Severe Bilateral Carotid Stenosis Research Articles

Abstract 126: Bilateral Limb Shaking TIA secondary to Severe Bilateral Carotid Stenosis

Introduction A case describing bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA. Methods '‐ Results CASE A 71‐year‐old male patient with a past medical history significant for type 2 diabetes mellitus and bilateral carpal tunnel syndrome is being followed for symptomatic management of known axonal sensorimotor diabetic polyneuropathy in the neuromuscular clinic. He reported on one of his follow‐up visits that he had been experiencing an eight‐month history of presyncopal to syncopal events occurring solely in the standing position, not followed by postictal state but amnesia to the syncope itself, and resulting in falls with mild injuries. He was experiencing new‐onset dry eyes and mouth but denied anhidrosis or early satiety, and cardiac event monitoring during one of these events was unremarkable for rhythmic causes. Examination was unchanged from previously and was significant for findings consistent with length‐dependent sensory loss with hyporeflexia/areflexia. The constellation of symptoms was suggestive of autonomic dysfunction, and while this may be seen with diabetic polyneuropathy, workup for alternative autonomic neuropathies (including SSA/SSB antibodies, paraneoplastic antibody panel, serum protein electrophoresis with immunofixation, serum free light chains, transthyretin amyloid) was obtained with plan for follow‐up. A few months later, he presented to the ED with intermittent upper extremity shaking (more pronounced on the right than on the left) preceding the syncopal events, which only occurred in the standing position or during physical activity and resolved with rest. There were no (transient) focal neurological deficits, including monocular vision loss or hemispheric syndrome. CTA of the head/neck was obtained and was notable for severe to critical stenoses of the bilateral internal carotid arteries (see figure 1). Duplex US revealed 80‐99% stenosis of both right and left proximal internal carotid arteries. The constellation of findings was most suggestive of bilateral limb‐shaking TIA secondary to bilateral carotid stenosis. He was started on secondary stroke prevention and referred to vascular surgery for evaluation of revascularization. The patient underwent left carotid endarterectomy briefly afterward and experienced resolution of the events – he later also underwent carotid endarterectomy of the right side and remains asymptomatic. DISCUSSION: Limb‐shaking TIA is a well‐described yet underrecognized manifestation of severe carotid disease reported by C.M. Fisher in 1962. The “limb shaking” episodes are typically unilateral, affecting the arm or leg, and are often mistaken for seizures [1]. Pathogenesis involves hemodynamic impairment related to extracranial/intracranial carotid stenosis or occlusion resulting in stereotypical recurrent contralateral limb shaking episodes precipitated by physical activity [2], [3]. The constellation of “limb shaking” spells precipitated upon standing or physical activity with resolution after activity cessation should raise suspicion for limb‐shaking TIA and warrant vascular imaging. Treatment includes medical secondary stroke prevention and revascularization procedures [4], which can alleviate or even resolve the transient symptoms [2]. Conclusion Limb‐shaking TIA is an important yet underrecognized manifestation of relative cerebral hypoperfusion related to severe cerebrovascular disease. This case describes bilateral limb shaking episodes in a patient with severe bilateral carotid disease ‐ a rare manifestation of limb‐shaking TIA.

Titrated segmental epidural anesthesia for bilateral total knee replacement in a patient with severe aortic stenosis and severe bilateral carotid artery stenosis: a case report

BackgroundTotal knee replacement is a major orthopedic procedure for severe, painful, and mobility-limiting knee arthritis. Aortic valve stenosis is the most frequent valvular heart disease and the most commonly performed valvular procedure. Stenosis of the valve may lead to left ventricular hypertrophy, ventricular dysfunction, myocardial ischemia, and a state of fixed cardiac output. Changes in hemodynamic parameters such as hypotension and bradycardia in patients with carotid artery stenosis may lead to cerebrovascular accidents, especially during anesthesia.Case presentationA 76-year-old woman with a 6-year history of bilateral knee pain. The pain was dull, aching, and severe in intensity, and it prevented her from sleeping despite optimal analgesics. A general physical examination revealed an elderly, frail woman in mild respiratory distress. She had bilateral small-volume radial pulses, positive hepatojugular reflux, and heart sounds of S1, S2, and S4 with an ejection systolic murmur, and carotid bruits were heard bilaterally. Epidural anesthesia was done by injection of 2.5 mL of 0.5% plain bupivacaine in aliquots every 5 min until the level of the block reached the suprapubic region (titrated segmental epidural anesthesia). The patient was not preloaded with intravenous fluid prior to the establishment of epidural anesthesia, and the epidural anesthesia-induced hypotension that may ensue was managed with intraoperative dopamine infusion at 5 µg/kg/min.ConclusionsTitrated segmental epidural anesthesia with intraoperative infusion of low-dose dopamine reduces the perioperative risk of myocardial infarction, cerebrovascular accident, and neurocognitive deficit in a patient with severe aortic stenosis and severe bilateral carotid stenosis.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

SAFETY OF ADEQUATE PREDILATATION IN CAROTID ANGIOPLASTY

Objective: In carotid angioplasty a lot of interventionists avoid predilatation or perform predilatation using smaller diameter balloons to avoid distal embolization. The objective of our study was to determine the procedural safety and complications of predilatation of carotid artery using adequate diameter balloon in patients undergoing angioplasty. Methodology: Symptomatic patients with greater than 50% common carotid artery (CCA) or internal carotid artery (ICA) stenosis, asymptomatic patients with 80% or more carotid stenosis, asymptomatic patients planned for Coronary Artery Bypass Graft Surgery (CABG) with bilateral severe carotid stenosis (70-99%) or a unilateral severe carotid stenosis with a contralateral occlusion undergoing CABG, were selected for carotid artery angioplasty. Cerebral angiogram was performed before and after carotid intervention. Results: A total of 25 patients were included in this study. Adequate diameter balloon used for predilatation before stenting in all cases. Post dilatation was required in 6 (24%) patients. Distal embolic protection device was used in all patients. No complication was seen after predilatation in any case. No mortality or neurological deficit was seen in the study. Conclusion: This study shows that proper predilatation with adequate diameter balloon, sized according to diameter of internal carotid artery, before carotid stent implantation is an effective and safe procedure. We believe that this leads to good stent expansion and full apposition with better long term outcomes. Moreover it is now important to adequately predilate carotid arteries, for proper sizing of carotid stents with close cell design, to avoid unnecessary longitudinal stent lengthening due to inadequately prepared carotid bed.

Influence of stenting with open-cell stents vs close-cell stents on the outcomes of patients with bilateral carotid stenosis.

Carotid artery stenting (CAS) is an effective way to prevent stroke in patients with severe carotid stenosis. However, several studies comparing the outcomes of stenting with open-cell stents (OCS) vs closed-cell stents (CCS) have yielded inconclusive results. This study aimed to compare the outcomes of CAS with OCS vs CCS in the same patients.From year 2000 to 2016, we included 52 patients with severe bilateral carotid stenosis who underwent OCS deployment in one artery and CCS deployment in the contralateral artery. Stents were selected according to arterial anatomy and lesion morphology, and the peri-procedural and long-term outcomes of treatment with OCS vs CCS, were compared in terms of rates of ischemic spot development on early post-procedural diffusion-weighted imaging (ISDWI), in-stent restenosis (ISR), and recurrent stroke.After stenting with OCS vs CCS, the number (rate) of arteries with no lesion, < 5 lesions, and ≥ 5 lesions on DWI was 9 (32%) vs 8 (27%), 8 (29%) vs 17 (57%), and 11 (39%) vs 5 (17%) (p = .10); number (rate) of arteries with 0%, < 50%, and >50% ISR was 34 (65%) vs 34 (65%), 9 (17%) vs 11 (21%), and 9 (17%) vs 7 (13%) (p = .71); number (rate) of recurrent strokes after CAS was 2 (4%) vs 0 (0%).The rates of peri-procedural cerebral ischemic insult, long-term stent patency, and stroke recurrence indicate that no one carotid stent cell design is superior to the other. We suggest both OCS and CCS are reasonable options for the treatment of severe carotid stenosis.

Abstract 98: Bilateral Carotid Intraplaque Hemorrhage Association With Simultaneous Bilateral Stroke

Introduction: Bilateral ischemic strokes are often attributed to central or cardiac embolic sources, especially in the absence of severe bilateral carotid stenosis. Carotid MRI detects carotid intraplaque hemorrhage (IPH), a marker of stroke risk independent of stenosis. Hypothesis: MRI-detected carotid IPH better identifies bilateral carotid source strokes compared to stenosis alone. Methods: In this retrospective cross sectional study, patients undergoing stroke workup were imaged with carotid and brain MRI. Stroke was determined by the AHA definition of CNS infarction. Patients with non-carotid stroke sources (e.g. cardiac sources), occluded or near-occluded carotids were excluded. A total of 425 patients were analyzed. Carotid imaging findings were recorded, including IPH and NASCET stenosis along with clinical cerebrovascular risk factors and medications. Receiver operating characteristic (ROC) analysis was performed to determine the predictive value (area under the curve, AUC) of carotid imaging findings. Results: Carotid IPH was present in 89/425 of cases, and was bilateral in 24/89 (27.0%). Bilateral carotid IPH was a good predictor of bilateral stroke (AUC=.808), performing better than bilateral stenosis with ≥50%, ≥60% or ≥70% cutoffs (AUC=.565 p=.001, AUC=.550 p&lt;.001, AUC=.523 p&lt;.001, respectively) but not significantly better than average bilateral stenosis (AUC=.800 p=.90). The combined predictive value of bilateral IPH and average bilateral stenosis was excellent (AUC=.891) and performed better than bilateral IPH alone (p=.07) or average bilateral stenosis alone (p=.002). Conclusions: Bilateral carotid IPH is associated with bilateral stroke, and adds significant discrimination of bilateral carotid stroke sources compared to stenosis. In the setting of bilateral stroke, carotid MRI may help uncover potential stroke sources undetected by lumen imaging alone.

Simultaneous Bilateral vs Unilateral Carotid Artery Stenting

Purpose: To evaluate clinical outcomes of simultaneous bilateral carotid artery stenting (sbCAS) compared with unilateral CAS (uCAS). Methods: The database in our institution was queried to identify all patients treated with CAS from January 2005 to December 2012. In this time frame, 120 (18.8%) patients (mean age 64.9±7.7 years; 96 men) underwent sbCAS and 517 (81.2%) patients (mean age 65.7±7.7 years; 421 men) received uCAS. The primary endpoint was the composite of stroke, myocardial infarction, or death within 30 days or any ipsilateral stroke within 1 year. Results: There was no significant difference in the rates of the primary endpoint between the sbCAS and uCAS groups (6.7% vs 4.6%, p=0.358). The rates of the primary endpoint among symptomatic patients was 8.0% in the sbCAS group and 5.0% in the uCAS group (p=0.299) and 3.1% and 4.0%, respectively (p=0.821) among asymptomatic patients. During the 30-day periprocedural period, the rates of the primary endpoint did not differ significantly between the sbCAS and uCAS groups among all patients (5.8% vs 4.4%, p=0.479), symptomatic patients (6.8% vs 5.0%, p=0.594), or asymptomatic patients (3.1% vs 3.5%, p>0.999). After this period, the incidences of any ipsilateral stroke were similarly low (0.8% and 0.2%, respectively; p=0.342). Conclusion: The study showed that simultaneous bilateral CAS had no more adverse events than unilateral CAS during the periprocedural period or within 1 year. This 1-stage strategy may become a valuable alternative in the treatment of patients with severe bilateral carotid stenosis.

Advantages of Selective Use of Intraluminal Shunt in Carotid Endarterectomy: A Study of 122 Cases.

Objectives: To assess the advantage of selective use of shunt in carotid endarterectomy (CEA) under local anesthesia. Materials and Methods: A total of 122 consecutive patients fulfilling international guidelines were included. Shunt was used selectively only in cases of bilateral severe carotid artery occlusive disease or in those patients who developed neurological symptoms on clamping of carotid artery. Follow up was done weekly for one month; then every month for 3 months; and then every 3 months for a year. Results: Shunt was used only in 5% (n = 6) patients. Of these, 2.5% (n = 3) patients were those who developed neurological symptoms on clamping the internal carotid and deployment of shunt resulted in complete resolution of symptoms. 2.5% (n = 3) had severe bilateral carotid stenosis and shunt was deployed. One of these patients developed stroke which was permanent. There was no mortality. The mean procedure time was 170 min in patients in whom shunt was used, when compared with 100 min in patients without shunt (P = 0.003). Conclusion: Use of shunt in carotid endarterectomy under local anesthesia as selective policy has an advantage in terms of cost effectiveness, operation time and prevention of potential complications.

Surgical Outcomes for Cervical Carotid Artery Stenosis: Treatment Strategy for Bilateral Cervical Carotid Artery Stenosis

Carotid endarterectomy (CEA) and carotid stenting (CAS) are beneficial procedures for patients with high-grade cervical carotid stenosis. However, it is sometimes difficult to manage patients with bilateral carotid stenosis. To decide the treatment strategy, one of the most important questions is whether contralateral stenosis increases the risk of patients undergoing CEA. This retrospective study included 201 patients with carotid stenosis who underwent a total of 219 consecutive procedures (CEA 189/CAS 30). We retrospectively analyzed outcomes in patients with carotid stenosis who were treated with either CEA or CAS and evaluated whether or not contralateral lesions increases the risk of patients undergoing CEA or CAS. Furthermore, we retrospectively verified our treatment strategy for bilateral carotid stenosis. The incidences of perioperative complications were 5.3% in the CEA patients and 6.7% in the CAS patients, respectively. There was no significant difference between these 2 groups. The existences of contralateral occlusion and/or contralateral stenosis were not associated with perioperative complications in both the groups. There were 32 patients with bilateral severe carotid stenosis (>50%). Of those, 13 patients underwent bilateral revascularizations; CEA followed by CEA in 8, CEA followed by CAS in 3, CAS followed by CEA + coronary artery bpass grafting in 1, and CAS followed by CAS in 1. Our date showed that the existence of contralateral carotid lesion was not associated with perioperative complications, and most of our cases with bilateral carotid stenosis initially underwent CEA.

Treatment Strategy for Bilateral Carotid Stenosis: 2 Cases of Carotid Endarterectomy for the Symptomatic Side Followed by Carotid Stenting

Since the introduction of carotid stenting (CAS), a combined treatment for bilateral lesions using carotid endarterectomy (CEA) and CAS has been developed. However, there has been only 1 report about CEA then CAS. Herein we describe 2 patients with bilateral severe carotid stenosis who were treated by CEA for the symptomatic side and CAS for the contralateral asymptomatic side. A 71-year-old man underwent CEA for the symptomatic side. Although the patient suffered hyperperfusion syndrome after CEA, he recovered fully after 3 weeks of rehabilitation. Two months later, CAS was performed for the asymptomatic side, and he was discharged with no deficit. A 67-year-old man underwent CEA for the symptomatic side. The patient developed no postoperative neurologic deficits except for hoarseness. Four weeks later, CAS was performed for the contralateral asymptomatic side. After the procedure, however, severe hypotension occurred, and treatment by continuous injection of catecholamine was necessary to maintain systematic blood pressure. The patient was ultimately discharged with no deficit. The combined therapy of CAS for the asymptomatic side and then CEA for the symptomatic side has been recommended by several authors. However, one of the problems of this strategy is the higher incidence of postprocedural hemodynamic complications, and hypotension after CAS may be dangerous for the symptomatic hemisphere. We suggest a combined therapy using CEA for the symptomatic side and then CAS for the asymptomatic side can be 1 beneficial treatment option for patients with bilateral carotid stenosis without coronary artery disease.

Influencing Factors for Early Acute Cerebrovascular Accidents in Patients with Stroke History following Off-pump Coronary Artery Bypass Grafting

To analyse risk factors for early acute cerebrovascular accidents following off-pump coronary artery bypass grafting (OPCAB) in patients with stroke history, and to propose preventive measures to reduce the incidence of these events. A total of 468 patients with a history of stroke underwent OPCAB surgery in Beijing Anzhen Hospital of China from January 2010 to September 2012. They were retrospectively divided into two groups according to the occurrence of early acute cerebrovascular accidents within 48 hours following OPCAB. Multivariate logistic regression analysis was used to find risk or protective factors for early acute cerebrovascular accidents following the OPCAB. Fifty-two patients (11.1%) suffered from early acute cerebrovascular accidents in 468 patients, including 39 cases of cerebral infarction, two cases of cerebral haemorrhage, 11 cases of transient ischaemic attack (TIA). There were significant differences between the two groups in preoperative left ventricular ejection fraction ≤ 35%, severe bilateral carotid artery stenosis, poorly controlled hypertension, intraoperative application of Enclose® II proximal anastomotic device, postoperative acute myocardial infarction, atrial fibrillation, hypotension, ventilation time > 48h, ICU duration >48h and mortality. Multivariate logistic regression analysis showed that preoperative severe bilateral carotid stenosis (OR=6.378, 95%CI: 2.278-20.987) and preoperative left ventricular ejection fraction ≤ 35% (OR=2.737, 95%CI: 1.267-6.389), postoperative acute myocardial infarction (OR=3.644, 95%CI: 1.928-6.876), postoperative atrial fibrillation (OR=3.104, 95%CI:1.135∼8.016) and postoperative hypotension (OR=4.173, 95%CI: 1.836∼9.701) were independent risk factors for early acute cerebrovascular accidents in patients with a history of stroke following OPCAB procedures, while intraoperative application of Enclose® II proximal anastomotic device was protective factor (OR=0.556, 95%CI: 0.337-0.925). This study indicated that patients with severe bilateral carotid stenosis, the left ventricular ejection fraction ≤35%, the postoperative acute myocardial infarction, postoperative atrial fibrillation and postoperative hypotension were more likely to suffer from early acute cerebrovascular accidents when they received OPCAB. Application of Enclose® II proximal anastomotic device may decrease the incidence of early acute cerebrovascular accidents during OPCAB.

Ischemic Postconditioning Alleviates Neuronal Injury Caused by Relief of Carotid Stenosis in a Rat Model of Cerebral Hypoperfusion

The effects of early relief of heavy bilateral carotid stenosis and ischemic postconditioning on hippocampus CA1 neurons are still unclear. In this study, we used a rat model to imitate severe bilateral carotid stenosis in humans. The rats were divided into sham group, carotid stenosis group, stenosis relief group and ischemic postconditioning group. Ischemic postconditioning consisted of three cycles of 30 s ischemia and 30 s reperfusion. The cerebral blood flow was measured with a laser Doppler flowmeter. Neuronal death in the CA1 region was observed by hematoxylin-eosin staining, and the number of live neurons was assessed by cell counting under a light microscope. The levels of oxidative products MDA and 8-iso-PGF2α, inflammatory factors IL-1β and TNF-α, and the activities of anti-oxidative enzymes SOD and CAT were assayed by specific enzyme-linked immunosorbent assay (ELISA) kits, respectively. We found that relief of carotid stenosis and ischemic postconditioning could increase cerebral blood flow. When stenosis was relieved, the percentage of live neurons was 66.6% ± 6.2% on day 3 and 62.3% ± 9.8% on day 27, which was significantly higher than 55.5% ± 4.8% in stenosis group. Ischemic postconditioning markedly improved the live neurons to 92.5% ± 6.7% on day 3 and 88.6% ± 9.1% on day 27. Further study showed that, neuronal death caused by relief of stenosis is associated with increased oxidative stress and enhanced inflammatory response, and the protection of ischemic postconditioning is related to inhibition of oxidative stress and suppression of inflammatory response.

Treatment Strategies for Carotid Stenosis in Patients at Increased Risk for Surgery

The purpose of carotid revascularization is stroke prevention. The merits of carotid revascularization as well as the type of revascularization are dependent on the “natural risk” and the “revascularization risk.” In general, the natural risk of stroke in any patient with carotid stenosis (CS) is dependent on the symptomatic status of the patient and CS severity. Contemporary choices for carotid revascularization include carotid endarterectomy (CEA) and carotid artery stenting (CAS). Anatomical (hostile neck situations, severe bilateral CS, CEA restenosis) and clinical (severe cardiopulmonary diseases, prior cranial nerve injury) factors may increase the risk of CEA. Likewise, anatomical (complex aortic arch and brachiocephalic arterial anatomy, presence of thrombus, and heavy calcification) and clinical (need for heart surgery within 30 days) factors may increase the risk of CAS. Other factors such as the presence of symptomatic CS (transient ischemic attack or stroke within 6 months), decreased cerebral reserve, chronic kidney disease, and age older than 75 years may increase the risk of CEA and CAS. In general, symptomatic patients with severe CS exceed revascularization risk. In contrast, asymptomatic patients who are high risk for CEA should be considered for CAS because the natural risk of stroke should undergo careful assessment of baseline cognitive function, aortic arch and carotid artery anatomy, and likelihood of survival for 3 years. Patients who have normal cognitive function, favorable anatomy, and high likelihood of survival more than 3 years should be considered for CAS, whereas patients with multiple unfavorable features may be treated with optimal medical therapy, without revascularization.

Carotid shunt provides cerebral protection during emergency coronary artery bypass grafting in a patient with bilateral high grade carotid stenosis: a case report

BackgroundManagement of patients with co-existent coronary and carotid disease is a controversial and challenging issue. The risk for stroke after coronary artery bypass grafting (CABG) in patients with hemodynamically significant carotid stenosis is up to 30%. In these patients a common practice is to proceed first with the restoration of cerebral perfusion and then perform the coronary revascularization. The rationale is that this strategy will reduce perioperative neurological morbidity and mortality. However, what happens when the carotid procedure is acutely complicated by cardiac instability which necessitates the interruption of the carotid procedure?Case reportWe describe a case of a patient with unstable angina and high grade asymptomatic bilateral carotid stenosis who underwent emergency combined CABG and carotid endarterectomy (CEA). Due to hemodynamic instability, ST-T changes, hypotension and bradycardia, upon completion of endarterectomy we placed a carotid shunt and the patient was put on cardiopulmonary bypass through median sternotomy. After triple CABG (duration of 90 minutes) we concluded the interrupted CEA procedure with primary closure of the carotid arteriotomy with the shunt in place. The postoperative course was uneventful and the patient was discharged after a week. In extreme cases with bilateral severe carotid stenosis and coronary artery disease where the carotid procedure should be interrupted, we suggest the use of carotid shunt which can provide adequate cerebral perfusion giving time to cardiac surgeon to perform the life saving cardiac procedure first.

Cough syncope and multiple pulmonary nodules

A 71-year-old farmer was admitted to the Intensive Care Unit because of acute respiratory failure following a 5-month history of chronic cough. His medical history included a tobacco smoking habit, and severe bilateral carotid stenosis. He had been suffering from exertional dyspnea for many years, but had never sought medical care. He had never travelled abroad, and was taking no medication. The vital signs were; blood pressure 135/85 mm/Hg, pulse 95 beats/min, respiratory rate 24 breaths/min, body temperature 37.3 C. The physical examination was unremarkable except for bilateral wheezing on lung auscultation. Arterial blood gas analysis on breathing room air showed pH 7.34, PCO2 48 mmHg, PO2 56 mmHg. Laboratory tests included a slightly elevated C-reactive protein level 46 mg/L, procalcitonin lower than normal 0.05 ng/ mL. The blood white-cell count was 10.6 cells/mm with marked hypereosinophilia (2040 cells/mm). The chest X-ray study showed no significant abnormality. A thoracic contrast computed tomography (CT scan) ruled out a pulmonary embolism, but showed bilateral nodules and patchy infiltrates, disseminated asymmetrically throughout lung parenchyma (Figs. 1, 2). The patient was initially treated with oxygen supplementation, antibiotics (amoxicilline clavulanate 1 g tid) and steroids (prednisone 40 mg/day), resulting in moderate improvement. Eosinophilia suggested multiple parasitological examinations of the feces; they were all negative. Nevertheless, 6 days after admission, immuno-enzymatic assay (ELISA) for Toxocara Canis appeared strongly positive. It was later confirmed by a western blot analysis. Closer questioning of the patient revealed that he was living alone with his dog after his wife had died 6 months prior. He had given up his daily work on the farm, and progressively had ceased cleaning up the dog’s feces. Intermittent dry coughing fits had then appeared, becoming increasingly frequent. Coughing had soon become permanent and disabling with several episodes of cough syncope that had led him to consult his general practitioner. Diagnosis Visceral larva migrans with pulmonary involvement caused by Toxocara Canis infection. Visceral larva migrans is a ubiquitous zoonosis resulting from infestation by the common roundworms of dogs and cats, Toxocara Canis and Cati, respectively [1]. The parasite undergoes a complete cycle in young dogs, which leads to the excretion of embryonated eggs in the environment. Human beings are infected after ingestion of the eggs, either via contaminated food, or (more commonly) via unwashed hands. The larvae that hatch from the eggs then invade the intestinal mucosa and disseminate to several organs, including the liver, the central nervous system and the lungs [1, 3]. In immunocompetent adult hosts, toxocarosis is most often asymptomatic, but can exhibit a wide variety of clinical features reflecting visceral spread of the larvae [1]. Mild, chronic infections usually presents with the clinical pictures of ‘‘covert’’ or ‘‘common’’ toxocariosis, while the term ‘‘visceral larva migrans’’ reflects more acute multiorgan presentations. Pulmonary involvement is reported in L. Kreitmann M. Lemyze Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France

Acute carotid stent thrombosis: review of the literature and long-term follow-up

Carotid artery stenting (CAS) is a reasonable alternative to carotid endarterectomy, especially in patients at high risk for surgery. Carotid stent thrombosis can cause thrombembolic events, but fortunately, it is a very rare complication. We present two cases of carotid stent thrombosis and their long-term follow-up. One patient had severe bilateral carotid stenosis and the other had contralateral carotid occlusion. Both patients were on correct antithrombotic treatment and received balloon expandable stents (bare metal stent and drug-eluting stent). During CAS, large thrombus formed within the stent followed by rapid hemodynamic and neurological alteration. We gave a bolus thrombolytic in the clot, followed by continuous intra-arterial infusion. In one case, we performed additional angioplasty. Repeated angiography showed complete resolution of the thrombus, followed by progressive improvement in the neurological state. At discharge, the patients had no neurological deficits. CT scans revealed no acute ischemic lesions. One patient had in-stent restenosis 3 years later, which was treated with an additional self-expandable stent. The last follow-up was done 4 and 9 years, respectively, from the initial CAS complication. Both patients did not experience any neurological events after the last procedure. Carotid stent thrombosis is a rare but potentially fatal complication following CAS. Rapid invasive diagnosis and reperfusion should be done to limit cerebral ischemia. The possible causes must be sighted and reperfusion must be started. Despite an initial dramatic course, a rapid reperfusion ensures a complete neurological recovery and a good prognosis in the long term.

Limb Shaking as a Manifestation of Low-flow Transient Ischemic Attacks

Limb shaking presenting as rhythmic involuntary hyperkinetic movements may represent as severe bilateral occlusive carotid disease. This unusual form of transient ischemic attack is often misdiagnosed as focal motor seizures. However, careful assessment reveals a lack of usual seizure characteristics such as a jacksonian march or facial involvement. The movements also appear to be precipitated by activities that lower blood pressure. We present two cases of patients with severe bilateral carotid stenosis leading to limb-shaking transient ischemic attacks. There was complete stenosis in the internal carotid artery (ICA) contralateral to the jerking limb, combined with significant stenosis in the ipsilateral ICA. Cerebral perfusion on the occluded ICA side was maintained through collateral circulation from the opposite ICA and posterior circulation. When blood pressure was lowered orthostatically or by medication, the resulting cerebral hypoperfusion manifested as limb jerking. Recognition of limb shaking as a rare form of transient ischemic attack and differentiating it from focal motor epilepsy can facilitate early identification of critical carotid stenosis, allowing for appropriate interventions and thus reducing the risk of a disabling stroke. We recommend that clinicians should consider carotid disease in elderly patients presenting with orthostatic or episodic movement disorders.

Brown-Sequard-type myelopathy due to cervical disc herniation associated with severe carotid stenosis prompting rapid combined corpectomy and carotid endarterectomy under deep anticoagulant therapy

Background context The risk of stroke because of carotid retraction during an anterior cervical spine surgery as well as the risk of bleeding complications after an anterior cervical corpectomy under deep anticoagulation and antiplatelet therapy is a surgical issue poorly addressed in the literature. Purpose To describe the feasibility and safety of a simultaneous carotid endarterectomy and anterior corpectomy and fusion under deep anticoagulation in a patient with a cervical spinal cord compression and a severe carotid artery stenosis. Study design Case report. Methods The authors describe the case of a 79-year-old man who had a 1-month history of progressive pain in the neck and left arm, associated with progressive weakness in the left arm and leg. He also presented a history of coronaropathy and bilateral severe carotid stenosis for which he was receiving a regimen of antiplatelet therapy. Results The cervical magnetic resonance imaging demonstrated a C4–C5 disc herniation migrating down to C5. His condition worsened rapidly during hospitalization prompting a rapid decompression. Given the necessity of a C5 corpectomy and the risk of stroke during anterior cervical spine surgery, it was therefore decided to undertake the surgical procedure under efficient anticoagulant and antiplatelet therapy. A combined endarterectomy and spinal decompression and fusion were then performed. The postoperative course was uneventful, and the patient recovered neurologically. Conclusions This case suggests that such a combined carotid endarterectomy and cervical corpectomy with fusion under anticoagulant and antiplatelet therapy is feasible. However, even if the unique clinical presentation of our patient led us to undertake such a surgical strategy, therapeutic decision in patients presenting with both severe carotid stenosis and cervical spinal cord compression should rely on a case-by-case analysis.

Results of carotid endarterectomy in diabetic patients

Patients with diabetes mellitus have been shown to have an increased incidence of complications after major vascular surgery. The objective of this study was to evaluate the results of carotid endarterectomy in diabetic patients, to determine if results differ from nondiabetic patients, and to examine the risk factors for poor outcome among diabetic patients. We reviewed all carotid endarterectomies performed in Emergency Hospital of Vilnius University. From 1995 to 2005, 707 carotid endarterectomies were performed. Of these, 100 operations were performed in diabetic patients (14%) and the remaining 607 in nondiabetic patients. Diabetic patients were younger (P<0.05) and were obese more often (P<0.001), they smoked less often (P<0.001) than nondiabetic patients. Diabetics were more likely to have severe bilateral carotid stenosis than nondiabetic patients (P<0.01). Postoperative complications (stroke) were more common in diabetic patients than in nondiabetic patients (12.0% vs. 3.4%, P<0.001) as well as intracerebral hemorrhages (3.0% vs. 0.3%, P<0.001); no perioperative myocardial infarction was found in diabetic patients. Risk factors for complications were age >/=75 (odds ratio (OR) 2.2; 95% confidence interval (CI)=1.0-4.9), smoking (OR 2.7; 95% CI=1.8-4.2), obesity (OR 6.1; 95% CI=3.9-9.5), and bilateral carotid stenosis (OR 2.1; 95% CI=1.3-3.6). Diabetes mellitus significantly increased the risk of mortality and intracerebral hemorrhage but not myocardial infarction. It should be taken into consideration in making decisions about the performance and perioperative management of carotid endarterectomy.

Simultaneous Bilateral Carotid Stenting under the Circumstance of Neuroprotection Device

In this study, in order to evaluate the feasibility and outcomes of simultaneous bilateral carotid artery stenting (CAS) with the use of neuroprotection in symptomatic patients, we conducted a retrospective analysis of 27 patients (19 men, eight women; median age, 69.2 years), all of whom had been scheduled to undergo bilateral CAS in a single setting. All patients presented with severe atherosclerotic bilateral carotid stenosis (> 50% for symptomatic side, > 80% for asymptomatic side), exhibiting symptoms of either a cerebrovascular accident or of a transient ischemic attack on at least one side. 48 arteries were treated with self-expandable stents. Neuroprotection devices were utilized for bilateral CAS in 11 patients, and in 16 unilateral CAS patients. We did not perform the second procedure in six patients, in cases in which a patient exhibited (a) hemodynamic instability, (b) a new neurological impairment, or (c) restlessness after a prolonged time for the first CAS. The second procedure was postponed in a staged manner. We achieved a mean residual stenosis of 8.1 +/- 5.0 % in the treated lesions. The mean procedural time for bilateral CAS was three hours and 18 minutes. 17 patients (63%) developed transient bradycardia during the balloon dilatation of one or both of the relevant arteries. Three patients (11%) exhibited persistent bradycardia and hypotension, which required the administration of intravenous vasopressors for several days (2~7 days). None of the patients ultimately required pacemakers, or any further therapy. Two of the patients (7%) developed transient ischemic attack during the periprocedural period, but recovered completely. One patient developed a new minor stroke after the first procedure, and the second procedure was delayed in a staged manner.We observed no periprocedural deaths, major strokes, or myocardial infarctions, nor did we detect any cases of hyperperfusion syndrome within 30 days. In summary, simultaneous bilateral CAS with neuroprotection can be performed in a single setting without increased concerns with regard to hyperperfusion syndrome, hemodynamic instability, thrombo-embolism, or procedure time, when the first CAS has been safely completed with no evidence of complications in a wellmanaged procedure time.