Internal Carotid Artery Stenosis Research Articles

Cognitive decline and cerebral vasoreactivity in asymptomatic patients with severe internal carotid artery stenosis

AbstractBackgroundThe aim of the study was to correlate cognitive decline and cerebral vasoreactivity in 150 asymptomatic right‐handed patients with severe ≥70 % unilateral internal carotid artery (ICA) stenosis and to evaluate the role of intracranial collateral circulation during cognitive testing.MethodsCognitive assessment was performed by means of Montreal Cognitive Assessment (MoCA) and Mini Mental State Exam (MMSE) scales. Cerebrovascular reactivity (CVR) and intracranial collateral circulation were evaluated by means of breath holding index (BHI) and transcranial color Doppler (TCD) sonography.ResultsThe results were compared with 150 right‐handed controls matched for demographic variables and vascular risk factors. Patients with severe unilateral ICA stenosis had MMSE scores within a normal range, but MoCA scores were lower than normal. By examining the side of the observed stenosis, it has been noted that patients with left‐sided ICA stenosis had lower MoCA scores in categories of language and episodic memory performance, while patients with right‐sided ICA stenosis had lower MoCA scores in a category of visual–spatial skills. All patients had BHI values lower than normal. Subjects with a single intracranial collateral artery recruited had slightly better cognitive results than the patients with two or more collateral arteries activated.ConclusionsResults of the study showed that altered cerebrovascular reactivity and cerebral hypoperfusion might be responsible for the reduction of specific cognitive functions ipsilateral to the ICA stenosis, therefore BHI and MoCA might be useful tools when screening for cognitive decline in asymptomatic patients with severe ICA stenosis.

Asymptomic carotid aterosclerosis as a risk factor of cognitive dysfunction after simultaneous surgeries

Background and Aims: Tо assess the dynamics of cognitive functions in patients with polyvascular disease (PolyVD), coronary atherosclerosis and asymptomatic ICA stenosis, who underwent simultaneous coronary (CABG) and carotid endarterectomy (CEE).

Follow-up after carotid endarterectomy and stenting: What to look for and why

Duplex ultrasound testing after open or endovascular extracranial carotid artery interventions is a clinical practice guideline with a strong recommendation from the Society for Vascular Surgery. Neurologic outcomes are improved by the recognition of repair site stenosis or atherosclerotic disease progression in the unoperated carotid artery. The benefit of surveillance outweighs its risk because duplex testing is free of complications and accurate in the detection of internal carotid artery (ICA) stenosis or occlusion. Surveillance for >70% ICA stenosis is recommended within 30 days of the procedure, then every 6 months for 2 years, and annually thereafter. Repair site and contralateral ICA stenosis classification should be based on angle-corrected pulsed Doppler measurements of peak systolic velocity (PSV), end-diastolic velocity (EDV), and the ratio of PSV at the stenosis to a proximal, nondiseased common carotid artery (CCA) segment (ICA/CCA ratio). Interpretation criteria of PSV >300 cm/s, EDV >125 cm/s, and ICA/CCA ratio >4 predicts >70% repair site stenosis. Endovascular intervention is recommended for a carotid repair site stenosis based on the occurrence of an ipsilateral neurologic event and appropriate anatomy for angioplasty. For asymptomatic restenosis, intervention is based on stenosis progression to elevated PSV and EDV >70% stenosis threshold values and the patient is deemed high risk for stroke due to contralateral ICA occlusion or incomplete functional patency of the circle of Willis.

COVID-19 Associated Encephalopathies and Cerebrovascular Disease

INTRODUCTIONThe coronavirus disease 2019 (COVID-19) pandemic that is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has had a dramatic impact on healthcare systems and a variable disease course. Emerging evidence demonstrates that SARS-CoV-2 is associated with central nervous system (CNS) disease. In this series, we describe CNS manifestations in critical COVID-19 patients at our tertiary academic center.METHODSA single center retrospective cross-sectional analysis of all patients admitted to our tertiary care academic center in New Orleans, Louisiana on April 22, 2020, who were in critical condition due to COVID-19 and developed new onset of neurological disease. Patients were grouped into one of three categories according to imaging and clinical features: encephalopathy, acute necrotizing encephalopathy, and vasculopathy.RESULTSA total of 27 of 76 (35.5%) critical COVID-19 patients met inclusion criteria. Mean age was 59.8 years (range 35–91 years) and most had an underlying medical condition, including hypertension (63%), diabetes mellitus type 2 (52%), obesity (26%), and/or chronic kidney disease (22%). Sixty three percent had evidence of neurological injury on CT, 30% on MRI, 15% on non-invasive vascular imaging, and 44% on EEG. CT findings most often included subacute ischemic strokes, diffuse hypoattenuation, subcortical parenchymal hemorrhages, and focal hypodensities within deep structures. MRI findings included diffuse involvement of deep white matter, the corpus callosum, and the basal ganglia. For patients with acute ischemic stroke, vascular findings consisted of irregular proximal focal stenosis of the supraclinoid internal carotid artery. Twenty patients (74%) were designated with COVID-19 associated encephalopathy, two (7%) with COVID-19 associated acute necrotizing encephalopathy, and five (19%) with COVID-19 associated vasculopathy.CONCLUSIONA one-day snapshot of COVID-19 admissions at a tertiary academic center in New Orleans, LA revealed a high percentage of patients with new neurological disease. Although clinical presentations varied, they were broadly categorized. A better understanding of the neurological sequalae and radiographic findings will help clinicians mitigate the impact of this disease.

Cerebrovascular Disease Progression in Patients With ACTA2 Arg179 Pathogenic Variants.

To establish progression of imaging biomarkers of stroke, arterial steno-occlusive disease, and white matter injury in patients with smooth muscle dysfunction syndrome caused by mutations in the ACTA2 gene, we analyzed 113 cerebral MRI scans from a retrospective cohort of 27 patients with ACTA2 Arg179 pathogenic variants. Systematic quantifications of arterial ischemic strokes and white matter lesions were performed on baseline and follow-up scans using planimetric methods. Critical stenosis and arterial vessel diameters were quantified applying manual and semiautomated methods to cerebral magnetic resonance angiograms. We then assessed correlations between arterial abnormalities and parenchymal injury. We found characteristic patterns of acute white matter ischemic injury and progressive internal carotid artery stenosis during infancy. Longitudinal analysis of patients older than 1.2 years showed stable white matter hyperintensities but increased number of cystic-like lesions over time. Progressive narrowing of the terminal internal carotid artery occurred in 80% of patients and correlated with the number of critical stenoses in cerebral arteries and arterial ischemic infarctions. Arterial ischemic strokes occurred in same territories affected by critical stenosis. We found characteristic, early, and progressive cerebrovascular abnormalities in patients with ACTA2 Arg179 pathogenic variants. Our longitudinal data suggest that while steno-occlusive disease progresses over time and is associated with arterial ischemic infarctions and cystic-like white matter lesions, white matter hyperintensities can remain stable over long periods. The evaluated metrics will enable diagnosis in early infancy and be used to monitor disease progression, guide timing of stroke preventive interventions, and assess response to current and future therapies.

Brachiocephalic atherosclerosis in patients with posterior circulation ischemic stroke

Aim. To study echographic and acoustic characteristics of atherosclerotic plaques (ASP) in brachiocephalic arteries (BCA) in patients with acute posterior circulation ischemic stroke (PCIS).Material and methods. In this study we included data of duplex ultrasound from 235 patients (men, 129; women, 106; age, 59±12 and 63±10 years, respectively) with PCIS. Pathogenesis of PCIS was established only in 23 cases: in 17 (74%) — atherothrombosis, in 3 (13%) — cardioembolism, in 3 (13%) — lacunar stroke. Atrial fibrillation was established in 18,5% of patients. A total of 903 asymptomatic individuals were included in the control group, comparable with studied patients by sex and age.Results. The prevalence of ASP in vertebral arteries (VA) was equal in both groups. Also, no significant differences in the degree of VA stenosis were observed. Atherosclerotic lesions of common (CCA) and internal carotid arteries (ICA) on both sides were more often observed in control group, but the degree of their stenosis was higher in PSIS group (р<0,003). In ischemic stroke, stenosis of the right ICA was 47±17%, left ICA — 46±18%, while in asymptomatic individuals, right ICA stenosis was 40±14%, left ICA — 39±15%. In patients with PCIS, ASPs were significantly more often regarded as concentric (22,0% vs 10,4% in PCIS and asymptomatic individuals, respectively), prolonged (24,2% vs 7,5%), homogeneous (41,0% vs 21,1%), as well as were more likely to have an uneven contour (27,7% vs 2,8%).Conclusion. In patients with acute PCIS, the peculiarities of BCA atherosclerosis were recorded, distinguishing it from that in the asymptomatic population.

Application of spectral CT in the diagnosis of contrast encephalopathy following carotid artery stenting: a case report

BackgroundContrast encephalopathy is a rare complication of carotid artery stenting (CAS). Contrast encephalopathy is a diagnosis of exclusion that often needs to be distinguished from high perfusion syndrome, cerebral haemorrhage, subarachnoid haemorrhage (SAH), cerebral infarction and so on.Case presentationIn this study, we report on a 70-year-old man who was admitted to the hospital with transient ischaemic attacks presenting paroxysmal weakness of limbs in the previous 2 years. He had severe stenosis of the left internal carotid artery diagnosed by digital subtraction angiography (DSA) and underwent CAS. Two hours after the operation, the patient developed paralysis of the right upper limb, unclear speech, fever and restlessness. Emergency skull computed tomography (CT) showed swelling and a linear high-density area in the left cerebral hemisphere. To clarify the components of this high-density area in the traditional CT, the patient had spectral CT, which made the diagnosis of the leakage of contrast clear. After 1 week of supportive treatment, the patient improved.ConclusionsSpectral CT can easily distinguish the components of high-density areas on traditional CT, which is haemorrhage, calcification or iodine contrast leakage. Therefore, spectral CT is worth consideration for the differential diagnosis of complications of vascular intervention.

Investigation of macular and optic nerve head structural changes using spectral domain optical coherence tomography in internal carotid artery stenosis

To demonstrate differences in optic nerve head (ONH), retinal nerve fiber layer (RNFL), and macular thickness in patients with internal carotid artery (ICA) stenosis using spectral domain optical coherence tomography (SD-OCT). A case-controlled study was conducted in 31 patients with a diagnosis of unilateral ICA stenosis (the percentage of stenosis was between 65 and 85%), and 53 age- and sex-matched healthy subjects (control group) from March 2016 to April 2018. The ONH parameters, RNFL, and macular thicknesses in the nine macular quadrants according to the Early Treatment Diabetic Retinopathy Study (ETDRS) were measured using SD-OCT. The average macular thickness and outer macular quadrants measurements were lower in the ICA stenosis group (P < 0.05). The thickness of the fovea and inner macular quadrants was similar in healthy and patient eyes. Similarly, the ONH and RNFL profiles based on SD-OCT parameters were similar between the groups. There was a negative weak correlation between mean macular and RNFL thicknesses and the duration and percentage of ICA stenosis. The average macular thickness and measurements of outer macular quadrants in the ICA stenosis group were lower than in the control group. Macular changes may occur before symptomatic ocular ischemic syndrome (OIS). SD-OCT macular measurements may be beneficial in the early detection of OIS due to ICA stenosis.

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.

Characteristics of cerebral hemodynamics in patients with chronic brain ischemia

Background. Literature sources report conflicting results regarding the severity of clinical symptoms of hydrocephalus (HC) and their association with cerebral arterial blood flow (CABF); most studies do not show a direct relationship, while some suggest a link between clinical severity and progressive decrease in CABF. The study of hemodynamic changes in the brain of patients with chronic brain ischemia (CBI), elucidation of their relationship with cognitive impairments helps to improve diagnostic approaches and optimize the prognosis of the disease. The purpose of this study is to investigate the state of cerebral hemodynamics and to establish its relationship with changes in cognitive functions in patients with CBI and HC. Materials and Methods. A comprehensive examination of 110 patients with CBI and HC was performed. The localization of the HC and results of Montreal Cognitive Test (MoCA scale) were taken into account. Computed tomography of the brain was performed with subsequent determination of morphometric parameters and indices. The state of cerebral blood flow and structural changes of blood vessels were studied using transcranial color-coded duplex ultrasonography (TCCS) of intracranial vessels and extracranial divisions. Microsoft Excel 2011 and Statistica were used for statistical processing of the results. Results. It was found that there was a significantly larger diameter of both common carotid arteries (CCA), thickness of complex intima\media (CIM), maximum systolic velocity (Vs), velocity at the end of the diastolic cycle (Vd), as well as peripheral resistance (IR) in left CCA (p &lt;0,05) in patients with CBI and HC compared with patients with CBI without HC. Significantly larger diameter of left internal carotid artery (ICA), Vs, Vd and IR was revealed; Vs and Vd in the right ICA; Vd in the extracranial devision of vertebral artery (VA) in patients with HC. A significant relationship was found between the following blood flow parameters and the values of the MoCA scale: Vs MCA/MoCA (r = 0,45, p &lt;0,05), Vs ACA/MoCA (r = 0,38, p &lt;0.05), ICA diameter/MoCA (r = -0,51, p &lt;0,05). It was found that the diameter of CCA and the thickness of CIM were significantly larger in patients with CBI with internal HC in comparison with patients with CBI with external HC (p &lt;0,01). Vs and Vd in patients with internal hydrocephalus were significantly lower, and IR was significantly higher compared with patients with external hydrocephalus (p &lt;0,01). The diameter of ICA and IR in patients with CBI with internal HC was significantly higher, and Vs was significantly lower compared with patients with CBI and external HC (p &lt;0,01). Significantly different values were found in Vs and IR meanings in middle cerebral artery (MCA) and Vs in anterior cerebral artery (ACA) in patients with CBI with internal HC compared with patients with CBI with external HC.Conclusions. Functional parameters of blood flow and structural changes of cerebral arteries in patients with CBI with concomitant hydrocephalus differed significantly from those in patients without hydrocephalus and depended on the type and severity of hydrocephalus. ICA occlusion, ICA stenosis &gt;50%, and intracranial venous stasis were significantly more common in patients with severe and moderate HC compared with those with mild HC. A weak relationship was found between the structure of carotid arteries and blood flow in intracranial arteries in patients with CBI and HC. There was a significant relationship between blood flow indices and the values of the MoCA scale, which indicated the effect of changes in the vessels of the anterior circular basin on the cognitive functions and the lack of such connection with blood flow indices in vertebrobasilar basin.

Factors associated with the symptomatic status of carotid artery stenosis: identification in a cross-sectional study and development of a scoring system.

The identification of asymptomatic patients at high risk of internal carotid artery (ICA) stenosis destabilization and symptom occurrence is crucial for prognosis estimation. This study aimed to determine differences between patients with symptomatic and asymptomatic ICA stenosis and to develop a predictive model for the risk of symptomatic stenosis based on data collected in routine clinical practice. The study included 163 patients with asymptomatic and 182 patients with symptomatic ICA stenosis greater than 70%. The study groups were compared in terms of stroke risk factors and comorbidities, coexisting ICA stenosis on the contralateral side, atherosclerosis in other arterial territories, and the morphology of atherosclerotic plaque assessed by transcervical ultrasound. Independent risk factors for symptomatic ICA stenosis included: male sex (odds ratio [OR], 2.94; 95% CI, 1.87-4.32; P <0.001), diabetes (OR, 2.86; 95% CI, 1.62-5.12; P <0.001), body mass index >25 kg/m2 (OR, 1.81; 95% CI, 1.72-1.86; P <0.001), chronic kidney disease (OR, 3.34; 95% CI, 1.34-8.87; P = 0.007), increased‑risk features of ultrasound plaque morphology (OR, 2.52; 95% CI, 1.29-3.72; P = 0.009), and coexisting atherosclerosis in 3 or 4 vascular areas (OR, 3.72; 95% CI, 1.77-7.23; P <0.001).The sensitivity and specificity of the scoring model designed to estimate the risk of symptomatic ICA stenosis reached 77.6% and 76.9%, respectively. This cross‑sectional study indicated that the analysis of selected imaging and clinical parameters may enable clinicians to estimate the risk of symptomatic ICA stenosis. The proposed scoring system requires further prospective validation.

Assessment of internal carotid artery stenosis and results of carotid stenting by angiography compared with intravascular ultrasound

Abstract Background/Introduction Intravascular imaging is commonly used in coronary interventions and improves outcomes. On the contrary, it is almost unrecognized for the guidance of carotid stenting (CAS). Purpose The aim of this study was to compare quantitative angiography (QA) and intravascular ultrasound (IVUS) in the assessment of the severity of carotid stenosis and residual stenosis in patients undergoing CAS and to provide reference values for IVUS measurements of the internal carotid artery (ICA) in the European population. Methods IVUS imaging was performed during 151 CAS procedures in 140 patients from April 2013 to December 2019. In total 162 self-expanding stents of different design were implanted (66% closed-cell, 22% open-cell, 8% hybrid, 4% double layer micromesh stents). IVUS was used to measure distal reference diameter and area of ICA, minimal luminal diameter (MLD) and minimal luminal area (MLA) before and after CAS. IVUS and QA were used to measure relative stenosis area (stenosis) at baseline and relative residual stenosis area (residual stenosis) after CAS. Relative stenosis area was calculated as [1 − (MLA / distal reference area)] x 100. Results Mean (±SD) distal reference diameter of ICA was 4.5±0.8 mm. MLD increased from 1.9±0.4 mm to 3.6±0.6 mm after CAS (p&amp;lt;0.001). MLA increased from 3.9±1.7 mm2 to 12.0±3.4 mm2 after CAS (p&amp;lt;0.001). Stenosis measured by QA and IVUS was 84±9% and 76±13% respectively (p=0.01). There was a moderate correlation (Pearson's correlation coefficient r=0.575; p=0.01) between QA and IVUS measurement of ICA stenosis severity. Residual stenosis measured by QA and IVUS was 12±10% and 40±16% (p&amp;lt;0.001) respectively with only weak correlation (r=0.433; p&amp;lt;0.001) between the two methods. Conclusion Angiography slightly overestimates stenosis of internal carotid artery and substantially underestimates residual stenosis after CAS compared to IVUS. Angiography alone is inaccurate in the assessment of ICA stenosis and results of carotid stenting. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): University Hospital Motol

Surgical Revascularization for Internal Carotid Artery Stenosis in the Acute Stage of Cerebral Infarction

Surgical Revascularization for Internal Carotid Artery Stenosis in the Acute Stage of Cerebral Infarction

Moyamoya Disease Associated with Graves’ Disease and Down Syndrome: A Case Report and Literature Review

BackgroundMoyamoya vessels are cerebral vasculopathies characterized by net-like collateral vessel formation at the cerebral basal area and stenosis of the terminal internal carotid artery, proximal middle cerebral artery, and anterior cerebral artery. A diagnosis of Moyamoya disease depends on the bilateral presence of Moyamoya vessels. Moyamoya disease associated with Graves' disease has rarely been reported to be a cause of ischemic events due to hyperthyroidism. However, there are extremely rare cases of Moyamoya disease with concurrent Graves' disease and Down syndrome. We aimed to report such a case, and to compare these cases’ clinical features, pathogenesis, and treatment effects to those of the cases of concurrent Moyamoya disease and Graves' disease alone. MethodsWe performed an English literature search using the PubMed database and the keywords Moyamoya, quasi-Moyamoya, Graves’ disease, thyrotoxicosis, Down syndrome, and trisomy 21. ResultsOnly five cases of Moyamoya disease with Graves' disease and Down syndrome have been reported, including our own. Four patients were female (80%), and all underwent antithyroid therapy and experienced ischemic episodes, including transient ischemic attacks. At the time of their vascular accident, two patients were in a thyrotoxic state; only our patient was in a euthyroid state. The mean age was 15.6 years (standard deviation: 6.1), which was younger than the mean age of 31.4 years (standard deviation: 13) in patients with Moyamoya disease and Graves' disease alone. Down syndrome is commonly associated with abnormal vascular networks due to increased endostatin concentrations or immunological abnormalities such as those that occur in Graves' disease. Graves' disease accelerates the progression of Moyamoya disease and ischemic attacks due to atherosclerosis, enhances sympathetic nervous system activity and immunological changes. As compared to Moyamoya disease patients, patients with concurrent Graves' disease only and Moyamoya disease patients with concurrent Graves' disease and Down syndrome may experience accelerated disease progression or more frequent ischemic attacks. ConclusionEarly imaging follow-ups and strict control of thyroid function are necessary in such cases; if ischemic attacks have already occurred, revascularization surgery may be effective.

Role of Carotid Artery Ultrasound Duplex Prior to Cardiac Surgery in Adults in Predicting Neurocognitive Complications.

BackgroundNeurocognitive complications (NCCs) after cardiac surgery are one of the most devastating complications. Significant internal carotid artery stenosis is assumed to be a predictor of NCCs. Carotid duplex ultrasound (DUS) is a non-invasive imaging study that remains the modality of choice and is routinely used in many centers for screening adult cardiac surgery patients prior to surgery. This study aims to assess the utility of preoperative carotid DUS in the prediction of NCCs in adult patients undergoing cardiac surgery in our center.MethodsWe retrospectively reviewed the medical records of patients who underwent coronary artery bypass graft (CABG), valvular or combined surgery, at King Faisal Cardiac Center in Jeddah between January 2017 and December 2018 (n = 229). The preoperative carotid DUS findings were evaluated. Risk factors associated with NCC were analyzed.ResultsOver the study period, a total of 229 patients underwent 233 procedures. Median age was 60 years (interquartile range [IQR] = 51-67 years), of whom 71% were males. Out of the diabetic patients, 67% had an HbA1C level above 7% pre-operatively. Carotid DUS was performed on 63% of patients, but only 6.9% developed a post-operative NCC. Patients who were actively smoking were more likely to develop NCC compared to nonsmokers or ex-smokers (14.7% vs 4.6%; p = 0.02), with an odds ratio of 3.6 (95% CI = 1.2-10.5). Patients who developed NCC had a significantly higher median intensive care length of stay (7 vs. 5 days; p = 0.05).ConclusionsAlthough international guidelines clearly define which patient should get preoperative carotid DUS screening, the level of evidence is low. Based on our findings, preoperative routine use of carotid DUS prior to cardiac surgery has low utility in predicting NCC. We recommend a more tailored approach based on signs, symptoms, and high-risk features to optimize the utilization of resources, avoid unwarranted delays, and personalize patient care.

Personalization of Aspirin Therapy Ex Vivo in Patients with Atherosclerosis Using Light Transmission Aggregometry.

Acetylsalicylic acid (ASA), also known as aspirin, appears to be ineffective in inhibiting platelet aggregation in 20–30% of patients. Light transmission aggregometry (LTA) is a gold standard platelet function assay. In this pilot study, we used LTA to personalize ASA therapy ex vivo in atherosclerotic patients. Patients were recruited who were on 81 mg ASA, presenting to ambulatory clinics at St. Michael’s Hospital (n = 64), with evidence of atherosclerotic disease defined as clinical symptoms and diagnostic findings indicative of symptomatic peripheral arterial disease (PAD), with an ankle brachial index (ABI) of <0.9 (n = 52) or had diagnostic features of asymptomatic carotid arterial stenosis (CAS), with >50% stenosis of internal carotid artery on duplex ultrasound (n = 12). ASA compliance was assessed via multisegmented injection-capillary electrophoresis-mass spectrometry based on measuring the predominant urinary ASA metabolite, salicyluric acid. LTA with arachidonic acid was used to test for ASA sensitivity. Escalating ASA dosages of 162 mg and 325 mg were investigated ex vivo for ASA dose personalization. Of the 64 atherosclerotic patients recruited, 8 patients (13%) were non-compliant with ASA. Of ASA compliant patients (n = 56), 9 patients (14%) were non-sensitive to their 81 mg ASA dosage. Personalizing ASA therapy in 81 mg ASA non-sensitive patients with escalating dosages of ASA demonstrated that 6 patients became sensitive to a dosage equivalent to 162 mg ASA and 3 patients became sensitive to a dosage equivalent to 325 mg ASA. We were able to personalize ASA dosage ex vivo in all ASA non-sensitive patients with escalating dosages of ASA within 1 h of testing.

Diagnosis and clinical course of ocular ischemic syndrome with retinal vascular abnormalities due to unilateral ocular artery and internal carotid artery stenosis in a child with neurofibromatosis type 1: a case report

BackgroundNeurofibromatosis type 1 (NF1) is a hereditary disease that causes neurofibromas generally, but it has been reported to sometimes be associated with various forms of blood vessel stenosis, occlusion and vascular abnormalities of unknown mechanism. However, a symptomatic case with simultaneous ophthalmic artery stenosis and internal carotid artery stenosis is an extremely rare pathogenesis in a child with NF1. In this report, we performed the diagnosis and observation using various imaging modalities for this rare pediatric case.Case presentationA 6-year-old girl diagnosed with NF1 presented with gradual visual loss in the right eye. Best corrected visual acuity (BCVA) was 20/40 OD and the intraocular pressure (IOP) was normal in both eyes. Retinal vascular abnormalities with tortuous vessels and optic disc pallor were observed in the right fundus. Widefield fluorescein angiography revealed multiple sites of neovascularization and a large non-perfusion area in the peripheral retina. Optical coherence tomography angiography showed retinal vascular abnormalities in the right eye and revealed differences in inner retinal thickness and blood flow signal between the left and right eyes. Laser speckle flowgraphy showed that chorioretinal blood flow was significantly decreased in the right eye. Cerebral angiography revealed the right ophthalmic artery was significantly narrowed throughout. In addition, Magnetic resonance angiography revealed that the right internal carotid artery was significantly narrowed in the ophthalmic segment. We diagnosed ophthalmic artery and internal carotid artery stenosis with retinal vascular abnormalities and ocular ischemic syndrome in NF1. Because IOP increased to 35 mmHg, due to neovascular glaucoma in addition to mild vitreous hemorrhage occurred, panretinal photocoagulation was performed after intravitreal bevacizumab injection. After treatments, IOP normalized, but BCVA decreased to 20/100 OD. Arterial spin labeling showed normal cerebral blood flow. The patient is currently being carefully monitored.ConclusionsWe have described the diagnosis and treatment of ocular ischemic syndrome due to multiple arteries stenosis in a child with NF 1. Utilization of various imaging modalities was helpful in diagnosing the complicated pathogenesis. However, since direct intervention by neurosurgery is not possible in this case, it is expected that treatment will be extremely difficult in the future.

Transcarotid Artery Revascularization by Prosthetic Conduit for Patients With Unfavorable Common Carotid Anatomy

Transcarotid artery revascularization (TCAR) using the ENROUTE Transcarotid Neuroprotection and Stent System (Silk Road Medical, Sunnyvale, Calif) is a hybrid technique with excellent initial outcomes. The technical success of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet the anatomic criteria for TCAR and are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy by the adoption of a prosthetic arterial conduit. Patient 1, a 57-year-old man, presented with recurrent >90% internal carotid artery (ICA) stenosis after carotid endarterectomy for symptomatic disease. Arteriography demonstrated severe stenosis of the ICA and diffuse CCA atherosclerosis (Fig, A). The CCA was replaced with a 6-mm polytetrafluoroethylene interposition graft incorporating a side arm limb for stent deployment (Fig, B-D). Patient 2 was a 62-year-old man with prior neck irradiation and asymptomatic >90% stenosis of the distal CCA. Computed tomography angiography showed a <5-cm distance from clavicle to carotid lesion. We performed TCAR by a 6-mm Dacron conduit sewn to the CCA. Patient 3 was an 80-year-old woman with recurrent symptomatic >80% ICA stenosis. TCAR was performed in the same manner as in patient 2, secondary to short distance. Patient 4, a 65-year-old man with prior neck irradiation and ICA stent, presented with severe in-stent stenosis and distal CCA stenosis. TCAR was performed by a Dacron conduit sewn to the proximal CCA with stenting of both ICA and CCA lesions. Technical success was 100% (Table). The 30-day ipsilateral stroke rate was 0%; however, the 30-day patency was 75%. Patient 2 experienced anaphylaxis after protamine administration and a subsequent cardiac arrest. He recovered without consequence. Computed tomography angiography 1 month postoperatively demonstrated stent thrombosis. TCAR is an excellent option for many patients with carotid artery stenosis. Unfavorable CCA anatomy has limited the applicability of this hybrid technology. TCAR by a prosthetic conduit has the potential to expand the eligibility for this promising therapy.TableResultsProcedure time2 hoursFlow reversal time8.5 minutesTechnical success100%30-day patency75%30-day stroke0% Open table in a new tab

Silent brain infarcts and white matter lesions in patients with asymptomatic carotid stenosis.

The association of carotid atherosclerosis with silent brain infarcts (SBIs) and white matter lesions (WMLs) currently remains unknown. This study aims to compare SBIs, deep white matter lesions (DWMLs), and periventricular white matter lesions (PWMLs) in ipsilateral and contralateral hemispheres to internal carotid artery (ICA) stenosis, and investigate their association with stenosis grade in patients with asymptomatic ≥ 50% unilateral extracranial ICA stenosis. Patients without previous history of stroke and/or transient ischemic attack who had ≥ 50% stenosis in unilateral ICA on carotid color Doppler ultrasound were enrolled in the study. Patient demographics, vascular risk factors and ICA stenosis grades; number, location, and size of SBIs, DWMLs, and PWMLs in ICA territory were evaluated in both hemispheres using magnetic resonance imaging of the brain. Of the 69 patients, 53 had 50-69% (76.8%) and 16 had ≥ 70% (23.2%) unilateral ICA stenosis. There was no statistically significant difference in SBIs between ipsilateral and contralateral hemispheres to ≥ 50% ICA stenosis. Comparison of ICA stenoses as 50-69% and ≥ 70% revealed a greater number of patients with SBI in ipsilateral hemisphere to ≥ 70% stenosis compared to contralateral (p = 0.025). The number of SBIs was also higher in ipsilateral hemisphere to ≥ 70% stenosis compared to contralateral (p = 0.022). While DWMLs and PWMLs did not differ between hemispheres, frequency of Fazekas grade1 DWMLs was lower in ipsilateral hemisphere to either 50-69% or ≥ 70% ICA stenosis compared to contralateral (p = 0.035 and p = 0.025, respectively). Results of the present study indicate that stenosis grade may be relevant in the association between asymptomatic carotid stenosis and SBIs, and ≥ 70% stenosis may pose a risk of SBI development.

Relaxation-Enhanced Angiography Without Contrast and Triggering (REACT) for Fast Imaging of Extracranial Arteries in Acute Ischemic Stroke at 3\u202fT

PurposeTo evaluate a novel flow-independent 3D isotropic REACT sequence compared with CE-MRA for the imaging of extracranial arteries in acute ischemic stroke (AIS).MethodsThis was a retrospective study of 35 patients who underwent a stroke protocol at 3 T including REACT (fixed scan time: 2:46 min) and CE-MRA of the extracranial arteries. Three radiologists evaluated scans regarding vessel delineation, signal, and contrast and assessed overall image noise and artifacts using 5-point scales (5: excellent delineation/no artifacts). Apparent signal- and contrast-to-noise ratios (aSNR/aCNR) were measured for the common carotid artery (CCA), internal carotid artery (ICA, C1 segment), and vertebral artery (V2 segment). Two radiologists graded the degree of proximal ICA stenosis.ResultsCompared to REACT, CE-MRA showed better delineation for the CCA and ICA (C1 and C2 segments) (median 5, range 2–5 vs. 4, range 3–5; P < 0.05). For the ICA (C1 and C2 segments), REACT provided a higher signal (5, range 3–5; P < 0.05/4.5, range 3–5; P > 0.05 vs. 4, range 2–5) and contrast (5, range 3–5 vs. 4, range 2–5; P > 0.05) than CE-MRA. The remaining segments of the blood-supplying vessels showed equal medians. There was no significant difference regarding artifacts, whereas REACT provided significantly lower image noise (4, range 3–5 vs. 4 range 2–5; P < 0.05) with a higher aSNR (P < 0.05) and aCNR (P < 0.05) for all vessels combined. For clinically relevant (≥50%) ICA stenosis, REACT achieved a detection sensitivity of 93.75% and a specificity of 100%.ConclusionGiven its fast acquisition, comparable image quality to CE-MRA and high sensitivity and specificity for the detection of ICA stenosis, REACT was proven to be a clinically applicable method to assess extracranial arteries in AIS.