Proximal Internal Carotid Artery Research Articles

Multiphasic Computed Tomography Angiography Findings for Identifying Pseudo-Occlusion of the Internal Carotid Artery.

Differentiation between pseudo-occlusion and true occlusion of internal carotid artery (ICA) is important in treatment planning for acute ischemic stroke patients. We compared the findings of multiphasic computed tomography angiography between cervical ICA pseudo-occlusion and true occlusion at the cervical ICA in patients with anterior circulation acute ischemic stroke to determine their diagnostic value. Thirty patients with nonvisualization of the proximal ICA were included. Diagnosis of pseudo- or true occlusion of the ICA was made based on digital subtraction angiography. Diagnostic performances of multiphasic computed tomography angiography findings-(1) a flame-shaped stump and (2) delayed contrast filling at the cervical ICA- were evaluated and compared. The Fisher exact test, χ2 test, or Wilcoxon rank-sum test and McNemar test were used in the data analysis. Twelve patients had true proximal ICA occlusion and 18 had pseudo-occlusion. Delayed contrast filling at the cervical ICA on multiphasic computed tomography angiography was found in all patients with pseudo-occlusion of the ICA, while 1 case of true occlusion showed delayed contrast filling (P<0.001). The presence of a flame-shaped stump was not significantly different between the pseudo- and true occlusion groups. The sensitivity of delayed contrast filling (0.94 [95% CI, 0.73-1]) was significantly higher than that of flame-shaped stump (0.75 [95% CI, 0.36-0.83]). We demonstrated that the delayed filling sign on multiphasic computed tomography angiography could be a useful and readily available finding for differentiating proximal ICA pseudo-occlusion from true occlusion.

Dual SAVE technique for mechanical thrombectomy rescue on MCA bifurcation clots

The Stent retriever Assisted Vacuum-locked Extraction (SAVE) technique in mechanical thrombectomy consists of the simultaneous use of a stent retriever and a distal aspiration catheter, with the removal of both...

GAMBARAN ULTRASONOGRAFI PLAK ARTERI KAROTIS

&lt;p&gt;Duplex Carotid Ultrasonography is non invasive and friendly examination, used to observe carotid artery. About 20-30% from total stroke cases, caused by extracranial carotid artery abnormalities. Atherosclerosis plaque at carotid artery is suspected as the etiology for more than 80% cerebral thromboembolism. &lt;strong&gt;Aim&lt;/strong&gt; : to find out ultrasonography image at carotid artery plaque. &lt;strong&gt;Method&lt;/strong&gt; : the method of this study is literature review towards experimental articles which were published internationally at Pubmed / Medline database from 1977 – 2015. The literature study is arranged based on Walker and Avant guideline, which is consist of : a) conceptual comprehension; b) aim or role identification; c) concept identification and the relation with role and aim.&lt;strong&gt; Result&lt;/strong&gt; : carotid artery ultrasonography examination covers common carotid artery, proximal internal and external carotid artery analysis. Parts to notice are artery diameter, carotid bulbous, intimal medial thickness, flow velocity, type of wave, present of plaque, also artery abnormalities, such as dysplasia, coiling, kinking, &lt;em&gt;and tortuosity. &lt;strong&gt;Conclusion : &lt;/strong&gt;atherosclerosis plaque imaging with conventional&lt;/em&gt; &lt;em&gt;ultrasonography is a relative easy, affordable and non invasive technique with specificity and sensitivity level equal with other imaging modalities. &lt;/em&gt;&lt;/p&gt;

Predictors of Successful First-Pass Thrombectomy with a Balloon Guide Catheter: Results of a Decision Tree Analysis

Complete recanalization after a single retrieval maneuver is an interventional goal in acute ischemic stroke and an independent factor for good clinical outcome. Anatomical biomarkers for predicting clot removal difficulties have not been comprehensively analyzed and await unused. We retrospectively evaluated 200 consecutive patients who suffered acute stroke and occlusion of the anterior circulation and were treated with mechanical thrombectomy through a balloon guide catheter (BGC). The primary objective was to evaluate the influence of carotid tortuosity and BGC positioning on the one-pass Modified Thrombolysis in Cerebral Infarction Scale (mTICI) 3 rate, and secondarily, the influence of communicating arteries on the angiographic results. After the first-pass mTICI 3, recanalization fell from 51 to 13%. The regression models and decision tree (supervised machine learning) results concurred: carotid tortuosity was the main constraint on efficacy, reducing the likelihood of mTICI 3 after one pass to 30%. BGC positioning was relevant only in carotid arteries without elongation: BGCs located in the distal internal carotid artery (ICA) had a 70% probability of complete recanalization after one pass, dropping to 43% if located in the proximal ICA. These findings demonstrate that first-pass mTICI 3 is influenced by anatomical and interventional factors capable of being anticipated, enabling the BGC technique to be adapted to patient’s anatomy to enhance effectivity.

A case report and experience of endovascular treatment for a patient with hemophilia who had a hyperacute ischemic stroke

No previous study has reported endovascular treatment (EVT) in a patient with hemophilia who had an acute ischemic stroke (AIS). Herein, we report the case of a patient with hemophilia A who presented with hyperacute stroke due to a near occlusion of the proximal internal carotid artery (ICA).A 54-year-old man was admitted to our emergency department with a sudden onset of left-sided weakness that occurred 4 hours prior to admission. He had been diagnosed with congenital hemophilia A during his childhood. Although brain computed tomography revealed no evidence of hemorrhage, we did not consider intravenous thrombolysis because of his bleeding-prone condition. Diffusion-weighted imaging revealed a restricted diffusion in the right anterior and middle cerebral artery territories. Magnetic resonance angiography revealed that the right proximal ICA was nearly occluded and had a residual stump. Digital subtraction angiography revealed a near occlusion of the right proximal ICA with a thread-like lumen. Balloon angioplasty was performed in the proximal ICA, and distal flow was restored, but residual stenosis was observed. Stepwise revascularization by carotid endarterectomy (CEA) was planned instead of immediate carotid stenting. He underwent CEA with preoperative and postoperative coverage of factor VIII and recovered without any bleeding complication.

Age and anatomical location related hemodynamic changes assessed by 4D flow MRI in the carotid arteries of healthy adults

PurposeTo evaluate hemodynamic changes (volume, velocity, wall shear stress, pressure gradient, and energy loss) in the common carotid artery (CCA) and internal carotid artery (ICA) of healthy adults among different ages and anatomical locations using 4D flow MRI. MethodsSixty-two healthy volunteers aged 20–75 years were enrolled in this study. 4D flow MRI examinations were performed for each subject and were analyzed using the CVI42 platform to generate hemodynamic parameters. Hemodynamic parameters were compared among different age groups and anatomical locations (proximal CCA, distal CCA, proximal ICA and distal CCA) using one-way ANOVA. The paired t-test was used to estimate the differences between left and right vessels. The relationship between age and hemodynamic parameters was quantified by Pearson’s correlation coefficient. ResultsThere were no differences between the left and right carotid arteries for any of the hemodynamic parameters (all p values > 0.05), so we set each vessel as an independent sample. The proximal ICA had significantly lower volume, velocity, wall shear stress, and pressure gradient values than the values determined for other locations (p < 0.05), and energy loss was similar among different locations. Wall shear stress (except in the distal ICA), velocity, pressure gradient, and energy loss decreased with age (p < 0.05). ConclusionsThe multiparameter analysis of 4D flow MRI can identify age and anatomical location changes in hemodynamic parameters in the carotid arteries of healthy adults. The lower velocity, wall shear stress, and pressure gradient in the proximal ICA and the reduced trend with age may be associated with disease occurrence.

Follow-up after carotid stenting with the CASPER stent system: A duplex ultrasound evaluation

ObjectiveTo report results of duplex ultrasound evaluation of consecutive patients after carotid stenting with the double layer Carotid Artery Stent designed to Prevent Embolic Release (CASPER) stent system. MethodsBetween January 2014 and June 2017, a single-center, retrospective study of 101 consecutive patients (21.8% female; median age, 72.1 years) was performed. Patients with internal carotid artery stenosis treated with the CASPER stent were included. Eligibility criteria for stenting included stenosis of ≥70% of the vessel diameter (or ≥50% diameter with ulceration) in symptomatic carotid artery stenosis or ≥80% stenosis in asymptomatic patients at the carotid artery bifurcation or the proximal cervical internal carotid artery. Duplex ultrasound examination was performed before and within 24 hours of implantation as well as at 14 days, and 3, 6, and 12 months. ResultsAt the 12-month follow-up visit, moderate in-stent restenosis (ISR) (≥50% and <70%) was detected in three stents (2.8%) and severe (≥70%) ISR in two (1.9%; including one case of stent occlusion). All but the two latter patients remained asymptomatic during the follow-up period. One patient required retreatment for ISR after a minor stroke and another patient with stent occlusion also re-presented with a minor stroke. Multivariable logistic regression was unable to detect any significant factors associated with ISR. ConclusionsDuplex ultrasound examination after carotid stenting is a useful tool for patient follow-up and determination of ISR. We found a low incidence of ISR assessed by duplex ultrasound examination at 12 months after CASPER stenting, but further studies are warranted.

2D parametric contrast time-density analysis for the prediction of complete aneurysm occlusion at six months' post-flow diversion stent.

Indications for the treatment of cerebral aneurysms with flow diversion stents are expanding. The current aneurysm occlusion rate at six months ranges between 60 and 80%. Predictability of complete vs. partial aneurysm occlusion is poorly defined. Here, we evaluate the angiographic contrast time-density as a predictor of aneurysm occlusion rate at six months' post-flow diversion stents. Patients with unruptured cerebral aneurysms proximal to the internal carotid artery terminus treated with single flow diversion stents were included. 2D parametric parenchymal blood flow software (Siemens-Healthineers, Forchheim, Germany) was used to calculate contrast time-density within the aneurysm and in the proximal adjacent internal carotid artery. The area under the curve ratio between the two regions of interests was assessed at baseline and after flow diversion stents deployment. The area under the curve ratio between completely vs. partially occluded aneurysms at six months' follow-up was compared. Thirty patients with 31 aneurysms were included. Mean aneurysm diameter was 8 mm (range 2-28 mm). Complete occlusion was obtained in 19 aneurysms. Younger patients (P = 0.006) and smaller aneurysms (P = 0.046) presented higher chance of complete obliteration. Incomplete occlusion of the aneurysm was more likely if the area under the curve contrast time-density ratio showed absolute (P = 0.001) and relative percentage (P = 0.001) decrease after flow diversion stents deployment. Area under ROC curve was 0.85. Negative change in the area under the curve ratio indicates less contrast stagnation in the aneurysm and lower chance of occlusion. These data provide a real-time analysis after aneurysm treatment. If validated in larger datasets, this can prompt input to the surgeon to place a second flow diversion stents.

Abstract 56: Neuroimaging in Ischemic Stroke is Different Between Men and Women in the Defuse 3 Cohort

Introduction: Clinical deficits from ischemic stroke are more severe in women but the pathophysiological basis of this sex difference is unknown. Sex differences in core and penumbral volumes were assessed in this sub-study of the Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke (DEFUSE)-3 clinical trial. Methods: DEFUSE 3 randomized patients to thrombectomy or medical management who presented 6-16 hours from last known well with proximal middle cerebral artery or internal carotid artery occlusion and had target core and perfusion mismatch volumes on CT or MRI. Using univariate and adjusted regression models, the effect of sex was assessed on pre-randomization measures of core, perfusion, and mismatch volumes and hypoperfusion intensity ratio, and on core volume growth using 24-hour scans. Results: All patients were included in the analysis (n=182) with 90 men and 92 women. There was no sex difference in the site of baseline arterial occlusion. Adjusted by age, baseline NIHSS, baseline modified Rankin score, time to randomization, and imaging modality, women had smaller core, hypoperfusion, and penumbral volumes than men. Median (IQR) volumes for core were 8.0 mL (1.9-18.4) in women vs 12.6 mL (2.7-29.6) in men, for T max &gt;6 seconds 89.0 mL (63.8-131.7) vs 133.9 mL (87.0-175.4), and for mismatch 82.1 (53.8-112.8) vs 108.2 (64.1-149.2). The hypoperfusion intensity ratio was lower in women, 0.31 (0.15-0.46) vs. 0.39 (0.26-0.57), p = 0.006, indicating better collateral circulation, which was consistent with the observed slower ischemic core growth than men within the medical group (p = 0.003). Conclusions: In the large vessel ischemic stroke cohort selected for DEFUSE 3, women had imaging evidence of better collateral circulation, smaller baseline core volumes, and slower ischemic core growth. These observations suggest sex differences in hemodynamic and temporal features of anterior circulation large artery occlusions.

Visual Vignette

Case Presentation: A 40-year-old woman with primary hyperparathyroidism (pHPT) and unlocalized disease (negative neck ultrasonography and sestamibi scan) underwent neck exploration. Two borderline appearing inferior parathyroid glands were removed and a normal right superior gland was left in situ while the left superior gland was not identified. The removed parathyroid glands were of increased weight and histologically showed borderline hyperplasia. However, the postoperative calcium remained raised at over 3.0 mmol/L (2.2 to 2.6 mmol/L). A subsequent, 4-dimensional (4D) computed tomography (CT) scan failed to identify the parathyroid adenoma. Parathyroid angiography and venous sampling demonstrated no vascular blush, but significant elevation of parathyroid hormone (PTH) within the veins draining the left side of the neck. Extensive re-exploration of the left neck failed to identify a parathyroid gland and no drop in intraoperative PTH occurred after a left hemithyroidectomy. Repeated venous sampling was consistent with the source of PTH being within the left superior neck. Fluorine F 18-fluorocholine (FCH)-positive emission tomography (PET)/CT was undertaken and showed intense tracer uptake in a soft tissue focus (6 × 11 mm) lying within the carotid sheath just lateral to the proximal left internal carotid artery and medial to the internal jugular vein (Fig. 1). What is the diagnosis?

Predictors for the extent of pial collateral recruitment in acute ischemic stroke.

Pial arterioles can provide a variable degree of collateral flow to ischemic vascular territories during acute ischemic stroke. This study sought to identify predictive factors of the degree of pial collateral recruitment in acute ischemic stroke. Clinical information and arteriograms from 62 consecutive patients with stroke due to either middle cerebral artery (MCA) M1 segment or internal carotid artery (ICA) terminus occlusion within 6 h following symptom onset were retrospectively reviewed. Pial collaterals were defined based on the extent of reconstitution of the MCA territory. Patients with slow antegrade flow distal to the occlusion site were excluded and no anesthetics were used prior or during angiography. Results were analyzed using multivariate nominal logistic regression. Better pial collateral recruitment was associated with proximal MCA versus ICA terminus occlusion (p = 0.005; odds ratio (OR) = 9.3; 95% confidence interval (CI), 2.16-53.3), lower presenting National Institutes of Health Stroke Scale Score (NIHSSS) (p = 0.023; OR = 6.51; 95% CI, 1.49-41.7), and lower diastolic blood pressure (p = 0.0411; OR = 5.05; 95% CI, 1.20-29.2). Age, gender, symptom duration, diabetes, laterality, systolic blood pressure, glucose level, hematocrit, platelet level, and white blood cell count at presentation were not found to have a statistically significant association with pial collateral recruitment. Extent of pial collateral recruitment is strongly associated with the occlusion site (MCA M1 segment versus ICA terminus) and less strongly associated with presenting NIHSSS and diastolic blood pressure.

Use of Contralateral Trans-Anterior Communicating Artery Snare to Rescue Lost Access to a Pipeline Embolization Device Unsheathed in an Aneurysm.

A pipeline embolization device (PED; Medtronic, Minneapolis, MI, USA) is a new vascular reconstruction device used to treat large internal carotid artery (ICA) aneurysms in Japan. We herein present a PED-related complication and describe its rescue strategy. Rescue therapy using a snare via the posterior communicating artery from the contralateral side has already been reported. However, this is the first report of therapy via the anterior communicating artery (AcomA). A 49-year-old woman underwent vascular reconstruction with a PED for a large cavernous ICA aneurysm. During the placement of the PED, the proximal side of the PED slipped into the aneurysm. It was impossible to enter the true lumen of the PED from the proximal side because the orifice of the stent faced the aneurysmal wall. Contralateral trans-AcomA access to the PED was obtained through the distal ICA. The microwire from the distal ICA was connected with Goose Neck snares (Medtronic) from the proximal ICA. Pulling the snares to the proximal side, the PED was straightened and distal access was regained. Another PED was deployed such that it overlapped with the first PED to achieve vascular reconstruction. The patient finally recovered from aphasia, but paralysis of the right upper limb remained after rehabilitation. If the stent slips into the aneurysm, distal access through the true stent lumen may be very difficult. We presented a rescue technique for this complication, through the AcomA from the contralateral side.

Canine Assault with Blunt Trauma to the Chest Causing Acute Ischemic Stroke

Ischemic stroke occurs in a significant subset of patients with blunt traumatic cerebrovascular injury (TCVI). The patients are most often victims of motor vehicle crashes or assaults, and suffer ischemic stroke due to injury of the extracranial carotid or vertebral arteries. A 60 year old male described walking in a park when a large dog jumped up striking him in the chest and causing forceful rotation of the neck, but no head injury was reported. Immediately after the incident the patient complained of dizziness, clumsiness of the left arm, and difficulty seeing to the left. Computed tomography angiography of the neck demonstrated 50% stenosis of the proximal right internal carotid artery secondary to mural thrombus. Prior to the event the patient had no known history of carotid disease. Magnetic resonance imaging of the brain showed numerous subcentimeter foci of acute ischemia in the right cerebral hemisphere within the right middle and posterior cerebral artery distributions. Most literature about TCVI and stroke has been published in trauma, general surgery, and neurosurgery journals because these patients are generally primarily managed by trauma surgeons. Because of the increasing prevalence and awareness of TCVI, it is important to bring this clinical entity to the attention of all medical providers.

Carotid geometry is an independent predictor of wall thickness \u2013 a 3D cardiovascular magnetic resonance study in patients with high cardiovascular risk

BackgroundThe posterior wall of the proximal internal carotid artery (ICA) is the predilection site for the development of stenosis. To optimally prevent stroke, identification of new risk factors for plaque progression is of high interest. Therefore, we studied the impact of carotid geometry and wall shear stress on cardiovascular magnetic resonance (CMR)-depicted wall thickness in the ICA of patients with high cardiovascular disease risk.MethodsOne hundred twenty-one consecutive patients ≥50 years with hypertension, ≥1 additional cardiovascular risk factor and ICA plaque ≥1.5 mm thickness and < 50% stenosis were prospectively included. High-resolution 3D-multi-contrast (time of flight, T1, T2, proton density) and 4D flow CMR were performed for the assessment of morphological (bifurcation angle, ICA/common carotid artery (CCA) diameter ratio, tortuosity, and wall thickness) and hemodynamic parameters (absolute/systolic wall shear stress (WSS), oscillatory shear index (OSI)) in 242 carotid bifurcations.ResultsWe found lower absolute/systolic WSS, higher OSI and increased wall thickness in the posterior compared to the anterior wall of the ICA bulb (p < 0.001), whereas this correlation disappeared in ≥10% stenosis. Higher carotid tortuosity (regression coefficient = 0.764; p < 0.001) and lower ICA/CCA diameter ratio (regression coefficient = − 0.302; p < 0.001) were independent predictors of increased wall thickness even after adjustment for cardiovascular risk factors. This association was not found for bifurcation angle, WSS or OSI in multivariate regression analysis.ConclusionsHigh carotid tortuosity and low ICA diameter were independent predictors for wall thickness of the ICA bulb in this cross-sectional study, whereas this association was not present for WSS or OSI. Thus, consideration of geometric parameters of the carotid bifurcation could be helpful to identify patients at increased risk of carotid plaque generation. However, this association and the potential benefit of WSS measurement need to be further explored in a longitudinal study.

Neuroimaging in Ischemic Stroke Is Different Between Men and Women in the DEFUSE 3 Cohort.

Background and Purpose- Clinical deficits from ischemic stroke are more severe in women, but the pathophysiological basis of this sex difference is unknown. Sex differences in core and penumbral volumes and their relation to outcome were assessed in this substudy of the DEFUSE 3 clinical trial (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke). Methods- DEFUSE 3 randomized patients to thrombectomy or medical management who presented 6 to 16 hours from last known well with proximal middle cerebral artery or internal carotid artery occlusion and had target core and perfusion mismatch volumes on computed tomography or magnetic resonance imaging. Using univariate and adjusted regression models, the effect of sex was assessed on prerandomization measures of core, perfusion, and mismatch volumes and hypoperfusion intensity ratio, and on core volume growth using 24-hour scans. Results- All patients were included in the analysis (n=182) with 90 men and 92 women. There was no sex difference in the site of baseline arterial occlusion. Adjusted by age, baseline National Institutes of Health Stroke Scale, baseline modified Rankin Scale score, time to randomization, and imaging modality, women had smaller core, hypoperfusion, and penumbral volumes than men. Median (interquartile range) volumes for core were 8.0 mL (1.9-18.4) in women versus 12.6 mL (2.7-29.6) in men, for Tmax>6 seconds 89.0 mL (63.8-131.7) versus 133.9 mL (87.0-175.4), and for mismatch 82.1mL (53.8-112.8) versus 108.2 (64.1-149.2). The hypoperfusion intensity ratio was lower in women, 0.31 (0.15-0.46) versus 0.39 (0.26-0.57), P=0.006, indicating better collateral circulation, which was consistent with the observed slower ischemic core growth than men within the medical group (P=0.003). Conclusions- In the large vessel ischemic stroke cohort selected for DEFUSE 3, women had imaging evidence of better collateral circulation, smaller baseline core volumes, and slower ischemic core growth. These observations suggest sex differences in hemodynamic and temporal features of anterior circulation large artery occlusions. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02586415.

Complication Rates Using CASPER Dual-Layer Stents for Carotid Artery Stenting in Acute Stroke : A3-Year Single Center Experience.

The number of acute and early stent occlusions after emergency stenting of the internal carotid artery (ICA) in patients with tandem lesions is unclear and only mentioned in asmall number of publications, ranging from 0-20%. Arecent article by Yilmaz etal. reported ahigh rate of acute in-stent occlusions of 45% within 72 h after deployment of CASPER dual layer stents. All patients with acute ischemic stroke treated with a CASPER stent between August 2014 and April 2018 were retrospectively evaluated for occlusion rates, periinterventional medication and early complications. Atotal of 66patients, 45with tandem pathologies and 21with proximal ICA stenosis only were enrolled. Thrombotic complications occurred in 16 out of 66 patients (24%) and hemorrhagic complications in 8/66 (12%) and 15 of the 16thrombotic complications and 7/8symptomatic intracranial hemorrhages (sICH) occurred in patients with tandem lesions and accessory intracranial thrombectomy. Of the patients with sICH five were treated in aprolonged or unknown time window. In patients with intraprocedural thrombotic complications ultrasound imaging showed patent stents in 13 of the 14patients CONCLUSIONS: The CASPER stent system showed ahigh technical success rate in patients with acute stroke. The number of patients with sICH was not higher than the numbers reported in the published literature despite the early use of Gp IIb/IIIA inhibitors, whereas the number of thrombotic complications was smaller than that reported in recent studies. The majority of sICH occurred in patients treated because of tandem lesions in an unknown or prolonged time window.

Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy.

The technique of the eversion carotid endarterectomy (ECEA), as an alternative to the conventional endarterectomy with primary or patch angioplasty, is an established technique for managing internal carotid artery stenoses and recently its application has been upgraded through the European Society for Vascular Surgery guidelines (Recommendation 55: Class 1, Level A). However, the typical eversion method has been associated with postoperative hypertension due to loss of the baroreceptor reflex; the standard oblique transection at the bulb performed in the eversion endarterectomy interrupts either the baroreceptor sensoring tissue, which is mostly located in the adventitia at the medial portion of the proximal internal carotid artery, or even the proper Hering nerve, a branch of the glossopharyngeal nerve. These actions deregulate the natural negative feedback of the carotid baroreceptor. Guided by the anatomical location of the baroreceptor sensor we have elaborated a slight modification of the classical ECEA to maintain as much as possible of the viable carotid baroreceptor sensoring surface. By extending the oblique incision distal to the carotid bifurcation in the medial part of the internal carotid artery stem, an eyebrow-like part of the proximal internal carotid artery is maintained and the axis from the sensoring tissue to the nerve of Hering is protected and following the endarterectomy, postoperative arterial blood pressure levels are lower than in the classical ECEA due to the maintenance of the efficiency of the baroreceptor reflex. During the period from September 2016 to November 2018, carotid endarterectomy was performed in 57 patients. Twenty-eight of them underwent the typical ECEA and 29 patients had the modified eyebrow eversion carotid endarterectomy (me-ECEA). The changes of blood pressure baseline during the postoperative course in ECEA and me-ECEA group were analyzed and compared. Postoperative hypertension was defined as an elevation of systolic blood pressure (SBP) greater than 140 mm Hg. Patients who underwent typical ECEA had significantly higher postoperative blood pressure values compared with those who underwent me-ECEA. Actually, the mean postoperative SBP was 172.67 ± 24.59 mm Hg in the typical ECEA group compared with 160.86 ± 12.83 mm Hg in the me-ECEA group ( p = 0.023). The mean diastolic blood pressure in the ECEA group was 65.42 ± 11.39 mm Hg compared with 58.06 ± 9.06 mm Hg in the me-ECEA group ( p = 0.009). Our proposed me-ECEA technique seems to be related to lower rates of postoperative hypertension compared with the typical ECEA, probably due to the sparing of the main mass of the baroreceptor apparatus; this improved modification (me-ECEA) of the typical eversion procedure could represent an alternative ECEA technique with its inherent advantages.

Anatomical assessment of the endoscopic endonasal approach for the treatment of paraclinoid aneurysms.

Endoscopic endonasal approaches (EEAs) are increasingly being incorporated into the neurosurgeon's armamentarium for treatment of various pathologies, including paraclinoid aneurysms. However, few anatomical assessments have been performed on the use of EEA for this purpose. The aim of the present study was to provide a comprehensive anatomical assessment of the EEA for the treatment of paraclinoid aneurysms. Five cadaveric heads underwent an endonasal transplanum-transtuberculum approach to expose the paraclinoid area. The feasibility of obtaining proximal and distal internal carotid artery (ICA) control as well as the topographic location of the origin of the ophthalmic artery (OphA) relative to dural landmarks were assessed. Limitations of the EEA in exposing the supraclinoid ICA were also recorded to identify favorable paraclinoid ICA aneurysm projections for EEA. The extracavernous paraclival and clinoidal ICAs were favorable segments for establishing proximal control. Clipping the extracavernous ICA risked injury to the trigeminal and abducens nerves, whereas clipping the clinoidal segment put the oculomotor nerve at risk. The OphA origin was found within 4 mm of the medial opticocarotid point on a line connecting the midtubercular recess point to the medial vertex of the lateral opticocarotid recess. An average 7.2-mm length of the supraclinoid ICA could be safely clipped for distal control. Assessments showed that small superiorly or medially projecting aneurysms were favorable candidates for clipping via EEA. When used for paraclinoid aneurysms, the EEA carries certain risks to adjacent neurovascular structures during proximal control, dural opening, and distal control. While some authors have promoted this approach as feasible, this work demonstrates that it has significant limitations and may only be appropriate in highly selected cases that are not amenable to coiling or clipping. Further clinical experience with this approach helps to delineate its risks and benefits.

Surgical treatment of a patient with stent restenosis in the mouth of the general carotid artery and the proximal department of the internal carotid artery

The results of surgical intervention on a patient with stent restenosis at the mouth of the common carotid artery (CCA) and proximal internal carotid artery (ICA) are presented herein. In 2013, the patient underwent stenting of the CCA and ICA. One month later, the aortic valve was replaced with a mechanical prosthesis MedEng-23 (MedEng, Penza, Russia) and mammarocoronary anastomosis with an envelope artery was performed under extracorporeal circulation. After the intervention, the patient regularly received 3.75 mg of warfarin, and was under the observation of a cardiologist. In 2018, the patient suffered a transient ischaemic attack. Subsequent examination of the patient revealed sub-occlusion of the left subclavian artery and signs of vertebral–subclavian steal syndrome on the left, and confirmed patency of the mammarocoronary shunt in envelope artery. The patient underwent carotid–subclavian shunting using the BASEX (A.N. Bakulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia) (8-mm prosthesis. Nine months after the patient underwent carotid–subclavian shunting, 85% restenosis was observed in the stent of the left ICA using control multi-spiral computed tomography with angiography (MSCT AG). The patient also exhibited up to 94% restenosis of the stent of the left ICA, occlusion of the right ICA, and up to 81% stenosis of the proximal anastomosis of the carotid–subclavian shunt. The patient underwent surgery for the removal of the following: the stent from the ICA with endarterectomy from the CCA, ICA with arterial plastic patches from the xenopericardium and prosthesis on the left (8-mm Vascutek prosthesis, Vascutek Ltd., UK). The brain was protected by raising the patient’s systemic blood pressure to 180/90 mm Hg. During the postoperative period, MSCT AG was performed to image the ICA. The MSCT AG images indicated that the prosthesis was passable. Presently, no clear standards exist for achieving revascularisation in this category of patients. The present clinical case emphasised the requirement for the detailed observation of patients after reconstructive interventions in different arteries as well as the possibility of surgically correcting the revealed lesions.Received 13 August 2019. Revised 8 November 2019. Accepted 9 November 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsDrafting the article: A.N. KazantsevLiterature review: R.Yu. LiderIllustrations: A.R. Shabayev, A.N. VolkovCritical revision of the article: N.N. Burkov, A.I. AnufriyevPreoperative patient preparation: A.R. Shabayev, E.V. RubanPostoperative care: A.N. VolkovNeurological examination: E.V. RubanFinal approval of the version to be published: A.N. Kazantsev, N.N. Burkov, A.R. Shabayev, A.N. Volkov, E.V. Ruban, R.Yu. Lider, A.I. Anufriyev

Persistent Trigeminal Artery: Neuroanatomic and Clinical Relevance

Persistent trigeminal artery (PTA) is the most common remnant of primitive circulation communicating the developing carotid and vertebrobasilar junction. Although discovered incidentally, an altered hemodynamic may lead to an increased association of aneurysms, vascular malformations, and stroke. Neurosurgeons should be aware of the presence and significance of PTA when interpreting imaging and planning interventions. We retrospectively reviewed all magnetic resonance angiography and cerebral digital subtraction angiography performed between 2012 and 2017 for the presence of PTA. The radiologic and anatomic details were noted and analyzed along with the clinical profiles. We categorized the radiologic findings with respect to the available classification systems. A review of the available literature was done comparing our results. We found 33 cases of incidentally detected PTA. The average age of the patients was 45.42 years. The lateral surface of the proximal cavernous internal carotid artery was the most common origin (n= 23). Only 3 cases had a medial/transsellar course. Most cases were Saltzman/Weon type I (19/33). Intracranial aneurysms were associated with 6 patients (18.18%). Trigeminal neuralgia (TN) was a presenting feature in 5 patients. None had a direct neurovascular conflict at the root entry zone. Our study is one of the largest to describe the incidence of PTA. We emphasized the importance of PTA to the neurosurgeons; increased association of aneurysms, as a route for intervention in occlusive disease of the posterior fossa; risk of injury and bleeding during transsphenoidal surgery; and the association with TN. However, we found that only PTA variants are likely to be associated with TN because of their cisternal course causing NV conflict.