Segment Of Carotid Artery Research Articles

Clinical Outcome of Intravenous Alteplase Treatment in Patients With Acute Mild Cerebral Infarction

ABSTRACTBackgroundThe efficacy of intravenous alteplase therapy for acute cerebral infarction is well established, regardless of the ischemic stroke subtype. However, its effectiveness in patients with mild cerebral infarction remains controversial, raising concerns about the significance of the treatment.AimTo retrospectively evaluate the efficacy of intravenous alteplase in patients with mild cerebral infarction and other factors affecting the outcome.MethodsA total of 527 patients received intravenous alteplase (0.6 mg/kg) at our hospital between October 2012 and March 2023. Of these, 118 patients with mild cerebral infarction (National Institutes of Health Stroke Scale [NIHSS] ≤ 5) who were treated with intravenous alteplase without mechanical thrombectomy were retrospectively evaluated for treatment efficacy and the factors affecting the efficacy.ResultsThe modified Rankin scale (mRS) outcome at 90 days was good (mRS: 0–1) in 85 (72%) patients and poor (mRS: 2–5) in 33 (28%) patients. Branch atheromatous disease (BAD) and proximal anterior circulation large vessel occlusion (proximal LVO: internal carotid artery and M1 segment of middle cerebral artery) were observed more frequently in the poor outcome group than in the good outcome group. Multivariate analysis, adjusted for age and sex, identified BAD and proximal LVO as factors associated with poor outcomes after intravenous alteplase treatment for mild cerebral infarction. Symptomatic intracranial hemorrhage was observed in one patient with BAD.ConclusionMost patients with mild cerebral infarction who were treated with intravenous alteplase alone had good outcomes. BAD and proximal LVO were other factors influencing poor outcomes.

Enhanced Vasoconstriction in Sickle Cell Disease is Dependent on ETA Receptor Activation.

Sickle Cell Disease (SCD) carries a significant risk for poor vascular health and vascular dysfunction. High levels of vascular reactive oxygen species (ROS) as well as elevated plasma endothelin-1 (ET-1), a potent vasoconstrictor with actions via the ETA receptor, are both common phenotypes in SCD. Alpha-1 adrenergic receptor activation is a major mediator of stress-induced vasoconstriction. However, the mechanism of the SCD enhanced vasoconstrictive response is unknown. We hypothesized that SCD induces enhanced alpha-1 adrenergic mediated vasoconstriction through the ET-1/ETA receptor pathway in arterial tissues. Utilizing humanized SCD (HbSS) and genetic control (HbAA) mice, alpha-1a, but not alpha-1b or alpha-1d, receptor expression was significantly greater in aortic tissue from HbSS mice compared to HbAA mice. Significantly enhanced vasoconstriction in aortic and carotid arterial segments were observed from HbSS mice compared to HbAA mice. Treatment with ambrisentan, a selective ETA receptor antagonist, and a ROS scavenger normalized the aortic vasoconstrictive response in HbSS mice. In a randomized translational study, patients with SCD were treated with placebo or ambrisentan for 3 months, with the treatment group showing an increase in the percent brachial arterial diameter. Taken together, these data suggest that the ETA receptor pathway interaction with the adrenergic receptor pathway contributes to enhanced aortic vasoconstriction in SCD. Findings indicate the potential of ETA antagonism as a therapeutic avenue for improving vascular health in SCD.

Modified salpingopharyngeus myomucosal flap: a novel technique for skull base reconstruction.

Advancements in endoscopic skull base surgery have enabled complex tumor resections, necessitating a variety of reliable reconstructive techniques to repair resultant defects. Vascularized flaps represent optimal options, but frequently used local pedicled intranasal flaps may be unavailable due to tumor invasion or prior surgery. This study applies a modification to the previously described salpingopharyngeus myomucosal flap (Dicle flap) with potential for its use in extensive endoscopic skull base surgery defect's repair. Cadaveric dissections (n = 5) were performed utilizing endoscopic visualization to access the skull base via endonasal and transoral routes. A superiorly based posterior pharyngeal myomucosal flap along the salpingopharyngeus muscle was elevated off the superior pharyngeal constrictors, preserving their vascular pedicles. This combined flap could be 180 degrees transposed to reconstruct clival defects up to the sella turcica. The modified salpingopharyngeus myomucosal flap (Modified Dicle flap) provided approximately 40 cm2 of robust vascularized tissue based on the ascending pharyngeal artery and random posterior pharyngeal vessels. It was sufficiently mobilized to cover extensive skull base defects in the craniocervical junction, sella turcica, and protecting the exposed internal carotid artery segments. The modified Dicle flap offers a viable reconstructive option for extensive endoscopic endonasal skull base defects when commonly utilized vascularized flaps are unavailable. Further research on clinical cases is warranted to investigate postoperative function and refine techniques to minimize donor site morbidity. Not applicable.

Electroencephalographic monitoring in detection and prediction of delayed cerebral ischemia due to non-traumatic subarachnoid hemorrhage

Intensive care of patients with acute non-traumatic subarachnoid hemorrhage primarily relies on diagnostics of delayed cerebral ischemia (DCI). The major difficulty in detecting DCI emerges upon suppression of wakefulness, when clinical assessment of growing neurological deficit becomes complicated. Widely used transcranial dopplerography allows solely to verify a vasospasm development not always leading to DCI exhibiting a multifactorial underlying mechanism. Electroencephalography (EEG) is the only broadly available instrumental tool ensuring a continuous monitoring of cerebral functional status including in subjects at intensive care unit. To date, non-specific EEG parameters pointing at development of acute cerebral injury were identified that provide varying diagnostic and predictive informative value in DCI. We reviewed publications aimed at assessing the data on visual and quantitative EEG parameters such as regional slowing, alpha rhythm spectral power and relative variability, alpha-to-delta power ratio, and detection of epileptiform activity. Having searched international and Russia-wide medical databases, we found only 7 publications quantitatively assessing diagnostic value of EEG monitoring, which showed that for DCI diagnosis its sensitivity ranged from 76% to 100%, and specificity – from 54% to 100%. We also present a clinical case with a 70-year-old female patient who underwent surgery for non-traumatic subarachnoid hemorrhage due to a ruptured aneurysm of the communicating segment of the right internal carotid artery. During the continuous videoEEG monitoring 2 days before clinical deterioration and appearance of ischemic changes in the right cerebral hemisphere on computed tomography scans, an ictal-interictal continuum pattern was noted to emerge. Future studies should be aimed at clarifying and validating the most informative DCI biomarkers including while recording EEG with intracranial electrodes that may contribute to development of automated algorithms for DCI detection.

Treatment of Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage Using the Compliant Manually Adjustable Mesh Comaneci.

Background and purpose: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Compliant and noncompliant balloons and manually adjustable mesh may be used in this indication. We describe our initial experience with the Comaneci (Rapid Medical, Yokneam, Israel) in cerebral vasospasm treatment following aSAH. Methods: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Comaneci device for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details, and outcomes were obtained from electronic medical records. Results: Between February 2022 and June 2023, seven consecutive patients underwent CV treatment with the Comaneci. Angioplasty of 37 arterial segments (supraclinoid internal carotid artery, A1, A2, and A3 segments of the anterior cerebral artery and M1 and M2 segments of the middle cerebral artery) was attempted, and 35/37 (95%) were performed. The vessel diameter improved significantly following angioplasty (+64%), while brain hypoperfusion decreased (-45% of the mean T Max). There was no long-term clinical complication, and 6% per-procedural complications occurred. Conclusions: The Comaneci is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device in the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Extracranial internal carotid artery aneurysm: Surgical approach to a rare entity.

Extracranial internal carotid artery aneurysms are rare entities that arise within the carotid triangle. Although rare, they are clinically significant due to the risk of neurologic thromboembolic events, compression of cranial nerves and vasculature, rupture, and ischemia. Surgery is the gold-standard treatment for symptomatic patients of all ages with extracranial internal carotid artery aneurysm. A 26-year-old female patient was admitted to our institution with complaints of left auricular pain, hoarseness, and uncontrollable hypertension. She had a pulsatile mass located at the left cervical region. After diagnosing the extracranial internal carotid artery aneurysm, it was decided that surgery was necessary to relieve the patient's discomfort and prevent possible complications from the aneurysm in the left carotid artery. In the operation, the aneurysmatic segment was resected and sent for histopathological evaluation. Saphenous vein graft was interposed as end to end anastomosis to the proximal and distal healthy segments of the internal carotid artery. This case report highlights the surgical management of a 26-year-old female patient who presented to our institution with complaints of left auricular pain, hoarseness, uncontrolled hypertension, and a pulsatile mass localized at the left cervical region and diagnosed extracranial internal carotid artery aneurysm.

FreeClimb 88 catheter with Tenzing 8 delivery for contact aspiration mechanical thrombectomy of anterior circulation large vessel occlusions.

Contact aspiration mechanical thrombectomy (CAMT) with 0.088-inch catheters may improve first-pass success rates, but delivery of such catheters can be challenging and limit effectiveness. This study examines the initial multicenter experience using the FreeClimb 88 catheter paired with the Tenzing 8 delivery catheter. Retrospective analysis was performed of consecutive patients with large vessel occlusion (LVO) of the internal carotid artery (ICA) or M1 segment of the middle cerebral artery treated with off-label CAMT using the FreeClimb 88 and Tenzing 8 at eight sites participating in the early limited release for these devices. Demographic and procedural variables were collected and analyzed with descriptive statistics and multivariable analysis. Fifty-three consecutive patients were treated. Large vessel occlusion was located in the ICA in 19/53 (35.8%) patients; 34/53 (64.2%) were in the M1 segment. FreeClimb 88 was successfully delivered to the site of occlusion in 50/53 (94.3%) of patients. First-pass TICI 2c or 3 was achieved with FreeClimb 88 delivered by Tenzing 8 in 36 (67.9%) cases. Among cases with successful FreeClimb 88 delivery 9/50 (18.0%) required additional smaller devices to perform thrombectomy of distal occlusions after recanalization of the initial LVO. No complications or symptomatic hemorrhages occurred following thrombectomy. Contact aspiration mechanical thrombectomy performed for ICA or M1 LVOs using FreeClimb 88 delivered with Tenzing 8 was safe, effective, and efficient in this early experience, with first-pass TICI 2c or 3 was achieved in 68% of patients without procedural complications occurring in any cases.

Improved technical outcomes with converting thrombectomy techniques after failed first pass recanalization

BackgroundA higher number of recanalization attempts reduces the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke secondary to large vessel occlusion (LVO). We assessed the impact of switching EVT...

Unruptured intracranial aneurysms in pediatric sickle cell disease: clinical and MR imaging follow-up of 296 patients.

Currently available data regarding unruptured intracranial aneurysms (UIAs) in sickle cell disease (SCD) are largely based on adult patients; this has made it challenging to reach a consensus on treatment decisions and follow-up strategies for pediatric SCD patients with UIAs. A retrospective review of 296 SCD patients (aged 18 years or younger) who underwent MRA from January 2008 to September 2022 was performed. The vessel of origin and characteristics of the UIAs, including maximum diameter, laterality, and number, were evaluated. Demographic data, as well as history of vaso-occlusive crisis and moyamoya syndrome, were recorded. Interval change in size or morphology, as well as a new aneurysm development, were reviewed on follow-up MRA. Forty-nine aneurysms were identified in 32/296 (10.81%) patients, and they all had saccular morphology. In total, 30/49 (61.22%) aneurysms were in the anterior circulation. The ophthalmic segment of the internal carotid artery and the posterior cerebral artery were the most common locations (n = 12 [24.49%] each). Multiple aneurysms were seen in 11/32 patients (34.37%). Most of the African American patients had multiple aneurysms (n = 25/28 [89.3%]). Most aneurysms (n = 43 [87.75%]) were 3 mm or less in diameter. No significant difference in aneurysm size was noticed between aneurysms located in anterior or posterior circulation (p = 0.22). Similarly, age, sex, ethnicity, genotype, or aneurysm multiplicity were not associated with size. Follow-up MRA was available for 24/32 patients (75%). All except 2 aneurysms (n = 2/38 [5.3%]) were stable in size and morphology on follow-up. Interval progression in aneurysm size was noticed in 2 patients with multiple intracranial aneurysms (n = 2/11 [18.2%]). In pediatric SCD patients, the incidence of UIAs was higher than previously reported. Those aneurysms demonstrated a tendency for multiplicity, an atypical anatomical distribution compared with that of adult brain aneurysms, bilateral involvement, and higher prevalence in African Americans. Although most of the aneurysms were stable, some showed interval growth in size.

Importance of an unclear fascial layer, stylopharyngeal fascia: an anatomical study

Objectives: The stylopharyngeal fascia is an important anatomical structure; however, its exact location and relationship with other neighboring structures have not been clearly demonstrated. Therefore, our aim was to reveal the stylopharyngeal fascia to demonstrate its course and neurovascular relationship in the parapharyngeal space. Methods: Ten fresh frozen cadaveric necks were dissected through a transparotideal and transcervical approach extending to the parapharyngeal region. All the neurovascular structures and muscles were preserved to demonstrate the stylopharyngeal fascia. Results: The stylopharyngeal fascia was mostly found on the lateral aspect of the internal carotid artery and could be found by advancing into the plane between the posterior belly of the digastric and stylohyoid muscles at the parapharyngeal space borders. The stylopharyngeal fascia covered not only the parapharyngeal segment of the internal carotid artery but also the cranial nerves X–XII at the parapharyngeal space. The cranial nerve IX coursed laterally to this fascial structure, posterior to the stylopharyngeus muscle in the parapharyngeal space. Conclusion: Although the stylopharyngeal fascia was previously shown to be related to other neurovascular structures, its anatomical course and histology remain unclear. Moreover, the stylopharyngeal fascia was defined using different nomenclatures in different studies. In this study, the stylopharyngeal fascia was shown to be an important anatomical landmark for dissection at the border of the parapharyngeal space. Further studies investigating its histological structure and defining its proper nomenclature are required. Therefore, we propose the term “parapharyngeal fascia”.

Surgical treatment of one traumatic carotid artery dissection: A case report and review of the literature.

Dissection of the cervical arteries is the most commonly identified cause of stroke in young patients. This report helps to investigate the etiology, diagnosis, and treatment of cervical artery dissection (CAD). A 40-year-old female presented with a 3-week history of right carotid artery dissection due to a fall. The patient was admitted to the local hospital 3 weeks ago with a right neck impingement after a fall, and presented with right neck pain. The local hospital CT scan showed a dissection of the middle segment of the right common carotid artery. The patient clinical manifestations and imaging tests confirmed that right carotid artery dissection. Medical treatment with antiplatelet failed, and the CT scan showed progression of dissection. Carotid endarterectomy (CEA) was performed, and the prognosis is good. This patient was followed up at 1 and 6 months after the operation, CT scan showed the original stenotic vessels returned to standard diameter. Diagnosis of CAD mainly depends on clinical manifestations and imaging. we recommend that clinicians can prescribe either anticoagulants or antiplatelet therapy. CAD can be effectively treated by surgical reconstruction, if medical treatment with anticoagulation or antiplatelet fails or if carotid aneurysms and/or high-grade carotid stenosis persisted or have newly developed.

Anatomical Comparison of Endoscopic and Microscopic Exposure of the Petroclinal Core Area Through the Extended Middle Skull Base Approach.

To compare the range of endoscopic and microscopic exposure of the petroclival core area through the middle skull base and to observe the corresponding anatomical structures. Ten intact adult cadaveric head specimens fixed with formaldehyde were craniotomized through an expanded middle skull base epidural approach on 20 sides. The distance from the greater superficial petrosal nerve to the petrous ridge was measured. When different degrees (1-3 degrees) of the Kawase triangle bone were removed, the exposed anatomical structure was observed, and the exposed core area of the rock slope was measured under an endoscope and microscope. The average distance from the greater superficial petrosal nerve to the petrous ridge was 14.26mm. During 1 to 2 degrees of bone removal, the petrous segment of the internal carotid artery (ICA) was not exposed, whereas during 3 degrees of bone removal, the petrous segment of the ICA was exposed. At 1 degree of bone removal, 400.62 ± 15.73mm2 of the area was exposed by endoscopy and 170.87 ± 8.93mm2 by microscopy, and the abducens nerve was not exposed. However, there was a significant difference between the two areas (P < 0.001). During 2 degrees of bone removal, 689.30 ± 32.06mm2 of the abducens nerve was exposed by endoscopy, but 366.84 ± 30.30mm2 of the abducens nerve could not be exposed by microscopy; moreover, there was a significant difference in the area of exposure between the two (P < 0.001). At 3 degrees of bone removal, the endoscopic exposure area was 875.92 ± 31.87mm2, the microscopic exposure area was 699.26 ± 48.00mm2, and the abducens nerves were exposed. There were significant differences between the two areas (P < 0.001). However, the difference between the 2-degree endoscopic exposure area and the 3-degree microscopic exposure area was studied by using paired t tests, and there was no difference (P > 0.05). When the same degree of the Kawase triangle bone was removed, the extent of endoscopic exposure of the petroclival core area was significantly greater than the extent of microscopic exposure. At 2 degrees of bone removal, an endoscopic application can maximally expose the petroclival core area, thus reducing the probability of exposure damage to the ICA and abductor nerve.

A 2.5D Self-Training Strategy for Carotid Artery Segmentation in T1-Weighted Brain Magnetic Resonance Images.

Precise annotations for large medical image datasets can be time-consuming. Additionally, when dealing with volumetric regions of interest, it is typical to apply segmentation techniques on 2D slices, compromising important information for accurately segmenting 3D structures. This study presents a deep learning pipeline that simultaneously tackles both challenges. Firstly, to streamline the annotation process, we employ a semi-automatic segmentation approach using bounding boxes as masks, which is less time-consuming than pixel-level delineation. Subsequently, recursive self-training is utilized to enhance annotation quality. Finally, a 2.5D segmentation technique is adopted, wherein a slice of a volumetric image is segmented using a pseudo-RGB image. The pipeline was applied to segment the carotid artery tree in T1-weighted brain magnetic resonance images. Utilizing 42 volumetric non-contrast T1-weighted brain scans from four datasets, we delineated bounding boxes around the carotid arteries in the axial slices. Pseudo-RGB images were generated from these slices, and recursive segmentation was conducted using a Res-Unet-based neural network architecture. The model's performance was tested on a separate dataset, with ground truth annotations provided by a radiologist. After recursive training, we achieved an Intersection over Union (IoU) score of (0.68 ± 0.08) on the unseen dataset, demonstrating commendable qualitative results.

Carotid Stump Syndrome: Rare Cause of Recurrent Stroke Post-Ipsilateral Carotid Occlusion - A Case Report.

Carotid stump is blind remnant of occluded proximal segment of the internal carotid artery (ICA) that can become the potential source of embolism. Carotid stump syndrome is a potentially treatable cause of recurrent ischemic events in the carotid territory in the setting of occlusion of the ipsilateral ICA. It is thought to be caused by turbulent blood flow in the patent stump of the occluded ICA causing microemboli migrating in the brain through external carotid-ophthalmic anastomotic channels and retrograde flow. Here, we report a patient with known ipsilateral chronic ICA occlusion, who was on best medical management, presented on two separate occasions with recurrent embolic infarctions in ipsilateral carotid territory. She was diagnosed with carotid stump syndrome and treated through endovascular route with clinical and angiographic follow-up.

Supraclinoid aneurysm of the internal carotid artery presenting with monocular visual loss, mimicking retrobulbar neuritis

The majority of aneurysms involving the cerebral vasculature are silent and may be found incidentally on neuroimaging. Approximately 85% of cerebral aneurysms are located in the anterior parts of the circle of Willis, especially at bifurcation sites. Unruptured intracranial aneurysms are often asymptomatic unless they enlarge and cause compression on adjacent structures. Aneurysms arising from the anterior parts of the circle of Willis, including cavernous and supraclinoid segments of the internal carotid (IC) artery or from the anterior communicating artery can compress on the anterior visual pathways, causing visual dysfunction. We hereby report the case of a 49-year-old lady, who presented with progressive loss of vision in the right eye evolving over 2 weeks; she was suspected to have retrobulbar neuritis, and on evaluation was noted to have a right supraclinoid IC aneurysm, compressing the optic nerve.

Preliminary outcomes of endovascular treatment of moyamoya disease

PurposeThis study aimed to investigate the effectiveness and safety of endovascular revascularisation of intracranial artery occlusion and stenosis in moyamoya disease using stent angioplasty. Materials and methodsWe recruited 12 patients (8 women and 4 men) with occlusion and stenosis of intracranial arteries in the context of moyamoya disease who underwent endovascular stent angioplasty. Clinical data, baseline conditions, lesion location, treatment outcomes, periprocedural complications, and follow-up outcomes were analysed. ResultsThe occlusion was located at the M1 segment of the middle cerebral artery in 8 patients, at both the M1 and A2 segments in one patient, and at the C7 segment of the internal carotid artery in 3. Thirteen stents were deployed at the occlusion site, including the low-profile visualized intraluminal support (LVIS) device in 8 patients, an LVIS device and a Solitaire AB stent in one, and a Leo stent in 3, with a success rate of 100% and no intraprocedural complications. Plain CT imaging after stenting revealed leakage of contrast agent, which disappeared on the second day, resulting in no clinical symptoms or neurological sequelae. Follow-up angiography studies were performed in all patients for 6–12 months (mean, 8.8). Slight asymptomatic in-stent stenosis was observed in 2 patients (16.7%), and no neurological deficits were observed in the other patients. All preoperative ischaemic symptoms completely disappeared at follow-up. ConclusionStent angioplasty is a safe and effective treatment for occlusion and stenosis of intracranial arteries in moyamoya disease.

Placing the balloon-guide catheter in the high cervical segment of the internal carotid artery is associated with improved recanalization

BackgroundMechanical thrombectomy (MT) is part of the standard of care for stroke treatment, and improving its efficacy is one of the main objectives of clinical investigation. Of importance is placement...

Benign Natural Progression of Small Cavernous Carotid Aneurysms Suggests Limited Clinical Utility of Serial Longitudinal Follow-up.

Aneurysms in the cavernous segment of the internal carotid artery (ICA) often present in an indolent fashion with limited morbidity. However, their growth progression and possible rupture over time remains poorly defined, thereby limiting optimization of serial follow-up. Thus, we aim to describe the progression of cavernous ICA aneurysms over time, as well as the patient and aneurysm characteristics associated with possible growth and rupture status. We identified a consecutive cohort of 157 patients from 2007 to 2021 with cavernous ICA aneurysms. Patient demographic data, possible risk factors, presenting symptoms, radiographic features of aneurysms, size progression, rupture status, and concomitant noncavernous aneurysm rupture data were manually extracted. One hundred and fifty-seven patients (mean age at diagnosis 57.2 ± 15.6 years; 85.4% females) with 174 cavernous carotid aneurysms (CCAs) were followed for an average of 7.1 ± 4.8 years. 76.4% of aneurysms were identified incidentally, with predominantly ocular palsies as the presenting symptoms in remaining primary cases. Most aneurysms were small, and of the 168 aneurysms that were followed, 98.2% did not demonstrate appreciable growth. Of the aneurysms that grew, it took an average of 6.0 years to grow 1.6 ± 0.2 mm. Demographic data, hypertension, and smoking status were not associated with aneurysm growth. Most radiographic features also were not associated with growth, except long-axis diameter, which had an odds ratio of 1.4 (CI: 1.2, 1.8) on multivariable analysis. Presenting clinical symptoms were not associated with growth. No CCAs ruptured during follow-up. Cavernous ICA aneurysms in our series demonstrate no rupture and limited growth over years of clinical follow-up. No radiographic or patient risk factors were associated with growth except initial aneurysm size. Hence, small CCAs may not require close follow-up over time.

An anatomical road map of the parapharyngeal internal carotid artery in lateral and endoscopic ventral approaches

Objective:To describe the road map of the lateral and endoscopic ventral approaches for the pharyngeal segment of the internal carotid artery, propose a sub-segmentation scheme, systematically and comprehensively understand its anatomical details and relationships with the surrounding structures. Methods:Five fresh cadaveric head specimens（10 sides in total） were dissected through lateral and endoscopic ventral approaches to evaluate the anatomical details of the parapharyngeal internal carotid artery and its relationship with the surrounding structures. Results:From the bifurcation of the common carotid artery to the vertical part of the internal carotid artery, alongside the direction of blood flow, the parapharyngeal internal carotid artery passes through four distinct anatomical tissues. Based on this, the parapharyngeal internal carotid artery can be divided into four sub-segments: nerve, muscle, fascia and osseous sub-segments. The boundaries and important adjacent structures of each segment are described in detail. Conclusion:The anatomical road map of the parapharyngeal internal carotid artery and the sub-segmentation scheme serving as a practical guide to navigate modular endoscopic skull base surgery of the parapharyngeal space while reduce the risk of internal carotid artery injury.

Adult craniopharyngioma concomitant with unruptured intracranial aneurysms: incidence, risk factors, and treatment strategies.

Concomitant unruptured intracranial aneurysms (UIAs) in patients with craniopharyngioma (CP) pose a challenge for surgical management. This study presents the largest known single-institution case series to investigate the incidence of UIA in CP patients, with the aim of exploring the potential risk factors for the occurrence of UIA in CP patients and proposing treatment strategies. The authors retrospectively reviewed the records of 289 adult CP patients treated in their department between January 2020 and August 2022. Routine CT angiography (CTA) was performed preoperatively in all cases. Logistic regression analysis was used to identify the risk factors for the occurrence of aneurysms. Aneurysms with the following characteristics were considered to have a high risk of intraoperative rupture and required treatment before tumor resection: 1) preliminary assessment of a high inherent risk of rupture (risk of rupture in their natural progression); and 2) location close to the tumor, irregular shape, and/or growth toward the tumor, even if the preliminary assessment indicated a low inherent risk of rupture. Twenty-three of 289 CP patients (7.96%, 95% CI 5.36-11.6) were diagnosed with both CP and UIA (CP-UIA). Hypertension (OR 4.148, 95% CI 1.654-10.398; p = 0.002), estrogen deficiency (OR 3.097, 95% CI 1.241-7.731; p = 0.015), and suprasellar tumor (OR 4.316, 95% CI 1.596-11.67; p = 0.004) were independent risk factors for intracranial aneurysms (IAs) in CP patients. Among the 23 CP-UIA patients, 6 (26.1%) with a high risk of aneurysm rupture underwent endovascular treatment (EVT) before tumor resection. Seventeen (73.9%) patients with a low risk of rupture underwent tumor resection only. The incidence rate of IA in patients with CP was higher than that in the general population. Routine preoperative CTA is advised for adult CP patients. Patients with papillary CP exhibited a higher proportion of CP-UIAs. Older age, hypertension, estrogen deficiency, and suprasellar tumor were independent risk factors for the occurrence of IAs in CP patients. IAs in CP patients are predominantly located in the C6 and C7 segments of the internal carotid artery and are often suitable for EVT. When treating CP-UIAs, tumor-related symptoms, risk of aneurysm rupture, the spatial relationship between the tumor and IA, and the approach for tumor resection should be considered.