Right Internal Carotid Artery Research Articles

Giant cavernous aneurysms occluded by aneurysmal thrombosis, calcification, parent artery occlusion: A case report and review of literature

BACKGROUND Patients with giant intracranial aneurysms (GIAs) are at a high risk of rupture, morbidity, and mortality even after surgical or endovascular treatment. We described a case of a spontaneously occluded GIA secondary to gradual growth of the GIA, continuously progressed aneurysmal thrombosis, complete aneurysmal calcification and complete occlusion of the parent artery-the right internal carotid artery (RICA). CASE SUMMARY A 72-year-old female patient complained of sudden pain in her right eye upon admission to our hospital. She had been diagnosed with a GIA [30 mm (axial) × 38 mm (coronal) × 28 mm (sagittal)] containing an aneurysmal thrombus located in the cavernous sinus segment of RICA diagnosed by magnetic resonance imaging (MRI), enhanced MRI, and magnetic resonance angiography more than 14 years ago. Later, with slow growth of the cavernous carotid GIA, aneurysmal thrombosis progressed continuously, spontaneous occlusion of the RICA, complete aneurysmal calcification, and occlusion of the GIA occurred gradually. She had no history of subarachnoid hemorrhage but missed the chance for endovascular therapy at an early stage. As a result, she was left with severe permanent sequelae from the injuries to the right cranial nerves II, III, IV, V1/V2, and VI. CONCLUSION The risk of rupture of the cavernous carotid GIAs was relatively low and possibly further be reduced by the stasis flow and spontaneous occlusion of the parent artery internal carotid artery (ICA) induced by the mass effect of the cavernous carotid GIAs and the extremely rare aneurysmal calcification. However, nowadays, it is advisable to recommend early endovascular treatment for the cavernous carotid GIAs to prevent injuries to the surrounding intracranial nerves and occlusion of the ICA, mainly caused by the mass effect of the cavernous carotid GIAs.

Abstract 116: Reversal of Acute Ocular Ischemic Syndrome Following Rescue Carotid Revascularization: A Case Report

Introduction Ocular ischemic syndrome (OIS) is a rare, vision‐threatening condition resulting from severe carotid artery disease secondary to severe atherosclerosis or arteritis. Common clinical features include acute/subacute to gradual vision loss, ocular pain, amaurosis fugax, photophobia and diplopia. We are presenting a case of acute ocular ischemic syndrome secondary to acute re‐occlusion of the right internal carotid artery (RICA) post Carotid Endarterectomy (CEA), that reversed with carotid revascularization. Methods Case Summary: 59‐year‐old male with history of T2DM, hyperlipidemia, tobacco use presented to an outside hospital with complaints of dizziness, blurry vision, left upper extremity weakness and multiple falls with head trauma. Exam revealed left lower quadrantanopia, mild left arm weakness and left hemineglect. Computed Tomography (CT) Head showed scattered right middle cerebral artery (MCA) territory infarcts. CT Angiography (CTA) revealed ulcerated plaque with a small focus of thrombus intraluminally in the RICA. Subsequently, the patient was initiated on heparin infusion and underwent CEA. On postoperative day (POD) 2, the patient experienced severe stabbing right eye pain with reduced visual acuity and worsening of left arm weakness. Imaging revealed complete occlusion of the right common carotid artery (RCCA). Perfusion imaging did not reveal a core or a penumbra. Given acute loss of vision likely secondary to ocular ischemic syndrome, decision was taken to proceed with rescue stenting. Using a transfemoral approach, an 8‐French balloon guide catheter was advanced into the proximal RCCA. A primary suction thrombectomy was performed under proximal flow arrest. After achieving a complete recanalization in one pass, we started the patient on cangrelor 30 mcg/kg intravenous bolus followed by 4 mcg/kg/min infusion. Post bolus, we placed a tandem closed‐cell carotid stent measuring 8x36mm & 10x37mm. The patient reported immediate relief of ocular pain, vision and weakness following the procedure. He transitioned from cangrelor infusion to ticagrelor 90 mg twice daily and aspirin 81 mg daily. On post‐stenting day 7, the patient experienced acute onset headache, and imaging revealed re‐occlusion of the entire carotid artery sparing only the ophthalmic segment of the RICA which now filled retrograde via anterior communicating artery (AcoA) from the contralateral carotid artery. However, his visual acuity remained unchanged and reported no ocular pain. At one month follow‐up the patient remains symptom‐free. Results Discussion: Incidence of OIS is estimated to be 7.5 cases per million every year. Carotid artery atherosclerosis is the most common etiology. Majority of OIS (∼90%) present with gradual vision loss and approximately 40% present with ocular pain. Gradual vision loss is predominantly related to chronic ocular hypoperfusion and resultant iris neovascularization and glaucoma. In this case, patient suffered acute vision loss secondary to acute ICA occlusion following CEA. Emergent carotid revascularization resulted in restoration of vision and resolution of ocular pain. Conclusion Our main goal is to emphasize the importance of rescue stenting to address symptoms of aOIS. Immediately post‐stenting, there was remarkable improvement in ocular pain and visual acuity. Although, the carotid re‐occluded within seven days post‐stenting, we hypothesize that gradual re‐occlusion while on DAPT provided enough time recruit and preserve collaterals into the right ophthalmic artery via retrograde flow into the ophthalmic segment of RICA from the contralateral carotid artery via the AcoA which was subsequently confirmed on imaging.

QUALITY OF LIFE OF A PATIENT WITH PERSISTENT COMPLICATIONS AFTER SARS-COV-2 INFECTION REQUIRING URGENT SURGICAL INTERVENTION – ENDARTERECTOMY WITH EMERGENCY ANGIOPLASTY OF AN INFLAMED, BLEEDING RIGHT INTERNAL CAROTIDARTERY (RICA) USING THE TRANS-CAROTID ARTERY REVASCULARIZATION(TCAR)

SUMMARY The purpose of this study was to determine the quality of life of a patient with persistent complications of SARS-CoV-2 infection requiring urgens surgical intervention – endarterectomy with emergency angioplasty of an inflamed, bleeding Right Internal Carotid Artery (RICA) by direct access via Right Common Carotid Artery (RCCA), known as Transcarotid Artery Revascularization (TCAR).A patient in her 60s was infected with the SARS-CoV-2 virus and contracted COVID-19 in March 2022, as confirmed by RT PCR antigen test. The infection was followed by short- and long-term complications, many of which can be linked to COVID. These include significant weakness persisting for months after the illness, rapid weight loss of 25 kg, sleep disturbances, chronic fatigue, severe dizziness, onset of diabetes, decrease dimmunity with increased periodontal inflammation (including formation of a periapical abscess of a molar tooth) and secondary suppuration of the submandibular lymphnodes, one of which lying jacent to the right internal carotidartery (RICA). This accumulation of symptoms led the patient to seek medical and neuropsychological help. Test ingusing the Beck Depression Inventory (BDI) confirmed depression, with vegetative disorders being the most predominant. Eight months after undergoing COVID-19, the patient suffered a Transient Ischemic Attack (TIA). The accumulation of diseases (diabetes mellitus, stage III hypertension and TIA) had a dramatic impact on the patient's health, including life-threatening conditions.A vascular surgeon consulted the patient advised immediate surgical treatment: carotid endarterectomy. The urgency of the situation was exacerbated by bleeding during the operation from the operated, secondarily inflamed wall of the RICA (lying adjacent to the suppurated submandibular node).This prompted an emergency decision for an endovascular procedure: the implantation of a stent covered with water-proof material (peripheral stent graft). This was made by a direct access via puncture of the common carotid artery (RCCA) below the endarterectomy level (TCAR).The SF-36 questionnaire was chosen to measure health-related quality of life (HRQOL).The SF-36 results are presented in such a way that higher scores correspond to fewer complaints, indicating better health and higher quality of life. Before revascularization, the patient's HRQOL was found to be lower, which was related to the negative impact of long COVID, while after the procedure, the quality of life gradually improved in subsequent surveys. A significant difference was found in physical function, with a mean score of 66.0 (p<0.001) compared to a score of 94.9 (9.4) for 100 age-matched health subjects. A similar result was found in the physical role (p < 0.001). The patient's overall quality of life score was 331.0 compared to a score of 578.0 (111.9) for age-matched normal healthy people.Better quality of life in patients with long COVID is an important therapeutic goal that can be achieved through comprehensive, multispecialty treatment for both physical and psychological conditions.

When Carotid Artery Stenosis Cause Posterior Fossa Infarct. An Unusual Case of Persistent Hypoglossal Artery.

The primitive anastomosis between the carotid artery and the vertebrobasilar arteries usually regress, in rare cases they persist beyond fetal development and form vascular anomalies such as primitive persistent hypoglossal artery(PPHA), with prevalence of 0.02-0.1% in the general population. A 77-year-old female presented with aphasia, weakness of both legs and arms. Computed Tomography Angiography (CTA) revealed subacute infarct in right pones, severe stenosis of the right internal carotid artery(RICA) and ipsilateral PPHA. We performed Right carotid artery stenting (CAS) using a distal filter into the PPHA to protect the posterior circulation, with good result. The posterior circulation was utterly dependent on the RICA, therefore, despite the general notion that carotid stenosis is usually associated with anterior circulation infarcts, in cases having vascular anomalies it may cause a posterior stroke. Carotid artery stenting offer a safe and simple solution, however the use of EPD requires special considerations regarding decision on the suitable protection technique and placement. Neurological symptoms in the presence of carotid artery stenosis and PPHA can manifest as ischemia of the anterior and/or the posterior circulation. In our opinion, CAS gives a simple and safe treatment solution.

Abstract Number ‐ 71: Management of Delayed Carotid Stent Fracture with an Overlapping Open Cell Design Stent: Case Report

Introduction Stent fracture after carotid angioplasty and stenting is rare. Risk factors include presence of angulation, calcification, and restenosis increasing the risk of stent fracture. Although literature indicates that not all carotid stent fractures are associated with adverse outcomes, there is limited details on successful endovascular management of this entity. We describe a unique case of carotid stent fracture with symptomatic restenosis treated with an overlapping open cell stent with no residual stenosis and resolution of symptomology. Methods Case Report. Results A 79‐year‐old man with medical history of right sided symptomatic carotid artery stenosis which had been previously treated with endarterectomy and subsequently carotid stenting after a follow up carotid ultrasound demonstrated recurrence of severe right internal carotid artery (RICA) stenosis. Approximately 2 years after this index procedure, the patient returned with acute onset of left‐hand numbness. Cerebral angiography was performed that demonstrated 85% stenosis with a fractured carotid stent at segment of stenosis (Figure 1A, B). Furthermore, the lesion was found to be heavily calcified. This was determined to be the primary contributing factor in resultant artery wall stress, which over time led to carotid stent fracture. Angioplasty with placement of a new open cell stent and distal embolic protective device was performed successfully. The open cell stent was chosen for this approach as closed cell stents have been associated with an increased odds of in‐hospital stroke/death for carotid lesions, attributable to the lower degree of conformability with closed cell stents. After our stent placement, there was no significant residual stenosis visualized (Figure 1C, D). The patient’s symptoms resolved without any subsequent complaints on follow‐up visit. Conclusions While carotid stent fractures are a rare occurrence, we report a case of symptomatic carotid artery restenosis with a fractured stent due to significant lesion calcification and wall stress. This case was successfully treated with angioplasty and new open cell stent placement due to its potential advantages over closed cell stents in carotid artery lesions. Current literature indicates that carotid stent fractures have a low prevalence. However, there is a paucity of studies on the mechanism of stent fracture as well as optimal management of these fractured stents, suggesting a need for further study and characterization.

Evaluation of Extra-Cranial Carotid Arteries by Digital Subtraction Angiogram (DSA) in Stroke Patients in a Tertiary Care Hospital

Introduction: Carotid artery stenosis is one of the important causes of ischemic stroke. This may be diagnosed by Doppler Ultrasound and Digital Subtraction Angiogram (DSA) both of which have some advantages and disadvantages. Objective: The aim of this study was to assess extra-cranial carotid artery with the help of DSA among patients of ischemic stroke and transient ischemic attack (TIA). Materials and Methods: This observational cross sectional study was conducted in the Department of Neurology in Bangabandhu Sheikh Mujib Medical University (BSMMU) Dhaka from July 2013 to June 2015 for a period of two years. This study included a total of 50 patients. Diagnostic performance test of DSA was done at 50%, 50-69%, 70-99%, 100% cut off point of stenosis of right internal carotid artery (RICA) and Left internal carotid artery (LICA). Results: The mean age of cases was 61 ± 11.42 years. Out of 50 vessels, maximum cases were diagnosed as <50% stenosis of carotid artery (26 cases of RICA, 23 cases of LICA. Out of 50 vessels, 50%-69%, 70 but _ less than near occlusion and total occlusion were found among 10, 10, 4 vessels in RICA and 10, 9, 8 vessels in LICA respectively. The present study showed that 50 vessels of RICA was measured by DSA and diagnosed 28 (56%), 10 (20%), 7 (14%) and 5 (10%) carotid vessels as _ 50%, 50-69%, _70% but less than total occluded and total occluded cases respectively. This study also showed that 50 vessels of LICA was measured by DSA and diagnosed 23 (56%), 12 (24%), 8 (16%), 7 (14%) carotid vessels as _ 50%, 50-69%, _ 70% but less than total occluded and total occluded cases respectively. Conclusion: DSA as the gold standard has amply been performed in most diagnostic circumstances of carotid artery stenosis. So, the present study was done to evaluate extra cranial carotid arterial system by DSA in stroke patients in Bangladesh. Medicine Today 2022 Vol.34(2): 121-124

Cerebral infarction and risk factors in acute type A aortic dissection with arch branch extension.

Stanford type A aortic dissection (AAD) may affect the supra-aortic arteries, which are associated with acute ischemic stroke (AIS) or transient ischemic attack (TIA). This study aimed to investigate cerebral perfusion, the infarction incidence and risk factors in AAD patients. A total of 156 consecutive AAD patients were enrolled and divided into two groups according to whether the aortic arch branches were involved: the affected group (n = 90) and the unaffected group (n = 66). Clinical, echocardiographic/carotid Doppler data and cerebral infarction morbidity were compared between the groups. Independent predictors of 30-day AAD mortality were identified through multivariable Cox regression, and perioperative risk factors were analyzed. In total, 57.7% of AAD patients had aortic arch branch involvement. Abnormal Doppler waveforms were more common in the affected group (p <0.05). Regarding intracranial perfusion, the blood flow volumes (BFVs) of the bilateral internal carotid arteries (ICAs) and right vertebral artery (RVA) in the affected group were significantly reduced (p <0.05). The incidence of cerebral infarction in the affected group was significantly higher than that in the unaffected group (35.6% vs. 19.7%, p = 0.031). Multivariable analysis revealed that age >45 years old, right internal carotid artery (RICA) involvement and reduced left ventricular ejection fraction (LVEF) were significant predictors of perioperative death. Aortic arch branch involvement is common in patients with AAD and is associated with reduced cerebral blood flow (especially on the right side) and a higher incidence of cerebral infarction. Age, extension of the RICA dissection and LVEF impairment are independent risk factors for AAD-related death.

Carotid artery diameter assessment in men and women and the relation to age, sex and body mass index using ultrasonography

Background: Carotid artery dimensions are increasingly used for detecting early atherosclerosis and predicting clinical complications. Aim was to explore relationships between gender, age and body mass index (BMI) and the diameters of the common carotid artery (CCA) and internal carotid artery (ICA) using ultrasonography.Methods: This was a cross-sectional study carried out at the University of Maiduguri Teaching Hospital between February-October, 2011. The 400 adult males and females above 18 years underwent carotid artery ultrasonography for measurement of the IMT of the common and internal carotid arteries. The influence of age, sex, weight, height, and the basal metabolic index (BMI) was investigated.Results: There were 239 (59.80%) males and 161 (40.20%) females aged between 18 to 81 years (Mean±SD, 36.74±14.79 years). The mean±SD diameters for right common carotid artery (RCCA) and left common carotid artery (LCCA) were 6.39±0.71mm and 6.28±0.74mm respectively. The right internal carotid artery (RICA) and left internal carotid artery (LICA) had mean±SD diameters of 4.63±0.63 mm and 4.61±0.63 mm respectively. The luminal diameters of the carotid arteries increased significantly with age and increased BMI. The luminal diameters of the CCA and ICA were significantly smaller in women than in men.Conclusions: Common carotid and internal carotid artery luminal diameter tends to be larger in men than women among adults and increases with age and BMI. There is no difference in the luminal diameter between the left and right carotid artery.

The role of the circle of Willis in internal carotid artery stenosis and anatomical variations: a computational study based on a patient-specific three-dimensional model.

BackgroundThe aim of this study is to provide better insights into the cerebral perfusion patterns and collateral mechanism of the circle of Willis (CoW) under anatomical and pathological variations.MethodsIn the current study, a patient-specific three-dimensional computational model of the CoW was reconstructed based on the computed tomography (CT) images. The Carreau model was applied to simulate the non-Newtonian property of blood. Flow distributions in five common anatomical variations coexisting with different degrees of stenosis in the right internal carotid artery (RICA) were investigated to obtain detailed flow information.ResultsWith the development of stenosis in unilateral internal carotid artery (ICA), the cerebral blood supply decreased when the degree of stenosis increased. The blood supply of the ipsilateral middle cerebral artery (MCA) was most affected by the stenosis of ICA. The anterior communicating artery (ACoA) and ipsilateral posterior communicating artery (PCoA) functioned as the important collateral circulation channels when unilateral stenosis occurred. The blood flow of the anterior circulation and the total cerebral blood flow (CBF) reached to the minimum in the configuration of the contralateral proximal anterior cerebral artery (A1) absence coexisting with unilateral ICA stenosis.ConclusionsCommunicating arteries provided important collateral channels in the complete CoW when stenosis in unilateral ICA occurred. The cross-flow in the ACoA is a sensitive indicator of the morphological change of the ICA. The collateral function of the PCoA on the affected side will not be fully activated until a severe stenosis occurred in unilateral ICA. The absence of unilateral A1 coexisting with the stenosis in the contralateral ICA could be the most dangerous configuration in terms of the total cerebral blood supply. The findings of this study would enhance the understanding of the collateral mechanism of the CoW under different anatomical variations.

Associations between Carotid Artery Plaque Score, Carotid Hemodynamics and Coronary Heart Disease.

Background: The carotid artery plaque score (PS) is an independent predictor of Coronary Heart Disease (CHD). This study aims to evaluate the combination of PS and carotid hemodynamics to predict CHD. Methods: A total of 476 patients who underwent carotid ultrasonography and coronary angiography were divided into two groups depending on the presence of CHD. PS, carotid intima-media thickness, and carotid blood flow were measured. Receiver operating characteristic curve analysis was performed to establish the best prediction model for CHD presence. Results: Age, sex, carotid intima-media thickness of internal carotid artery and carotid bifurcation, PS, peak systolic velocity (PSA) of right internal carotid artery (RICA), and most resistance index data were significantly related with the presence of CHD. The area under the curve for a collective model, which included factors of the PS, carotid hemodynamics and age, was significantly higher than the other model. Age, PS, and PSA of RICA were significant contributors for predicting CHD presence. Conclusions: The model of PS and PSA of RICA has greater predictive value for CHD than PS alone. Adding age to PS and PSA of RICA further improves predictive value over PS alone.

Velocity Measurement in Carotid Artery: Quantitative Comparison of Time-Resolved 3D Phase-Contrast MRI and Image-based Computational Fluid Dynamics.

Background:Understanding hemodynamic environment in vessels is important for realizing the mechanisms leading to vascular pathologies.Objectives:Three-dimensional velocity vector field in carotid bifurcation is visualized using TR 3D phase-contrast magnetic resonance imaging (TR 3D PC MRI) and computational fluid dynamics (CFD). This study aimed to present a qualitative and quantitative comparison of the velocity vector field obtained by each technique.Subjects and Methods:MR imaging was performed on a 30-year old male normal subject. TR 3D PC MRI was performed on a 3 T scanner to measure velocity in carotid bifurcation. 3D anatomical model for CFD was created using images obtained from time-of-flight MR angiography. Velocity vector field in carotid bifurcation was predicted using CFD and PC MRI techniques. A statistical analysis was performed to assess the agreement between the two methods.Results:Although the main flow patterns were the same for the both techniques, CFD showed a greater resolution in mapping the secondary and circulating flows. Overall root mean square (RMS) errors for all the corresponding data points in PC MRI and CFD were 14.27% in peak systole and 12.91% in end diastole relative to maximum velocity measured at each cardiac phase. Bland-Altman plots showed a very good agreement between the two techniques. However, this study was not aimed to validate any of methods, instead, the consistency was assessed to accentuate the similarities and differences between Time-resolved PC MRI and CFD.Conclusion:Both techniques provided quantitatively consistent results of in vivo velocity vector fields in right internal carotid artery (RCA). PC MRI represented a good estimation of main flow patterns inside the vasculature, which seems to be acceptable for clinical use. However, limitations of each technique should be considered while interpreting results.

Intraarterial thrombocytic material revelative of essential thrombocytaemia in a 59‐year‐old woman

PurposeAim: to present a case of accidentally detected thrombocitic material in retinal arteries that was revelative of essential thrombocytaemia.MethodsMaterial/methods: 59‐year‐old woman presented in July 2013 with a suspicion of intraocular tumour. The patient was asymptomatic. There was a white nodular mass in her left eye infernasally, highly reflective on ultrasound. Initial diagnosis of choroidal granuloma was made. 4 weeks later, on the next follow‐up visit, a massive thromobocytic material circulating freely in the retinal arteries and multiple yellowish lesions were detected in her both eyes. Visual acuity was not disturbed.ResultsThe patient was admitted to hospital with the suspicion of right heart failure. Apart from the high level of thromobocytes and D‐dimers no pathology was revealed. The patient was sent for further counselling and bone marrow biopsy which revealed no pathology. Few months later she was readmitted with a severe cerebral ischaemia, throbocytaemia and critical stenosis of right internal carotid artery (RICA) to 80%. Haematologic treatment was not effective and the patient died due to cerebral ischeamia in June 2014.ConclusionsThromobocytic material associated with essential thrombocytaemia might be visible in retinal vessels. This is a rare phenomenon and might be associated with a poor prognosis for the patient.

Velocity Measurement in Carotid Artery: Quantitative Comparison of Time-Resolved 3D Phase-Contrast MRI and Image-based Computational Fluid Dynamics

Background: Understanding hemodynamic environment in vessels is important for realizing the mechanisms leading to vascular pathologies. Objectives: Three-dimensional velocity vector field in carotid bifurcation is visualized using TR 3D phase-contrast magnetic resonance imaging (TR 3D PC MRI) and computational fluid dynamics (CFD). This study aimed to present a qualitative and quantitative comparison of the velocity vector field obtained by each technique. Subjects and Methods: MR imaging was performed on a 30-year old male normal subject. TR 3D PC MRI was performed on a 3 T scanner to measure velocity in carotid bifurcation. 3D anatomical model for CFD was created using images obtained from time-of-flight MR angiography. Velocity vector field in carotid bifurcation was predicted using CFD and PC MRI techniques. A statistical analysis was performed to assess the agreement between the two methods. Results: Although the main flow patterns were the same for the both techniques, CFD showed a greater resolution in mapping the secondary and circulating flows. Overall root mean square (RMS) errors for all the corresponding data points in PC MRI and CFD were 14.27% in peak systole and 12.91% in end diastole relative to maximum velocity measured at each cardiac phase. Bland-Altman plots showed a very good agreement between the two techniques. However, this study was not aimed to validate any of methods, instead, the consistency was assessed to accentuate the similarities and differences between Time-resolved PC MRI and CFD. Conclusion: Both techniques provided quantitatively consistent results of in vivo velocity vector fields in right internal carotid artery (RCA). PC MRI represented a good estimation of main flow patterns inside the vasculature, which seems to be acceptable for clinical use. However, limitations of each technique should be considered while interpreting results.

Letter to the Editor Fracture of a carotid stent and restenosis of common carotid artery

Letter to the Editor Fracture of a carotid stent and restenosis of common carotid artery

The cerebral vasomotor response in varying CO2 concentrations, as evaluated using cine phase contrast MRI: Flow, volume, and cerebrovascular resistance indices

Previous studies have identified that impaired cerebral vasomotor reactivity (VMR) is associated with a higher risk of stroke and transient ischemic attack. This study aims to evaluate VMR by measuring the blood flow waveforms of the supplying arteries and dural sinuses using cine phase contrast MRI (PC MRI) and hypercapnic challenge. PC MRI flow quantification was performed on an oblique slice approximately perpendicular to the target vessels to include the left (LICA) and right internal carotid artery (RICA), basilar artery (BA), sinus rectus (SR), and superior sagittal sinus (SSS). A total of four PC MRI scans were performed at different CO(2) concentrations (room air and 3%, 5%, and 7% CO(2)). The analyses obtained the flow parameters and cerebrovascular resistance parameters for all five vessels. Results indicated that the vascular resistance indices decreased with increasing CO(2) concentration in four vessels (LICA, RICA, BA, and SR). The obtained VMR parameters demonstrated exponential increases with increasing CO(2) concentration. Using entire blood flow waveforms, this study applied separate flow dynamics during systolic and diastolic periods to obtain cerebrovascular resistance parameters and extensive flow-related information. It is the first to investigate the cerebrovascular resistance parameters under hypercapnic challenge using cine MRI. This technique could provide a useful tool for clinical application in cerebrovascular disease.

E-027 Stent graft repair of carotid pseudoaneurysm in a young child with short-term follow-up

IntroductionTraumatic pseudoaneurysm of the carotid artery is a dangerous complication of penetrating trauma. Stent grafting is an accepted treatment; however the youngest reported patient so treated at the time was...

Dynamic Internal Carotid Artery Dissection Demonstrated by Carotid Duplex Ultrasound

Background Carotid artery dissection is an important cause of stroke in young adults. Because warning signs usually precede stroke, the timely diagnosis of carotid dissection can have a significant clinical impact. We present a case of spontaneous carotid artery dissection with dynamic findings on duplex ultrasound examination. Case Report A 47-year-old man presented with acute neurologic symptoms. Carotid duplex ultrasound demonstrated a high resistive waveform in the right internal carotid artery (RICA) with absent end-diastolic flow (peak-systolic velocity [PSV] = 49 cm/sec, end-diastolic velocity = 0 cm/sec), a narrowing of the lumen in the distal RICA with low velocity flow (PSV = 10 cm/sec), and eventual loss of flow. The right common carotid artery demonstrated a high resistive waveform. The use of magnetic resonance angiography confirmed the presence of distal RICA dissection. The patient was treated with antiplatelet therapy and had marked clinical improvement within 48 hours. A duplex ultrasound study performed 24 hours after the first study demonstrated dramatic restoration of the diastolic flow in the RICA (PSV = 97 cm/sec, EDV = 44 cm/sec) with normalization of the Doppler waveforms. Repeat magnetic resonance angiography demonstrated near complete resolution of the RICA dissection, correlating with the ultrasound findings. Conclusion Our case demonstrates the potentially dynamic nature of carotid artery dissection and the utility of duplex ultrasound as an invaluable tool in the early diagnosis and management of this disorder. In addition, the case demonstrates the importance of carotid Doppler waveform clues as indirect evidence of more distal cerebrovascular disease that warrants further investigation.

Risk of Cognitive Decline in Older Patients After Carotid Endarterectomy: An Observational Study

To determine whether patients undergoing carotid endarterectomy (CE) for symptomatic left internal carotid artery (LICA) stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right internal carotid artery (RICA) disease. Observational. Vascular surgery day hospital. The analysis included 103 patients (mean age 72.6+/-7.0, 73 men), of whom 50 had LICA disease (29 symptomatic). Cognitive function was evaluated (age- and education-adjusted Mini-Mental State Examination (MMSE), and Clock tests (CLOX1 and 2)) at baseline and at the end of the study period (average follow-up+/-standard deviation 44.4+/-14.3 months) in a sample of patients aged 65 and older, free from cognitive impairment, consecutively undergoing CE. At the end of the study period, MMSE, CLOX1, and CLOX2 scores were significantly lower in patients with symptomatic LICA disease (P<.001, P<.001, and P=.002, respectively) and not in the other groups of patients. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals according to MMSE score (F=5.18, P=.002) or CLOX1 and 2 scores (F=5.66, P=.001, and F=4.33, P=.006, respectively). Patients undergoing CE for symptomatic LICA disease appear to be at greater risk of cognitive decline than other subjects. These findings suggest that future studies should evaluate the effects on cognitive function of different timing for CE in patients with LICA and RICA disease.

Neurofibromatosis Resulting in Carotid Aneurysms with Subsequent Rupture: Presentation and Follow-up Management with Duplex Ultrasound

Background Neurofibromatosis (NF) is a common genetic disorder responsible for the development of neuroectodermal tumors throughout the body. Although vascular involvement with these growths is uncommon, arteriovenous malformations, aneurysms, stenosis, and occlusions have been reported. We report a case of a patient with NF who presented with a ruptured internal carotid artery aneurysm and then developed a common carotid pseudoaneurysm with subsequent hemorrhage during repair. The use of duplex ultrasound (DU) in the initial diagnosis and follow-up management of this patient will be discussed. Case Report A 31 year-old man with a history of NF presented to the emergency department with pharyngitis and right neck swelling. The initial DU revealed a 2.4-cm distal right internal carotid artery (RICA) aneurysm, which was treated with a covered stent. On the first postoperative day, a new wall irregularity in the right common carotid artery measuring 1.6 cm and a high resistant Doppler signal in the RICA suggesting distal occlusion were demonstrated by DU. A transcranial duplex supported the ICA occlusion by demonstrating cross filling from the left to the right through the anterior communicating artery. Because of increased neck swelling, DU was repeated on the third day. At the site of the previously noted CCA irregularity, a 3.4-cm pseudoaneurysm had developed. During attempted repair in the endovascular suite, the patient developed massive hemorrhage. To control bleeding, intravascular coils were used to occlude the right external carotid artery, RICA, and right common carotid artery. An intraoperative DU confirmed the successful occlusion of the carotid vessels. Conclusion DU provided an accurate initial and follow-up diagnosis of the carotid aneurysms in a patient with vascular complications from NF.

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