Symptomatic Internal Carotid Artery Research Articles

Risk factors for carotid endarterectomy in the early period of stroke

The OBJECTIVE was to identify significant risk factors of complications after carotid endarterectomy in the acute period of ischemic stroke, thus improving the outcomes of surgical treatment of symptomatic internal carotid artery stenosis.METHODS AND MATERIALS. The results of treatment of 776 patients after carotid endarterectomy in the acute period of stroke operated in the State Budgetary Institution of Tuberculosis «Regional Clinical Hospital № 2» were subjected to the factor analysis. catamnesis of the disease was traced for at least one year from the surgical intervention.RESULTS. Repeated ispilatory stroke occurred in 13 patients. Significant factors were tortuosity of the target artery (OR, 6.94; 95 % cI=2.21–21.86; p=0.003), aneurysm in the tortuosity zone (OR, 138.5; 95 % cI=11.6–1643.1; p=0.001), the presence of an electric cardiac pacemaker in the patient (OR, 31.71; 95 % cI=2.69–373.84; p=0.05), and need for IcA resection (OR, 6.83; 95 % cI=2.1–21.48; p=0.004). The risk factor for contralateral stroke in the early postoperative period was the use of a temporary intraluminal shunt (OR – 35.86; 95 % cI=2.17–592.92; p=0.05). Tortuosity of the target artery (OR – 4.6; 95 % cI=1.1–18.3; p=0.017), the need for IcA resection and in the presence of complicated atherosclerotic plaque in the reconstruction area (OR – 6.84; 95 % cI=1.89–24.85; p=0.01) turned out to be the sig nificant risk of death in the immediate postoperative period.CONCLUSIONS. Significant risk factors for recurrent stroke and death after carotid endarterectomy performed in the acute period of stroke were the tortuosity of the target artery, an aneurysm in the tortuosity zone, the presence of an electric cardiac pacemaker in the patient and the need for IcA resection in the presence of complicated atherosclerotic plaque in the reconstruction zone. The only risk factor for contralateral stroke in the early postoperative period was the use of a temporary intraluminal shunt. Further large trials are needed to clarify the obtained results.

Guideline for the management of symptomatic and asymptomatic internal carotid artery stenosis

Stenoses of the internal carotid artery (ICA) with a≥ 50% degree of stenosis are common in the German population with aprevalence of approx. 4.2%. Furthermore, about 15% of ischemic strokes are due to stenosis or occlusion of the ICA. There are currently three approaches to the treatment of ICA stenoses: conventional therapy, endovascular treatment and surgical treatment. Summary of the S3guideline on the diagnosis, treatment and follow-up of extracranial carotid stenosis from 3February2020. Color-coded duplex sonography, computed tomography (CT) angiography and magnetic resonance (MR) angiography and, in exceptional cases, diagnostic subtraction angiography can be used to diagnose ICA stenoses, including the stenosis grade. The classification is into symptomatic and asymptomatic ICA stenoses. ICA stenoses can be treated conservatively, endovascularly with stenting or surgically by carotid endarterectomy. Invasive treatment should be carried out under inpatient conditions, whereby the hospital stay should be kept as short as possible. Color-coded duplex sonography should be performed regularly before discharge and at regular intervals thereafter to detect recurrent stenosis at an early stage and, if necessary, to initiate further invasive therapy. When choosing the treatment modality, particular attention must be paid to whether the stenosis is symptomatic or asymptomatic and the degree of stenosis. The S3guideline on the diagnosis, treatment and follow-up of extracranial carotid stenosis from 3February2020 provides guidance here.

Significance of atherosclerotic plaque location in recanalizing non-acute long-segment occlusion of the internal carotid artery

To investigate the significance of atherosclerotic plaque location in hybrid surgery comprising both endovascular recanalization approaches and carotid endarterectomy for symptomatic atherosclerotic non-acute long-segment occlusion of the internal carotid artery (ICA), 162 patients were enrolled, including 120 (74.1%) patients in the proximal plaque group and 42 (25.9%) in the distal plaque group. Surgical recanalization was performed in all patients, with successful recanalization in 119 (99.2%) patients in the proximal and 39 (92.9%) in the distal plaque group. The total successful recanalization rate was 97.5% (158/162) with a failure rate of 2.5% (4/162). Periprocedural complications occurred in 5 (4.2% or 5/120) patients in the proximal plaque group, including neck infection in two (1.7%), recurrent nerve injury in 1 (0.8%), and laryngeal edema in 2 (1.7%), and 2 (4.8%) in the distal plaque group, including femoral puncture infection in 2 (4.8%). No severe complications occurred in either group. Univariate analysis showed plaque location was a significant (P = 0.018) risk factor for successful recanalization, and multivariate analysis indicated that the plaque location remained a significant independent risk factor for recanalization success (P = 0.017). In follow-up 6–48 months after the recanalization surgery, reocclusion occurred in two (2.8%) patients in the proximal plaque group and 4 (13.3%) in the distal plaque group. In conclusion, although hybrid surgery achieves similar outcomes in patients with ICA occlusion caused by either proximal or distal atherosclerotic plaques, plaque location may be a significant risk factor for successful recanalization of symptomatic non-acute long-segment ICA occlusion.

Long-term outcomes after formation of a low-flow STA-MCA bypass for treatment of symptomatic occlusion of the internal carotid artery

Aim. To evaluate short‑ and long‑term effectiveness of low‑flow bypass between superficial temporal artery and M4 segment of middle cerebral artery (low‑flow STA‑MCA bypass) in patients with symptomatic occlusion of the internal carotid artery (ICA).Materials and methods. Between 2016 and 2019 at the Department of Neurosurgery of the N. V. Sklifosovsky Research Institute of Emergency Medicine, 54 patients who underwent low‑flow STA‑MCA bypass formation at the side of symptomatic ICA occlusion between 2013 and 2015 were examined. Symptomatic ICA occlusion was more common in men than in women (7:1 ratio). Patient age varied between 48 and 73 years (mean age was 62 years).During low‑flow STA‑MCA bypass formation surgery for symptomatic ICA occlusion, intraoperative flowmetry was used in 52 (96 %) patients, in 2 (4 %) patients this diagnostic method was impossible to perform due to technical difficulties. The main examination methods in the long term after cerebral revascularization were evaluation of neurological status dynamics per the National Institute of Health Stroke Scale (NIHSS); modified Rankin scale; Rivermead mobility index; computed tomography angiography of the extra‑intracranial arteries; ultrasound (US) examination of the STA‑MCA bypass for eval uation of linear and volumetric blood flow velocities; single‑photon emission computed tomography. The type and size of trephination were evaluated, and operative time was taken into account.The patients were divided into 3 groups: group 1 included patients with follow‑up period of 1–2 years after cerebral revascularization, group 2 – 3–4 years, group 3 – 5–6 years. All results were compared to preoperative, early, and longterm measurements.Results. In the long‑term postoperative period between 1 and 6 years after cerebral revascularization, 54 patients were examined. Computed tomography angiography and US showed functioning STA‑MCA bypass in 53 (98 %) patients. According to single‑photon emission computed tomography of the brain, regional cerebral blood flow in the longterm postoperative period varied between 28 and 40 mL / 100 g / min, median regional cerebral blood flow in the long‑term postoperative period was 38 mL / 100 g / min. Intraoperative flowmetry was performed in 52 (96 %) patients, median was 15.5 mL / min. US showed that linear blood flow velocity in the STA‑MCA bypass varied between 20 and 95 cm / s, median was 49 cm / s. Volumetric blood flow varied between 30 and 85 mL / min with median of 75 mL / min.Resection trephination was performed in 36 (67 %) patients, mean size of trephination hole was 3 cm3. In the study, operative time was measured: mean value was 212 min; no significant correlation between operative time and trephination size was observed.Improved neurological status was observed in all study groups. Per the NIHSS, in group 1 (1–2 years) improvement was observed in 59 % of patients, in group 2 (3–4 years) in 48 %, in group 3 (5–6 years) in 47 %. Per the modified Rankin scale, in group 1 improvement was observed in 36.4 % of patients, in group 2 – in 48 %, in group 3 – in 42.9 %. Per the Rivermead mobility index, in group 1 improvement was observed in 63.3 % patients, in group 2 – in 56 %; in group 3 – in 57.1 %. The best outcomes were observed in group 1 (63.3 %).Conclusion. Instrumental diagnostic methods and evaluation of neurological status showed positive dynamics both in the postoperative period and in long‑term period between 1 and 6 years after low‑flow STA‑MCA bypass formation. In the long term, repeat abnormalities of cerebral blood flow of ischemic type and repeat transient ischemic attacks were not observed. Correct selection of patients in the preoperative period and comprehensive treatment including drug therapy in the postoperative and long‑term periods allow to prevent repeat ischemic cerebrovascular disease and therefore improve patients’ quality of life.

Evaluating the association between vascular remodeling and plaque calcification patterns of the carotid artery and its effects on ischemic symptoms using CT angiography.

Arterial remodeling is a compensatory mechanism of the vessel wall in response to atherosclerotic plaque growth. However, the clinical significance of vascular remodeling of carotid lesions remains unclear. Through this study, we aimed to evaluate the association between vascular remodeling and ischemic symptoms in patients with an internal carotid artery (ICA) stenosis degree ≥50%, considering the differences in plaque calcification patterns. This retrospective cross-sectional study included adult patients with moderate-to-severe proximal ICA stenosis associated with atherosclerotic plaques admitted to the Zhejiang Hospital between September 2018 and March 2023. Parameters such as lumen diameter, plaque calcification types, calcium scores, and calcification thickness were assessed using non-contrast and contrast-enhanced computed tomography angiography (CTA). The remodeling ratio (RR) was calculated by dividing the maximum distance of the proximal ICA between the inner border of the arterial lumen at the plaque site and the outer borders of the plaque by the luminal diameter. Atherosclerosis risk factors and medications were recorded. The Mann-Whitney U test or chi-square test was used to compare the differences between groups. Correlations were measured using Pearson's correlation coefficient. Predictors of ischemic symptoms were assessed using multivariable logistic regression analysis, with results expressed as odds ratio (ORs) with 95% confidence intervals (CIs). A P value less than 0.05 (two-sided) was considered to indicate statistical significance The differences in RR among plaque calcification types and the association between vascular remodeling and clinical symptoms were analyzed. A total of 242 ICAs in 196 patients were included in this study, and 84 were symptomatic and 158 were asymptomatic. The RR in symptomatic ICA [median, 1.31 (interquartile range, 1.17-1.68)] was significantly greater than that in asymptomatic group [median, 1.20 (interquartile range, 1.05-1.45)], P=0.006). Significant differences in RR existed among plaque calcification types, among which type 5 and 6 plaques had the highest RR. About 71.5% (173/242) of all ICAs showed positive remodeling. Significant correlations were observed between RR and ischemic symptoms and between positive remodeling and calcification thickness (P<0.05 for all variables). On multivariable logistic regression analysis, calcification thickness remained significantly associated with positive remodeling of carotid arteries (OR 2.30; 95% CI: 1.06-5.01; P=0.036). Arterial remodeling exists in the ICA. A significant association between arterial positive remodeling and plaque calcification thickness was established. RR helps predict ischemic symptoms. The results of our study suggest that arterial remodeling serves as a novel measure to help ascertain the risk stratification of ischemic events in carotid atherosclerotic disease.

Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Single-Center Experience.

Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) can be managed with staged (CEA before CABG), reverse staged (CABG before CEA) or synchronous treatment. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG. Between 2000 and 2020 a total of 185 patients with symptomatic triple-vessel or left main coronary artery disease associated with 70-99% asymptomatic or 50-99% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. Study endpoints were defined as mortality, stroke and myocardial infarction at 30days. Additionally, the composite endpoint of these events was investigated. At 30days, mortality, stroke and myocardial infarction rates were 5.9%, 8.1% (permanent [unresolved deficit at discharge] 5.4%) and 3.8%, respectively, and the composite endpoint was reached in 13.0% of patients. Patientssuffering from a stroke more frequently had a contralateral 70-99% ICA stenosis (60.0% vs. 17.3%; p < 0.001), peripheral artery disease (73.3% vs. 38.9%; p = 0.013) and prolonged cardiopulmonary bypass time (mean 119 ± 62min vs. 84 ± 29min; p = 0.012). Multivariate logistic regression analysis revealed the duration of cardiopulmonary bypass (odds ratio [OR] 1.024; 95% confidence interval [CI] 1.002-1.046; p = 0.034), a history of type 2 diabetes mellitus (OR 5.097; 95% CI 1.161-22.367; p = 0.031) and peripheral artery disease (OR 5.814; 95% CI 1.231-27.457; p = 0.026) as independent risk factors for reaching the composite endpoint. Patients undergoing synchronous CEA and CABG face an elevated risk of perioperative cardiovascular events, particularly an increased stroke risk in patients with symptomatic and bilateral ICA stenosis. Graphical Abstract available for this article.

Perfusion Profiles May Differ Between Asymptomatic Versus Symptomatic Internal Carotid Artery Occlusion.

Perfusion Profiles May Differ Between Asymptomatic Versus Symptomatic Internal Carotid Artery Occlusion.

Effect of collateral circulation in patients with multiple craniocervical artery stenoses.

Based on previous findings, collateral circulation in the brain is vital in mitigating cerebral ischemia's effects and influencing stroke risk. This retrospective study examined collateral circulation, admission ischemic stroke status, and long-term recurrence in patients with multiple craniocervical artery stenoses. Consecutive symptomatic internal carotid artery (ICA) stenosis patients from the First Affiliated Hospital of Soochow University were recruited. Baseline data including medical histories and neurological function at admission were collected. Imaging techniques assessed collateral compensative capacity. Multivariate logistic regression analysis was used to investigate the association between collateral circulation and case status. A total of 559 patients with symptomatic ICA stenosis were included, among whom 153 (27.4%) had concurrent moderate to severe vertebro-basilar artery (VBA) stenosis. Dizziness, weakness/numbness, and slurring of speech were the primary symptoms in all patients. Over 36 months, 71 (12.7%) patients experienced a recurrence of acute ischemic stroke (AIS). In multivariate analysis, collateral circulation was found to be negatively associated with AIS (regional leptomeningeal collateral [rLMC] scores: OR: 0.798, 95% CI: 0.743-0.857, p < 0.001; Tan scores: OR: 0.478, 95% CI: 0.336-0.679, p < 0.001). Meanwhile, the collateral circulation scores were significantly associated with the recurrence of AIS within 3 years (rLMC scores: OR: 0.926, 95% CI: 0.860-0.997, p = 0.042; Tan scores: OR: 0.467, 95% CI: 0.306-0.712, p < 0.001). Most associations remained significant in the subgroup of patients with VBA stenosis. Favorable collateral circulation in multiple craniocervical artery stenosis patients reduced long-term ischemic event recurrence. Stratifying treatment risks is essential for optimizing outcomes.

Endovascular Recanalization for Nonacute Carotid Artery Occlusion: A Nationwide Registry‐Based Cohort Study

Background The management of nonacute symptomatic internal carotid artery occlusion remains unsatisfactory. Endovascular recanalization has been reported to be feasible but associated with a noteworthy risk of postprocedural complications in patients with symptomatic internal carotid artery occlusion. The present study aimed to investigate whether successful recanalization exerts clinical benefits over procedural risks. Methods We analyzed consecutive patients who underwent endovascular treatment of nonacute symptomatic internal carotid artery occlusion in a nationwide prospective registry. The primary outcome was the ipsilateral ischemic stroke recurrence. Other outcomes of interest included all strokes and death during follow‐up, and 30‐day symptomatic intracranial hemorrhage, and all strokes after intervention. Results The final analysis included 511 patients. Endovascular revascularization was successful in 300 patients (58.7%) but failed in 211 patients (41.3%). Patients with successful recanalization had less time from the last ischemic event to the endovascular treatment as compared with patients with failed recanalization (median [interquartile range] days, 18 [12–33] versus 22 [14–50]; P =0.003). Successful recanalization was associated with a higher rate of symptomatic intracranial hemorrhage within 30 days after intervention (odds ratio [OR], 7.99 [95% CI, 1.02–62.39]; P =0.047). Thirty‐day all strokes (OR, 1.91 [95% CI, 0.83–4.40]; P =0.128) and ischemic stroke (OR, 0.90 [95% CI, 0.33–2.46]; P =0.839) did not differ significantly. During a median follow‐up of 37 months, patients with successful recanalization demonstrated a reduced risk of ipsilateral ischemic stroke (adjusted hazard ratio, 0.28 [95% CI, 0.13–0.59]; P &lt;0.001). The 5‐year risk of all strokes and death was likewise lower in patients with successful recanalization (restricted mean survival time difference, 3.77 months [95% CI, 0.16–7.38]; P =0.041). Conclusion Despite an increase in the 30‐day symptomatic intracranial hemorrhage, successful recanalization was associated with reduced long‐term risk of ipsilateral ischemic stroke in patients with symptomatic internal carotid artery occlusion.

Safety of Tailored Transfemoral Carotid Artery Stenting for Symptomatic Elderly Patients: A Single Center Observational Study

Transfemoral carotid artery stenting (TFCAS) in symptomatic elderly patients (≥70 years old) may have a high periprocedural stroke rate. This study was performed to examine whether tailored TFCAS for symptomatic elderly patients is as safe as that for symptomatic nonelderly patients. The subjects were 185 patients with symptomatic internal carotid artery stenosis. Tailored TFCAS including postoperative management was performed based on preoperative examinations of vascular anatomy, plaque imaging, platelet aggregation activity, and cerebral hemodynamic impairment. The major 30-day perioperative stroke rates were examined. The patients included 51 (27.6%) <70 (group Y) and 134 (72.4%) ≥70 (group E) years old. Group E included significantly more cases with an elongated aortic arch, tortuous target lesion, and longer plaques (all P < 0.05). Among all cases, 181 (97.8%) procedures were performed as per preoperative planning. Group E had more frequent use of a proximal embolic protection device and a closed-cell or dual-layer micromesh stent (all P < 0.05). Seven patients (3.8%) had major stroke. Rates of major ischemic stroke (2.0% vs. 3.0%, P= 1.00) and intracranial hemorrhage (2.0% vs. 0.8%, P= 0.48) were low and did not differ significantly between groups Y and E. Symptomatic elderly patients have several unfavorable factors. However, tailored TFCAS for each patient based on preoperative examinations in symptomatic elderly patients may be as safe as that in symptomatic nonelderly patients.

Experience in surgical treatment of extra-intracranial tandem ICA stenosis at the National Medical Research Center for High Medical Technologies named after A. A. Vishnevsky of the Ministry of Defense of the Russian Federation

To date, the effectiveness and safety of reconstructive surgery for steno-occlusive lesions of the internal carotid artery (ICA) have been proven by multicenter cooperative studies Despite this, the indications and tactics of surgical treatment of patients with extra-intracranial tandem stenotic lesions of the ICA remain controversial. In the period 2010-2020, 32 patients with symptomatic (15 cases) and asymptomatic tandem ICA lesions were hospitalized for surgical treatment. The distribution of tandem lesions was as follows: 10 patients had bicarotid hemodynamically significant stenotic and occlusive lesions of the ICA ostium in combination with stenosis of more than 50% of the petrous (4 cases), cavernous (8 cases), and clinoid segments (5 cases), of these, four had bilateral intracranial stenosis; 22 patients with hemodynamically significant lesions of the ICA and vertebral artery (VA) in combination with stenosis of more than 50% of the petrous (10 cases), foramen lacerum (2 cases), cavernous (16 cases), clinoid (14 cases), and ophthalmic segments (1 cases), of these, six had bilateral intracranial stenosis of the ICA. All patients underwent staged surgical interventions on the arteries of the carotid and vertebrobasilar systems. In the postoperative period, there was one case of repeated ischemic stroke in the territory of the reconstructed artery after the application of extra-intracranial microanastomosis (EICMA). There were no relapses of restenosis or acute cerebrovascular accident (CVA) in the follow-up. Staged reconstructive and revascularization treatment is safe and effective for tandem extra-intracranial lesions of the ICA. It is necessaryto continue further study of this issue in order to develop unified tactics and methods of surgical treatment.

Risk of new cerebral ischemic events in patients with symptomatic internal carotid artery stenosis while awaiting carotid stent placement.

Although there is an emphasis on performing carotid artery stent (CAS) placement within 2weeks after index event of transient ischemic attack (TIA) or minor stroke in patients with significant extracranial internal carotid artery (ICA) stenosis, the risks and characteristics of recurrent cerebral ischemic event while waiting for CAS placement are not well defined. We analyzed patients admitted to our institution over a 45-month period with symptomatic extracranial ICA stenosis. We identified any new cerebral ischemic events that occurred between index cerebral or retinal ischemic event and CAS placement and categorized them as TIA and minor or major ischemic strokes. We calculated the risk of new ipsilateral cerebral ischemic events between index cerebral or retinal ischemic event and CAS placement. The mean age of 131 patients analyzed was 67years (range: 47-94 years; 92 were men), and 94 and 37 patients had 70%-99% and 50%-69% severity of stenosis, respectively. The mean and median time intervals between index cerebral or retinal ischemic event and CAS performance were 28 (standard deviation [SD] 30) and 7 (interquartile range 33) days, respectively. A total of 9 of 131 patients (6.9%, 95% confidence interval 2.5%-11.2%) experienced new cerebral ischemic events over 3637 patient days of observation. The risk of new ipsilateral cerebral ischemic events was 2.5 per 1000 patient days of observation. We estimated the risk of new ipsilateral cerebral ischemic events in patients with ICA stenosis ≥50% in severity while waiting for CAS placement to guide appropriate timing of procedure.

Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion

Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. ClinicalTrials.gov Identifier: NCT01758614.

Flow Diverter Stenting for Symptomatic Intracranial Internal Carotid Artery Aneurysms: Clinical Outcomes and Factors for Symptom Improvement.

Flow diverter (FD) stenting is expected to improve cranial nerve symptoms caused by aneurysms via the theoretical reduction of the mass effect by promoting spontaneous thrombosis through the flow diversion effect. However, the factors involved in symptom improvement after treatment remain unclear. This study was performed to identify factors for symptom improvement after FD stenting and the symptom improvement rate of each impaired cranial nerve. We retrospectively evaluated 33 patients who underwent FD stenting for symptomatic internal carotid artery aneurysms at our institution from January 2016 to June 2021. Twenty-three (69.7%) patients had resolved or improved symptoms after 1 year of treatment. The optic nerve was affected in 12 patients; the oculomotor nerve, in 16; the trigeminal nerve, in 2; and the abducens nerve, in 13. There was no statistically significant difference in the symptom improvement rate of each impaired cranial nerve. The patients were classified into the improved and nonimproved groups based on their symptoms after 1 year of treatment, and the factors related to the symptoms were analyzed. The time from onset to treatment was significantly shorter in the improved group than in the nonimproved group (197.1 and 800 days, respectively; p = 0.023). There were no significant differences in age, aneurysm diameter, adjunctive coil embolization, partial thrombosis, change in mass diameter on magnetic resonance imaging, or aneurysm occlusion rate on angiography between the two groups. These results suggest that early treatment after the onset of aneurysm-induced cranial neuropathies increases the likelihood of symptom improvement.

Endovascular recanalization for symptomatic chronic internal carotid artery occlusion: proposal of a modified angiographic classification and clinical outcomes

PurposeTo stratify angiographic images of chronic internal carotid artery occlusion (CICAO) into a newly modified angiographic classification, and identify suitable candidates for endovascular recanalization. MethodsThis study included 51 consecutive patients with symptomatic CICAO who underwent endovascular recanalization at our institution. Patients’ clinical information, angiographic findings, procedural results, and outcomes were recorded. We attempted to stratify all angiographic images into categories based on morphological occlusive patterns and distal internal carotid artery (ICA) lumen reconstitution on digital subtraction angiography (DSA). ResultsFour types (I–IV) of CICAO were identified based on angiographic characteristics. We defined type I as having a tapered (IA) or blunt stump (IB) and distal ICA lumen reconstitution with collateral filling; type II as having no stump but with distal ICA lumen reconstitution; type III as having a tapered (IIIA) or blunt stump (IIIB) but no distal ICA lumen reconstitution; type IV as having no stump and no distal ICA lumen reconstitution. The rate of successful recanalization was 90.3 % for type I, 60.0 % for type II, 50.0 % for type III, 0 % for type IV, respectively (P = 0.002). The overall intraoperative complication rate was 11.8 %, and none of them led to severe neurological damage or death. The follow-up modified Rankin Scale (mRS) scores were significantly decreased in successfully revascularized patients, whilst there were no significant changes in the other failed patients. ConclusionFor symptomatic CICAO, our newly modified angiographic classification may be comprehensive and useful in selecting suitable patients for recanalization and grading the difficulty of the procedures.

Dual- vs single-layer stents for endovascular treatment of symptomatic and asymptomatic internal carotid artery stenosis

BackgroundsPlaque protrusion is a common event among carotid artery stenting (CAS) patients and increases ischemic complication risk. Dual-layer stents (DLS) with micromesh technology may offer greater plaque protection compared to single-layer stents (SLS), but few data are available. The aim of the study is to compare clinical outcomes at 12 months for asymptomatic and symptomatic patients treated for primary CAS with DLS or SLS in a high-volume center. MethodsA retrospective analysis of consecutive symptomatic and asymptomatic patients treated with primary CAS for internal carotid artery (ICA) stenosis, with either DLS or SLS between 2015 and 2019, was performed. Primary endpoints included rates of ipsilateral transient ischemic attacks (TIA)/stroke and death within 1-year from CAS. Secondary endpoints included patency rates and survival according to stent type. ResultsOf the 301 patients who met inclusion criteria (74.8 % male; 73.6 mean age ± 8.7 years), most patients were asymptomatic (77.4 %). Among all patients DLS was most frequently deployed (66 %); also, among asymptomatic (62 %) and symptomatic patients (81 %), p < 0.01. Symptomatic patients had less comorbidities and severe disease than asymptomatic patients.Six peri-operative strokes were recorded and, within 1 year, 2 additional strokes were registered among symptomatic patients treated with SLS. No post-operative strokes were encountered in the DLS group (p = 0.04) among symptomatic patients. Higher rates of TIA were observed among asymptomatic patients treated with DLS compared to SLS while rates of TIA were reduced among symptomatic patients treated with DLS.There were no differences in patency rates for DLS and SLS in symptomatic and asymptomatic patients. Primary patency was similar among DLS stent types but differed among SLS stent types (p = 0.01).At a mean follow-up of 27 months ±17.6, survival was comparable between DLS and SLS groups (p = 0.98). ConclusionCAS with DLS seems to reduce the risk of post-procedural stroke for symptomatic patients compared to SLS whilst the choice of stent did not influence ipsilateral TIA, survival or patency rates. These data require confirmation from larger, randomized, prospective studies.

Endovascular Surgery Revascularization of Chronic Cervical Carotid Occlusions: Systematic Review and Meta‐Analysis

Background Chronic symptomatic internal carotid artery occlusion is an important cause of ischemic strokes. Medical management alone remains suboptimal for secondary prevention, and randomized controlled trials failed to demonstrate the efficacy and safety of extracranial‐intracranial vascular bypass. Carotid occlusion endovascular surgery (COES) is a promising technique, yet its efficacy and safety remain unclear. Methods This systematic review and meta‐analysis included studies in which patients with chronic symptomatic internal carotid artery occlusion underwent treatment with COES and medical management. Primary outcomes included successful reperfusion rates and periprocedural ischemic and hemorrhagic events rates. Secondary outcomes included rates of ischemic events recurrence, other periprocedural events, and mortality. Studies contained at least one of the treatment groups and outcomes of interest. Results Twenty‐two studies were selected for systematic review, with 18 of them for meta‐analysis. From 14 studies (N=561) the rate of successful recanalization was achieved in 74% of all patients undergoing COES. Thirteen studies (N=534) showed that the rate of COES was 2% both for periprocedural ischemic and hemorrhagic events. At long‐term follow‐up, the COES cohort included a total of 10 studies (N=311) and had a 12% rate of ischemic events, while the medical management group, which included 5 studies (N=313), showed a rate of 19%, with nonsignificant subgroup differences ( P =0.09, I 2 , 12%). Rates of other periprocedural mortality were 4% and 1%, respectively. Conclusion This meta‐analysis supports the use of COES as a promising and innovative technique for the secondary prevention of symptomatic internal carotid artery occlusion. Our findings suggest that COES may be superior to medical management alone, although further research is needed to fully evaluate its efficacy and safety.

An Investigation of the Relationship Between Carotid Artery Stenosis and White Matter Hyperintensities.

Introduction White matter hyperintensities (WMHs) are frequently detected on magnetic resonance imaging (MRI) with age. Although the etiology of WMH has not been fully explained, it was reported to be associated with internal carotid artery (ICA) stenosis as well as small vessel diseases. The number and volume of these lesions might increase in cases of internal carotid artery (ICA) stenosis. The present study aimed to calculate the localization and volumes of white matter lesions in the VolBrain Program and investigate the relationship between age and sex in patients with symptomatic and asymptomatic internal carotid artery stenosis. Methods MRI scans of patients with carotid stenosis with T1-weighted and fluid-attenuated inversion recovery (FLAIR) sequences were performed retrospectively for the present study, which had a retrospective design. The patients were divided into two groups (<70% and ≥70%) because endovascular intervention was considered in patients with asymptomatic stenosis over 70%. Digital subtraction angiography was used to detect carotid artery stenosis. They were also divided into four groups.According to laterality and degree of stenosis, ICA stenosis was separated as those with <70% stenosis on both sides (group 1), right side ICA <70%, left side ≥70% stenosis (group 2), right side ICA ≥70%, left side <70% stenosis (group 3), and ≥70% stenosis on both sides (group 4). A total of 102 patient images were selected that met the inclusion criteria. The measurements of white matter lesion volumes were made using the LesionBrain application in the VolBrain Program. Results The MRI of 82 patients (mean age: 65.55 ± 9.28 years), 28 females and 54 males, were used in the present study. According to LesionBrain Analysis, the total WMH volume was seen in the first and third groups at most. When analyzed in regional terms, stenosis was mostly detected in the first and third groups in the periventricular region. WMH volume was less in all areas in group 4. When examined according to the number of lesions, the most lesions were detected in the third group in the juxtacortical region. When the difference between the groups was examined, a significant difference was detected only in the volume change in the deep white region (p=0.011). No significant differences were found between WMH volumes and age and gender (p>0.05). Conclusion Stenosis of the external internal carotid artery might cause hypoperfusion and silent embolization in the brain. As a result, as well as pathological conditions in cortical areas, ischemic areas in the white matter might also cause cognitive disorders.

Transcarotid artery revascularization of a symptomatic carotid artery with a tortuous intrathoracic component

We present the case of a tortuous intrathoracic common carotid artery (CCA) with a symptomatic right internal carotid artery lesion. This patient had a complex medical history, including a previous intraoperative cardiac arrest during attempted carotid endarterectomy (CEA) initially attributed to heparin anaphylaxis. She received maximum medical management but presented 6 months later to our institution with a secondary transient ischemic attack. Surgical options for the case were discussed amongst a multidisciplinary team. Transfemoral and transradial stenting were deemed non-viable due to the tortuous nature of the CCA. Repeat CEA under general anesthesia was deemed risk-prohibitive from a cardiac risk perspective. For these reasons, the patient was offered transcarotid artery revascularization (TCAR) under regional anesthesia. Intraoperatively, the “sheath stopper” was removed from the TCAR device, allowing the sheath to be advanced to 6 cm, effectively removing the tortuous component of the CCA. Flow reversal was established, and the operation proceeded in the standard fashion without neurologic change. The patient has remained on dual antiplatelet therapy and completed 2-year follow-up without evidence of restenosis, access site complication, or repeat neurologic event. This case demonstrates the potential applicability of TCAR to benefit a subset of patients who previously lacked a surgical option due to anatomical constraints.

Staged endovascular recanalization for symptomatic atherosclerotic non-acutely occluded internal carotid artery

Symptomatic "non-acutely" occluded internal carotid artery (NAOICA) results in stroke, cognitive impairment, and hemicerebral atrophy through cerebral hypoperfusion and artery-to-artery embolism. Atherosclerosis is the main cause of NAOICA. Conventional one-stage endovascular recanalization showed effectiveness but was plagued by many challenges. This retrospective analysis reports the technical feasibility and outcomes of the staged endovascular recanalization in patients with NAOICA. Eight consecutive patients with atherosclerotic NAOICA and ipsilateral ischemic stroke within 3 months between January 2019 and March 2022 were retrospectively reviewed. The patients (all males, with a mean age of 64.6 years) underwent staged endovascular recanalization 13 to 56 days after documented occlusion by imaging techniques (mean 28.8 days); the mean follow-up period was 20 months (range: 6-28). The approach of the staged intervention was as follows. In the first stage, the occluded ICA was successfully recanalized using the simple small balloon dilation technique. In the second stage, angioplasty with a stent implant was performed with >50% residual stenosis in the initial segment or ≥70% residual stenosis in the C2-C5 segment. The technical success rate, the incidence of clinical adverse events (any stroke, death, cerebral hyperperfusion), and long-term in-stent stenosis (ISR) and reocclusion rates were evaluated. Technical success was achieved in seven patients, with early reocclusion occurring in one patient after the first-stage intervention. There were no adverse events observed within 30 days (0%), and long-term reocclusion and long-term ISR rates were both 14% (1/7). However, all patients developed iatrogenic arterial dissections during the first stage, indicating the challenge of reaching the true lumen through the occlusion site without damaging the intima. Based on the National Heart, Lung and Blood Institute (NHLBI) classification, there were two type A, four type B, three type C, and two type D dissections. The mean time interval between the two stages was 46.1 days (21-152 days). All type A and B dissections resolved spontaneously after ≥3 weeks of dual antiplatelet therapy, whereas most type C and all type D dissections did not heal spontaneously before the second stage. Also, one type C dissection led to reocclusion. This observation suggested that occlusions without flow limit and persistent vessel staining or extravasation could be clinically observed, while severe dissections (characterized as type C or greater) required prompt stenting rather than conservative treatment. Performing high-resolution MRI preoperatively to exclude fresh thrombus in the occluded vessel segment is indispensable in selecting appropriate candidates for endovascular recanalization. This could avoid downstream embolism during the interventional procedure. This retrospective study found that staged endovascular recanalization for symptomatic atherosclerotic NAOICA may be feasible with an acceptable technical success rate and a low complication rate in the selected candidates.