Symptomatic Internal Carotid Occlusion Research Articles

Symptomatic Occlusion of Internal Carotid Artery Caused by Pituitary Macro Adenoma Among the Patients Without Apoplectic Signs; Case Report and Review of the Literature

Introduction: Pituitary adenoma producing symptomatic carotid compression of the internal carotid artery without any apoplexy sign would be extremely rare and there was only one report regarding to this condition. Case Presentation: In this case report we have described a 57-year-old woman with a nonfunctional pituitary macro adenoma which has resulted to symptomatic internal carotid occlusion. Magnetic resonance imaging (MRI) revealed a large pituitary adenoma caused tight stenosis of right internal carotid. The patient has also experienced the transient ischemic attack which has confirmed to be the cause of internal carotid artery occlusion by this macro adenoma tumor. There was not any sign of apoplexy at the time of admission and the patient has not shown a history of pituitary adenoma. The patient then has undergone an endonasal transsphenoidal resection because of this nonfunctional pituitary adenoma. Conclusions: Pituitary macro adenoma producing symptomatic internal carotid occlusion might develop to several serious conditions including transient ischemic attack. Urgent surgical procedure might be the best approach to prevent further severe complications in such patients.

Symptomatic Occlusion of Internal Carotid Artery Caused by Pituitary Macro Adenoma Among the Patients Without Apoplectic Signs; Case Report and Review of the Literature

Introduction: Pituitary adenoma producing symptomatic carotid compression of the internal carotid artery without any apoplexy sign would be extremely rare and there was only one report regarding to this condition. Case Presentation: In this case report we have described a 57-year-old woman with a nonfunctional pituitary macro adenoma which has resulted to symptomatic internal carotid occlusion. Magnetic resonance imaging (MRI) revealed a large pituitary adenoma caused tight stenosis of right internal carotid. The patient has also experienced the transient ischemic attack which has confirmed to be the cause of internal carotid artery occlusion by this macro adenoma tumor. There was not any sign of apoplexy at the time of admission and the patient has not shown a history of pituitary adenoma. The patient then has undergone an endonasal transsphenoidal resection because of this nonfunctional pituitary adenoma. Conclusions: Pituitary macro adenoma producing symptomatic internal carotid occlusion might develop to several serious conditions including transient ischemic attack. Urgent surgical procedure might be the best approach to prevent further severe complications in such patients.

Abstract WP169: Endovascular Recanalization For The Total Occlusion Of The Internal Carotid Artery At Subacute To Chronic Stage: Clinical Outcome And Pitfalls

Objective: The efficacy and pitfalls of endovascular recanalization for totally occluded internal carotid occlusion were evaluated. Materials and methods: Twenty-five cases (twenty six lesions) of symptomatic internal carotid occlusion with hemodynamic compromise or recurrent symptoms were treated at the subacute to chronic stage using an endovascular technique. At the same period, total 1200 carotid artery stenting was performed in our group. Parodi’s embolic protection system or modified Parodi’s technique was used during the recanalization procedure to prevent embolic stroke by reversing the flow from the distal internal carotid artery to the common carotid artery. Results: Recanalization of the occluded ICA was possible in 23/26 (88.5%) lesions. The occlusion points were cervical internal carotid artery : 19, and petrous - cavernous ICA : 4 in successfully recanalized cases. The patient’s ischemic symptom disappeared completely after the treatment and new ischemic symptoms did not appear related to the treated leision. Single photon emission computed tomography findings demonstrated the improvement of hemodynamic compromise in all cases with hemodynamic compromise. One case (4.3%) caused right middle cerebral artery branch occlusion during the procedure but his neurological symptoms were stable because of preexisting hemiparesis. One case (4.3%) demonstrated asymptomatic re-occlusion at the treated site. Discussion: Endovascular recanalization was possible and effective to improve hemodynamic compromise, although the incidence of this treatment is only 2.2% of the total 1200 carotid artery stenting in our series. However, there still several problems existed, such as hyperperfusion syndrome after recanalization, cerebral embolism during the treatment, and durability after treatment, and difficult identification of the occlusion point before the treatment. Conclusion: Endovascular recanalization using an embolic protection device can be considered as an alternative treatment for the symptomatic internal carotid occlusion with hemodynamic compromise or refractory to antiplatelet therapy, even in the subacute to chronic stage of the illness.

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

Conclusion: Carotid artery angioplasty and stenting can be successfully performed in patients with internal carotid artery pseudo-occlusion or string sign. Summary: This report focuses on carotid angioplasty and stenting in a series of patients in whom the internal carotid artery (ICA) was thought occluded by conventional ultrasound but who actually had string signs. The authors treated 16 patients. Contrast computed tomography (CT) showed a patent distal ICA in 14 of the 16 patients treated. Contrast-enhanced ultrasound imaging also showed patent distal ICAs in 13 cases. This is actually a series of very high-grade ICA stenosis and/or string signs treated with angioplasty and stenting. The authors performed the angioplasty and stent placement under cerebral protection. Duplex imaging was performed at 14 days, 3 months, and every 6 months thereafter. CT scans were obtained at 2 to 9 months, and the mean follow-up period was 9.9 months. Most patients had nonhemispheric symptoms as the indication for treatment. Patients were treated with clopidogrel and aspirin before the procedure and were maintained on clopidogrel 90 days after treatment and on aspirin indefinitely. A 6F sheath was placed in the common carotid artery and the ICA accessed with a 5F diagnostic vertebral catheter. A 0.035-inch hydrophilic guide wire was then passed into the ICA, followed by the catheter. An interceptor filter (Medtronic, Minneapolis, MN) was passed through the catheter and opened in the lumen, and then the catheter was withdrawn. Predilation was performed with a 3-mm balloon through the filter wire, and then a self-expanding stent was placed in the proximal ICA and dilated with a 5-mm balloon. If necessary, a second distal stent was placed. Stent placement was successful in 13 of 16 patients. There were no deaths, conversions, or cardiac complications. One patient had paresis in the upper limb with recovery in 3 months. At follow-up, all 13 patients remained with patent arterial lumens and were symptom free. After 2 to 9 months, so-called string signs had calibers close or equal to those of normal arteries. Comment: The title of this article is misleading. Although conventional duplex ultrasound imaging showed the patients had occluded ICAs, all in fact had patent distal ICAs either by contrast-enhanced ultrasound or contrast CT scanning. The authors of the article, the Journal of Vascular and Interventional Radiology reviewers, and the editors should be ashamed for permitting such a misleading title. What the authors have shown us is that in their institution, conventional duplex ultrasound imaging is likely below standard in distinguishing high-grade carotid stenosis from occlusion. They have shown us that CT angiography and contrast-enhanced ultrasound imaging can detect carotid string signs, something we already knew. They have also shown us that if you can get a wire across a high-grade stenosis, then you can perform angioplasty and stenting, again something we already knew. They have demonstrated that such procedures can be performed, but whether they should be performed is an entirely different question.

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

To report a series of patients with symptomatic internal carotid artery (ICA) occlusion treated with angioplasty and stents. From a consecutive series of 50 patients experiencing neurologic ischemic symptoms and shown by conventional ultrasonography (US) to have a total ICA occlusion, 16 patients (ages 45-79 years; mean, 63 y; 10 men) were selected between August 2006 to September 2008 to be treated with angioplasty based on discovery of an open ICA distal to the occlusion through contrast-enhanced echo Doppler imaging and/or multislice contrast computed tomography (CT). Angioplasty and stent placement were performed under cerebral protection. Follow-up duplex imaging was performed at 14 days and 3 months and every 6 months thereafter and CT follow-up was performed at 2-9 months; the mean follow-up period was 9.9 months. Lesion crossing and stent placement was successful in 13 of 16 patients. There were no deaths, conversions, cardiac complications, or major strokes. One patient had a transient mild hemiparesis in the upper limb, with total recovery in 3 months. At follow-up, all 13 patients with a good initial result remained with patent arterial lumens and resolution of neurologic ischemic symptoms. After 2-9 months, ICAs with a "string sign" had calibers close or equal to those of normal arteries. Angioplasty with stent placement is an effective treatment with a low morbidity rate for selected patients who continue to experience neurologic ischemic symptoms despite US findings of total occlusion of the ICA.

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

Angioplasty and Stent Placement in Symptomatic Internal Carotid Occlusion

Cerebral blood flow and oxygen metabolism in symptomatic internal carotid artery occlusion by atherosclerosis and by cervical dissection

Symptomatic internal carotid artery occlusion by atherosclerosis and by cervical dissection are distinct conditions with different long-term prognoses. The purpose of the present study is to investigate if regional cerebral blood flow and oxygen metabolism, after onset of stroke, differ between both conditions. Seventeen patients with symptomatic unilateral atherosclerotic internal carotid occlusion and 10 patients with symptomatic internal carotid occlusion due to cervical dissection were submitted to a positron emission tomographic (PET) study between 1 and 2 months after stroke onset. The steady state technique with 15O was used in order to determine regional cerebral blood flow, regional oxygen extraction fraction, and regional cerebral metabolic rate for oxygen in the infarct area, the peri-infarct zone, the remaining homolateral hemisphere, and the contralateral hemisphere. The results were compared between both patient’s populations. The patients with cervical dissection were on average much younger than those with atherosclerotic occlusion, but neurological impairment on admission and disability at 3 months were comparable. Between both patient populations, no differences in rCBF, rOEF, and rCMRO 2 could be demonstrated in the different regions of interest when the results were age-adjusted. Except for age-related changes, no differences in PET findings could be demonstrated between patients with symptomatic internal carotid occlusion caused by either atherosclerosis or cervical dissection.

817 Improvement of Cerebrovascular Reserve Capacity in Patients with Symptomatic Internal Carotid Occlusion after EC-IC Bypass Surgery

Charbel, Fady T. MD; Du, Xinjian MD; Guppy, Kern MD, PhD; Zhao, Meide PhD; Maksoud, Yaser Abdel MD; Ausman, James MD, PhD

Improvement in the Retinal Circulation after Superficial Temporal to Middle Cerebral Artery Bypass

The retinal circulation of 35 patients (age, 30 to 71 years) with symptomatic internal carotid occlusion (22 cases) or severe inaccessible stenosis (13 cases) was studied both before and after superficial temporal to middle cerebral artery (STA-MCA) bypass surgery using ophthalmodynamometry (ODM) and intravenous fundus fluorescein angiography (IVFA). Ninety-four per cent of the patients were found preoperatively to have funduscopic findings or symptoms indicative of ocular ischemia. ODM values were abnormal preoperatively in 32 of 35 patients (91%), and improvement in ODM values for the ipsilateral eye was noted postoperatively in 25 patients (71%). ODM values obtained during the early (less than 3 months) and late (greater than 3 months) postoperative periods were significantly improved when compared to the preoperative values. IVFA values were abnormal in 25 of 29 patients (86%) preoperatively, and significant improvement was noted in 22 of 25 patients (88%) postoperatively. Preoperative patients with normal fundus examinations (10 cases) had significantly better values for IVFA and ODM than patients with venous stasis retinopathy. The findings of the study showed that STA-MCA anastomosis is beneficial in treating retinal ischemia secondary to ipsilateral severe inaccessible carotid artery stenosis or occlusion.