile tinnitus. The classical treatment was endarterectomy or ligation for proximal ICA disease or stenting for distal ICA lesions. Endovascular techniques offer new ways to treat atherosclerotic vascular stenosis lesions. We describe two cases of pulsatile tinnitus caused by stenosis within the petrous segment of the ICA and treated by stent-assisted angioplasty.

Abstract TP29: Endovascular Treatment for Intracranial Arterial Stenosis

Background and Purpose: The stenosis of the major intracranial arteries is a major cause of cerebral stroke. We report our experience of endovascular treatment (percutaneous transluminal angioplasty and stenting ; PTAS) for symptomatic stenosis of major intracranial arteries. Material and methods: Totally 134 cases of symptomatic intracranial arterial stenosis were treated by PTAS at Kyoto Medical Center from 1998. Indication of PTAS was 1)symptomatic stenosis, which was not successfully treated by medication , and 2)more than 60% stenotic lesion shorter than 15mm in length. Balloon angioplasty (BA) was performed first. Stenting was, then, performed in cases of 1) unsuccessful dilatation or arterial dissection after BA and 2)restenosis after BA. Results: Successful dilatation by BA was obtained in 21/26 internal carotid artery (ICA) lesions, in 5/6 middle cerebral artery (MCA) lesions and in 24/29 vertebral artery (VA) lesions (50/61; 82%). Restenosis occurred in 7/26 ICA lesions, 4/6 MCA lesions and 8/29 VA lesions (totally 19/61 lesions; 31%). Successful dilatation by stenting was obtained in 59/60 ICA lesions, 1/1 MCA lesion and 13/15 VA lesions (totally 73/76 lesions; 96%). Restenosis occurred in 5/60 ICA lesions, 1/1 MCA lesion and 1/15 VA lesions (totally 7/76; 9%). Symptomatic complications induced by PTAS occurred in two cases; cerebral stroke and intra cerebral hemorrhage. Stroke recurrence rate after PTAS was 1.1% /year of intracranial ICA lesion and 0.25 % /year of intracranial VA lesion. Conclusions: 1)Symptomatic intracranial arterial stenosis can be treated by PTAS with a low rate of stroke recurrence and complications. 2)Prevention of restenosis after PTAS is a problem to be solved. 3) Therapeutic merit of PTAS for intracranial lesion needs to be examined comparing to the recent aggressive medical therapy.

Coexistence of Internal Carotid Artery Stenosis in Patients with Abdominal Aortic Aneurysm

Background and ObjectivesAbdominal Aortic Aneurysm (AAA) and carotid disease have medical and social significance, considering their morbidity, disability, and economic consequences. The study objectives were to determine the prevalence of asymptomatic internal carotid artery (ICA) lesions ≥70% in patients with AAA, the correlation of AAA diameter with the degree of ICA stenosis and symptoms, and the importance of preventive ultrasound checkups.Subjects and MethodsA prospective non-randomized controlled study including 740 patients, aged from 18-85 years, who were suitable for the inclusion and exclusion criteria and reported at the vascular laboratory of the Institute for Vascular and Endovascular Surgery, Clinical Center of Serbia from 1st of December 2011 to the 1st of November 2012.ResultsThe prevalence of asymptomatic ICA stenosis ≥70% in patients with AAA is 10.8%. Male representatives have more symptomatic ICA stenosis ≥70%. Patients with small aneurysms more often have asymptomatic ICA stenosis ≥70%. The occurrence of symptoms of carotid disease was more prevalent among patients with ICA stenosis ≥70% compared to the group with stenosis <70%. There was no correlation found between the grade of ICA stenosis with the size of AAA.ConclusionThe prevalence of asymptomatic ICA stenosis ≥70% in patients with AAA is found to be 10.8%. Male patients with ICA stenosis ≥70% more often had symptoms of carotid disease. In the smaller aneurysms, ICA stenosis ≥70% occurs frequently, but without the symptoms of carotid disease, and there was no correlation between the size of AAA and the grade of ICA stenosis. Clinical implications of ICA imaging in patients with previously diagnosed AAA is necessary.

頚動脈内膜剝離術における解剖に基づいた手術手技の工夫

In this article, we present a non-invasive approach to the high cervical internal carotid artery lesion based on the anatomical features of the parotid gland and the carotid sheath.

Selective shunt during carotid endarterectomy using routine awake test with respect to a lower shunt rate.

PurposeTo evaluate shunt rate and discuss the resultsrelated to selective shunt placement during carotid endarterectomy (CEA) using routine awake test.MethodsPatients with CEA from 2007 to 2011 were retrospectively reviewed from prospectively collected data. The need for shunt placement was determined by the awake test, based on the alteration in the neurologic examination. We collected data by using the clinical records and imaging studies, and investigated factors related to selective shunt such as collateral circulation and contralateral internal carotid artery (ICA) stenosis.ResultsThere were 45 CEAs under regional anesthesia with the awake test in 44 patients. The mean age was 61.8 ± 7.1 years old. There were 82.2% (37/45) of males, and 68.9% (31/45) of symptomatic patients. Selective shunt placement had been performed in only two (4.4%) patients. Among them fewer cases (4%) had severe (stenosis >70%) contralateral ICA lesions, and more cases (91%) of complete morphology of the anterior or posterior circulation in the circle of Willis. There was no perioperative stroke, myocardial infarctionor death, and asymptomatic new brain lesions were detected in 4 patients (9%), including 2 cases of selective shunt placement.ConclusionCEA under routine awake test could besafe and feasible method with low shunt placement rate in selected patients.

Treatment of Cervical Internal Carotid Artery Spontaneous Dissection with Pseudoaneurysm and Unilateral Lower Cranial Nerves Palsy by Two Silk Flow Diverters

Internal carotid artery (ICA) lesions in the parapharyngeal space (a dissection and a pseudoaneurysm) may present as isolated lower cranial nerves (IX, X, XI, and XII) palsy (Collet-Sicard syndrome). Some arteriopathies such as fibromuscular dysplasia and tortuosity make a vessel predisposed to dissection. Extreme vessel tortuosity makes the treatment by a stent graft impossible. Two Silk stents were used in a 46year-old man with left lower cranial nerves (IX-XII) palsy for the treatment of left ICA spontaneous dissection with pseudoaneurysm. A follow-up angiogram 5months later confirmed pseudoaneurysm thrombosis and patency of the left ICA. The patient recovered completely from the deficits.

Double-barrel extracranial–intracranial bypass surgery followed by endovascular carotid artery occlusion in a patient with an extracranial giant internal carotid artery aneurysm due to Ehlers–Danlos syndrome

ObjectiveIn this case report we describe a successful interdisciplinary approach (including flow redirection and endovascular occlusion) applied to a patient with a continuously growing extracranial giant aneurysm of the right...

Pseudo-occlusion of the extracranial carotid artery caused by intracranial carotid artery stenosis

A 70-year-old female with hypertension and diabetes presented to the emergency room with sudden-onset drowsy mentation and disorientation. Her blood pressure was 130/80 mmHg, pulse rate was 70 beats per minute, respiratory rate was 18 breaths per minute, and body temperature was 36.7 C. Neurologic examination indicated confusion and generalized myoclonic jerks. Blood chemistry tests revealed an elevation of blood urea nitrogen and creatinine (83 and 3.5 mg/dl, respectively). Small deep infarcts on the right basal ganglia and corona radiata were visible on brain MRI (Fig. 1a), but a high signal intensity was not evident on the diffusion weighted image. In addition, her right proximal internal carotid artery (ICA) was invisible on contrast-enhanced magnetic resonance angiography (CE-MRA) (Fig. 1b). MRI was performed with a Signa Excite XI Twin Speed 1.5T system (GE Healthcare, Milwaukee, WI, USA). Her neurological symptoms resolved upon reduction of her blood urea nitrogen and creatinine levels, therefore, the patient was tentatively diagnosed with uremic encephalopathy. After improvement of her symptoms, we performed carotid duplex ultrasonography (CDUS, GE LOGIQ 7 PRO US machine, 12 MHz linear array transducer) to evaluate the right ICA on hospital day 6. There was no sonographic evidence of blood flow from the right carotid bifurcation to the proximal ICA (Fig. 1c). Transcranial Doppler could not be performed because she had a poor temporal window. Since MRI and CE-MRA showed multiple silent infarcts mainly in the right anterior circulation and string sign around the lacerum segment of the ipsilateral distal ICA, we planned further investigation including digital subtraction angiography (DSA) to assess her cerebral vascular reserve and vasculature and to determine how to prevent a stroke. DSA, performed on hospital day 8, revealed that the lacerum segment of the right ICA was severely stenotic, but the bulbous segment was not. Proximal to distal blood flow in the right ICA was significantly slower compared to the external carotid artery blood flow (Fig. 1d). The right anterior cerebral artery was filled by the left anterior cerebral and communicating arteries, but the right middle cerebral artery was only supplied by the ipsilateral ICA and was not visualized on vertebral or contralateral cerebral angiography. On hospital day 12, we decided to perform percutaneous transluminal balloon angioplasty (Fig. 2a). Since the diameters of the proximal and distal parent vessels adjacent to the stenotic lesion were 2.03 and 1.89 mm, respectively, we did not deploy a stent. On hospital day 14, follow-up CDUS showed normal configuration of the ICA and normal blood flow velocity (peak systolic velocity: 69.8 cm/s, end diastolic velocity: 33.2 cm/s; Fig. 2b). Since then she has been healthy and asymptomatic, and the blood flow velocity of the right proximal ICA (peak systolic: 69.1 cm/s, end diastolic: 34.8 cm/s; image not shown) was not reduced on 2-year follow-up CDUS. Pseudo-occlusion of the ICA was defined in previous studies as a collapsed distal ICA due to the reduced flow velocity caused by a severe stenotic lesion of the proximal ICA [1]. In this case, contrary to the classical definition of a D. Lee S. H. Heo D.-I. Chang (&) Departments of Neurology, College of Medicine, Kyung Hee University Hospital, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea e-mail: dichang@khmc.or.kr

Transsphenoidal surgery assisted by a new guidance device: Results of a series of 747 cases

Objective The objective of this study is to report the efficacy and safety of microsurgical transsphenoidal surgery using a frame for sella guidance in a series of patients with untreated pituitary adenoma. Methods In this study, seven hundred and forty-seven patients undergoing transsphenoidal resection of a pituitary adenoma involving use of the frame were included. Follow-up of twelve to one hundred months was performed in all patients. Results During the procedures using the frame, pituitary adenomas were fully exposed, and no cavernous sinus haemorrhage due to anteroposterior displacement or internal carotid artery lesion due to right-and-left deviation occurred. The duration of the surgical procedure ranged from 28 min to 87 min with a mean of 44 min. The most frequent tumour type was prolactin-secreting adenoma (32.4%), followed by clinically non-functioning adenoma (NFPA) (28.5%), growth hormone-secreting adenoma (25.0%), and adrenocorticotropin-secreting adenoma (13.7%). Normalisation of visual defects occurred in 226 (42.2%) of the 535 patients with visual disturbances. Normalisation of hormone occurred in 458 of 551 patients with endocrine-active tumour in the follow-up period. Two patients died as a consequence of surgery. Conclusion The endonasal transsphenoidal technique is a safe, quick, and effective approach to pituitary adenomas. Our guidance frame allows the surgeon to open and close the wound rapidly, which avoids trajectory deviation and shortens the duration of the surgical procedure.

Management of Simultaneous Common and Internal Carotid Artery Occlusive Disease in the Endovascular Era

Combined or tandem lesions of the common carotid artery and the ipsilateral carotid bifurcation are uncommon and the management of patients with this disease pattern can be challenging. The development of endovascular techniques has contributed a variety of options for managing these combined lesions; either as part of a hybrid approach (carotid endarterectomy and common carotid artery stent) or with stenting alone for both lesions. In this article, we review the technique and results of managing carotid revascularization in the context of tandem common carotid and internal carotid artery lesions in the endovascular era.

Extracranial Internal Carotid Artery Aneurysm: A Rare Cause of Stroke

Aneurysms of the extracranial carotid artery are rare but may have debilitating clinical consequences. A case causing a cerebrovascular accident is reported followed by a discussion of the clinical features, investigation and treatment of this condition. Aneurysms usually develop in the common or internal carotid artery (ICA) and presentation typically results from cerebral embolization. Distal ICA lesions are often not detected during ultrasound examinations, and computed tomography is most commonly used to plan treatment. This may be performed by open surgery or endovascular intervention.