Thrombosis Of Internal Carotid Artery Research Articles

Acute Carotid Artery Thrombosis: Description of 12 Surgically Treated Cases

The morbidity and mortality of stroke secondary to acute internal carotid artery thrombosis range from 40 to 69% and from 15 to 55%, respectively, after purely medical treatment. This report describes a series of 12 patients who underwent urgent surgical treatment for primary acute carotid artery thrombosis between January 1999 and December 2002. Upon admission, all patients had severe neurologic deficits contralateral to carotid artery thrombosis. One patient experienced ongoing changes in the level of consciousness. The interval between the onset of symptoms and admission was less than 6 hr in all cases. Initial work-up in all patients included a brain computed tomographic scan with contrast injection and carotid duplex scan. The operative procedure consisted of carotid thomboemdarterectomy after shunt placement with prosthetic patch closure. Intraoperative angiography was performed in all cases. Following treatment, we observed deterioration of neurologic status leading to death in one case; improvement with partial regression of initial neurologic deficit in two cases, including one patient who died from causes unrelated to carotid artery disease; and full neurologic recovery in nine cases. The delay to revascularization was longer than 6 hr in both patients who died. These data support surgical intervention for carotid artery thrombosis in selected patients without major disturbances of consciousness or hemorrhagic infarction, provided that the delay to revascularization is less than 6 hr.

Patch closure improves results with carotid endarterectomy.

The type of closure after a carotid endarterectomy, primary closure versus patch angioplasty, is controversial. Most authorities agree that in a small carotid artery (</=4 mm), particularly in the presence of technical difficulties at the internal carotid artery end of the arteriotomy, closing with a patch may avoid restenosis. Our randomized prospective studies confirm the conclusions of several others that patching in general is superior to primary closure in lowering the incidence of perioperative stroke, acute postoperative internal carotid artery thrombosis, or both. Both vein patch closure and polytetrafluoroethylene patching are superior to primary closure in this regard. Patching (polytetrafluoroethylene or saphenous vein patching) is also significantly superior in reducing significant recurrent carotid artery stenosis over the long-term. We also conclude that for those who like to preserve the saphenous vein, the preferential use of polytetrafluoroethylene or Dacron Hemashield Finesse patching may be appropriate.

Patch closure improves results with carotid endarterectomy

The type of closure after a carotid endarterectomy, primary closure versus patch angioplasty, is controversial. Most authorities agree that in a small carotid artery (≤4 mm), particularly in the presence of technical difficulties at the internal carotid artery end of the arteriotomy, closing with a patch may avoid restenosis. Our randomized prospective studies confirm the conclusions of several others that patching in general is superior to primary closure in lowering the incidence of perioperative stroke, acute postoperative internal carotid artery thrombosis, or both. Both vein patch closure and polytetrafluoroethylene patching are superior to primary closure in this regard. Patching (polytetrafluoroethylene or saphenous vein patching) is also significantly superior in reducing significant recurrent carotid artery stenosis over the long-term. We also conclude that for those who like to preserve the saphenous vein, the preferential use of polytetrafluoroethylene or Dacron Hemashield Finesse patching may be appropriate.

Thrombectomy for Acute Internal Carotid Thrombosis: Five Thrombectomy Devices Compared

Objective. To test the safety and efficiency of commercially available thrombectomy catheters in clearing simulated internal carotid artery (ICA) thrombosis.Design. Comparative in vitro study.Materials and methods. A model of the ICA was filled with human thrombus, the ‘circle of Willis’ back pressure was set at either 10 or 30 cm of water. Five thrombectomy devices (Hydrolyser, Clot Buster, Acolysis System, AngioJet and Fogarty embolectomy catheter) were compared for (i) efficiency at removing thrombus, (ii) pressure changes at the tip of each device, and (iii) distal embolisation by flow cytometry.Results. Thrombus clearance was greatest with the AngioJet (median 95%, range 92–97%) and least with the Acolysis System (median 34%, range 12–50%). The Clot Buster and Hydrolyser were safest as they produced only negative tip pressures, the AngioJet and Balloon catheter produced positive and negative pressures risking distal embolisation. The Acolysis system produced no pressure change during use. Distal embolisation (of particles between 5 and 40 μm diameter) was greatest with the Fogarty balloon catheter at 10 cm water (P<0.05) and least with the Hydrolyser and Clot Buster.Conclusion. Balloon embolectomy for ICA thrombosis risks further embolic cerebral damage. The Hydrolyser and the Clot Buster show the greatest promise for ICA thrombectomy.

Mucormycose rhinocérébrale

We report a case of a rhinocerebral mucormycosis with extensive cavernous sinus thrombophlebitis and internal carotid artery thrombosis. This case illustrates the usual clinical and imaging features of the disease, which is a potentially devastating infection in immunocompromised patients.

Cerebral haemodynamics and embolization during carotid angioplasty in high-risk patients.

Patients with symptomatic internal carotid artery (ICA) stenosis greater than 70 per cent in association with a contralateral ICA occlusion may have an increased risk of stroke following carotid endarterectomy. Such patients might benefit from the theoretically shorter ischaemic time offered by carotid angioplasty and stenting. Nine patients who underwent carotid angioplasty and stenting were monitored using near-infrared spectroscopy, continuous jugular venous oximetry and transcranial Doppler ultrasonography to detect both haemodynamic ischaemia and embolic events. Significant ischaemia occurred in four of the nine patients once the stenosis had been crossed by the guidewire (spectroscopy and oximetry). Inflation of the angioplasty balloon resulted in a brief period of ischaemia and showers of emboli in all patients (ultrasonography) and this persisted for more than 3 min after balloon deflation in three patients. One patient had a major disabling stroke due to ICA thrombosis. Angioplasty and stenting in these high-risk patients may not confer any advantage over conventional surgery in terms of both haemodynamic ischaemia and embolization.

The effect of intraoperative duplex on the management of postoperative stroke

Background. Stroke after carotid endarterectomy (CEA) may be a result of intraoperative ischemia, embolism, or thrombosis at the operative site. Intraoperative duplex should eliminate the occurrence of a severe internal carotid artery (ICA) thrombosis and, thus, negate the benefit of reoperation. This article will detail the results of our evolving treatment algorithm for immediate versus delayed post-CEA neurologic deficit (ND). Methods. We studied patients who had an ND after CEA from 1988 to 2000. Results. Thirty-two patients (3.2%) had a post-CEA ND (26 related stroke or transient ischemic attack, 6 other); 31 had a satisfactory intraoperative duplex post-CEA, 1 was not tested. Fifteen patients awoke from operation with a related deficit, 5 of whom were re-explored and all had a patent ICA. One patient without lateralizing signs who was not re-explored had extensive thrombosis at postmortem. The remaining 9 all had a duplex-proven patent ICA. Ten patients had a lucid interval before their related ND. Six patients were re-explored and all had thrombosed ICAs; 5 of the 6 improved postthrombectomy. Four patients were not re-explored for various reasons; a carotid thrombosis was not later diagnosed in any of these patients. Conclusions. Intraoperative and postoperative duplex has modified our treatment of post-CEA stroke. No longer are all patients re-explored. Patients with a normal intraoperative duplex who awaken with an immediate stroke do not usually have occlusive thrombus and routine re-exploration does not benefit these patients. Patients who have an ND develop after a lucid period may have a thrombosed ICA despite a normal intraoperative duplex, and unless there is a timely normal duplex, re-exploration is recommended and appears to benefit these patients. (Surgery 2002;132:761-6.)

Delayed presentation of carotid dissection, cerebral ischemia, and infarction following blunt trauma: two cases

Carotid artery dissection followed by cerebral infarction as a result of blunt trauma can occur in a number of forensically relevant situations. We describe two such cases. In the first case, a 19-year-old female was involved in a road traffic accident, when her car crashed into the rear of another car. Initially, the young woman presented a minor head injury without loss of consciousness and minor bruising to the left side of the neck. After 48 h, she had developed confusion, speech difficulties, right facial nerve paralysis, and right hemiplegia. CT scan and carotid angiography showed cerebral ischemia with infarction in the territory of the middle left cerebral artery and complete dissection of the left carotid artery. In the second case, a 33-year-old male with depression attempted to hang himself. The rope gave way and he fell down. He had also taken a paracetamol, and a non-steroidal anti-inflammatory drug overdose. He did not lose consciousness but appeared withdrawn and depressed. Approximately 6 h later, his conscious state deteriorated. A CT scan revealed thrombosis of the left internal carotid artery, extending to the middle cerebral artery. The patient died. Both cases reinforce the need for full neurological assessment and review of any individual subject to blunt trauma to the neck, whether accidental or deliberate or where the history is incomplete. In the forensic setting, in particular, RTAs, suspension by the neck, strangulation, and garotting are all instances when examination and assessment must be thorough – and clear advice given – in the absence of any immediate signs or symptoms – that any new symptoms or signs require immediate and thorough neurological investigation. There should be low threshold for prolonged neurological observation or further neurovascular investigations such as ultrasound, CT or MRI scan or angiography, to minimize the risk of developing potentially fatal or incapacitating sequelae.

Non-traumatic neurological emergencies: emergency neuroradiological interventions.

This article summarizes recent developments in the growing field of interventional neuroradiology for the treatment of acute cerebrovascular disease. We describe the possibilities in endovascular therapy of acute cerebral aneurysms using electrolytically detachable coils combined with trispan neck bridging devices and stent implantation to occlude acute wide neck aneurysms. Techniques and results of local intra-arterial thrombolytic therapy in acute stroke and central retinal artery occlusion are described and we discuss the potential for rapid, large-burden thrombus removal in cases of internal carotid artery thrombosis by rheolytic thrombectomy, percutaneous transluminal angioplasty and stent implantation. Emergency endovascular therapy using the transvenous approach to treat severe intracranial or intraocular hypertension and multifocal haemorrhagic venous infarction due to cerebral sinus thrombosis or dural fistulas is also described. In cases of acute bleeding of head and neck lesions following trauma, tumours after radiotherapy, arteriovenous malformations, epistaxis or from iatrogenic origin, angiography plays a major role in localizing the source of bleeding and occluding the damaged vessel during the same session using the same endovascular approach.

Skull Base Erosion by Sphenoid Fungus Balls: Diagnosis and Endoscopic Treatment

Fungus balls typically are innocuous lesions found in immunocompetent hosts. They are located most commonly in the maxillary sinus but may be life-threatening when found in the sphenoid sinus. We review our series offour sphenoid fungus balls with skull base erosion. Our average patient age was 68.7 years old (56-86 years) with three women and one man. One patient was insulin-dependent diabetic, the other three patients were otherwise healthy. The most common presenting symptoms were headache and dizziness with relatively few sinus-specific complaints. Endoscopy revealed polyps in two of the four patients. Computerized tomography scans revealed thickened osteitic bone in three cases and two of the four computed tomography scans showed microcalcification. All patients had bony erosion over the internal carotid arteries. Additionally, one patient internal carotid artery thrombosis, one patient had erosion of the planum sphenoidale, and a third patient had erosion to the brainstem inferior to the sella turcica. Three patients had magnetic resonance imaging that revealed heterogeneous lesions. Two magnetic resonance images showed hypointense T1 and T2 imaging. The third was isointense on T1 and hypointense on T2. All patients were treated with endoscopic marsupialization and removal of all gross fungal debris without complications. All pathological specimens were diagnostic for fungus balls. One offour cultures was positive for fungus. All patients are asymptomatic at time of lastfollow-up. Sphenoid fungus balls present with vague, non-rhinological symptoms, but may have significant local expansion and destruction. These potentially lethal lesions usually can be suspected on preoperative imaging and are best treated with endoscopic removal.

Carotid thromboendarterectomy for recent total occlusion of the internal carotid artery

Background: The efficacy of emergency carotid thromboendarterectomy (CTEA) for acute internal carotid artery (ICA) thrombosis has been questioned. We evaluated the use of CTEA in patients with recent ICA occlusion. Methods: From August 1989 to December 1999 patients who underwent urgent CTEA for recent ICA thrombosis were retrospectively evaluated. Patient data analyzed included age, sex, comorbid risk factors, diagnostic evaluation, operative procedure, and long-term follow-up with clinical assessment and carotid duplex scan. Neurologic status was evaluated with the Modified Rankin Scale (MRS) before the operation, immediately after the operation, and at 3- to 6-months' follow-up. Results: Twenty-nine patients underwent emergency ipsilateral CTEA for acute ICA thrombosis over the last 10 years. The average age of the patients was 69.9 ± 1.7 years, and 66% were men. Patient risk factors included diabetes (7 [24%]), hypertension (21 [72%]), coronary artery disease (8 [29%]), and history of tobacco abuse (20 [69%]). Presenting symptoms included cerebrovascular accident (7 [24%]), transient ischemic attack (nonamaurosis) (10 [34%]), crescendo transient ischemic attack (7 [24%]), stroke in evolution (2 [7%]), and amaurosis fugax (3 [10%]). Diagnostic evaluation included computed tomographic scan (29 [100%]), magnetic resonance imaging/magnetic resonance angiography (4 [14%]), duplex scan evaluation of the carotid arteries (23 [79%]), and cerebral angiography (18 [64%]). Antegrade flow in the ICA was successfully established in 24 (83%) of 29 patients and confirmed with intraoperative angiography or duplex sonography. Postoperative morbidity included 2 hematomas (7%), 4 transient cranial nerve deficits (14%), and 1 conversion to hemorrhagic stroke (3.6%), which resulted in the only death (3.6%). MRS scores averaged 3.4 ± 0.2 preoperatively. Follow-up averaging 74.1 ± 21 months (range, 3-140 months) was obtained in 27 (93%) patients. Improvement or deterioration was defined as a change in MRS ± 1. Immediately postoperatively, 14 (48%) patients were improved, 2 (7%) deteriorated, and 13 (45%) had no change. At 3 to 6 months, 20 (74%) of 27 patients were improved, seven (26%) had no change, and none deteriorated. Of patients with successful CTEA, 23 (96%) of 24 had a patent ICA on follow-up duplex scan evaluation, and there was no evidence of recurrent ipsilateral neurologic events at an average of 49 months. Conclusion: These data support an aggressive early surgical intervention for acute ICA thrombosis in carefully selected patients. In the previous decade we reported a 46% success rate for establishing antegrade flow in the ICA long term. Data from this decade show a 79% (P =.0114) success rate for establishing antegrade flow long term in all patients undergoing emergency CTEA. New and improved imaging modalities have allowed better patient selection, resulting in improved outcomes. (J Vasc Surg 2001;33:242-50.)

LESSON OF THE MONTH: Misdiagnosed Post-traumatic Occlusion of the Internal Carotid Artery in a Young Woman

Introduction and the right second rib associated with findings indicative of lung contusion in the right upper lobe. Non-penetrating carotid injury occurs in less than 1 There was no evidence of pneumoor haemothorax. of 1000 blunt injuries. Acute occlusion due to disShe was admitted into the surgical ward for obsection of the internal carotid artery (ICA) is the most servation. Twelve hours later the patient developed a common consequence after blunt injury of the neck in left-sided hemiparesis which progressed within 1 h to young individuals without history of atherosclerosis. complete hemiplegia involving both the upper and However, ICA thrombosis after blunt trauma may lower limb and the left side of the face. occur without a preceding dissection. The diagnosis The first brain (CT) scan done half an hour after the of this uncommon entity can be easily missed on initial development of symptoms and signs was normal, examination because early signs and symptoms may whereas a subsequent brain CT scan carried out 4 h be masked by the presence of coexistent brain and later showed a small mildly hypodense area in the spinal injuries. middle-cerebral artery territory of the right hemiWe present a case of a misdiagnosed ICA thrombosis sphere. A diagnosis of brain contusion as a result of after blunt trauma in order to highlight the diagnostic direct injury was made and the patient was treated clues that the practising clinician should bear in mind conservatively with Fraxiparine (nadroparine calcium) and to discuss issues concerning the management of 0.3 ml twice daily, subcutaneously, Tazocin (piperthis entity. acillin 4 g+tazobactam 0.5 g) 4.5 mg 8-hourly, intravenously and Romidon (propoxyphene Hcl) 75 mg 6hourly, intramuscularly. Physiotherapy was initiated the next day and the patient remained stable with no Case Presentation neurological deterioration the following days. By the tenth day she was in good condition, and could slightly A 35-year-old woman sitting in the front passenger move the lower limb. The patient was discharged from seat of a motor vehicle, and wearing a seat-belt with the hospital without any further medication and after a diagonal strap, was involved in a road traffic ac1 month of intense physiotherapy she was able to cident. The patient was transferred to our hospital in bend the knee and to rotate the left lower limb. At a good general condition, fully conscious, haemothat time she was referred to a vascular surgeon. The dynamically stable, having few bruises in the face, the patient’s history and the mechanism of the trauma right temporal area and the right upper chest. X-ray raised the suspicion of a traumatic occlusion of the examination revealed a fracture of the right clavicle internal carotid artery. Thus, the patient was subjected to a brain magnetic resonance imaging (MRI) scan 40 days after the accident, which showed a large infarct ∗ Please address all correspondence to: D. Giannoukas, Division of in the middle cerebral artery territory of the right Vascular Surgery, University Hospital of Heraklion, Heraklion, Crete, Greece. hemisphere (Fig. 1a). A subsequent brain magnetic

Internal carotid artery thrombosis and Horner’s syndrome as complications of parapharyngeal abscess

Deep neck infections and abscesses may still occur despite the widespread use of antibiotics. Approximately 50% of deep neck infections occur in the lateral pharyngeal space, which offers minimal resistance to infection. Complications of parapharyngeal abscesses—such as jugular thrombophlebitis, cavernous sinus thrombosis, mediastinitis, and hemorrhage from the carotid artery—are well known to otolaryngologists and can be life threatening. 1 Surgical intervention is often required to manage these infections, but 10% to 15% of all the patients with lateral pharyngeal space infections can be treated with medicine alone. 2

Traumatic internal carotid artery thrombosis after impalement injury

Traumatic internal carotid artery thrombosis after impalement injury

Management of oropharyngeal trauma in children.

To determine the indications for admission, requisite imaging studies, and urgent medical or surgical intervention. We retrospectively reviewed the charts of 26 children (age range, 5 months to 14 years) who were seen by the otolaryngology service in the emergency department at the Children's National Medical Center, Washington, DC, from 1985 to 1993 and who were diagnosed as having oropharyngeal trauma. We specifically looked for common findings in the history and physical examination on initial presentation to predict the necessary steps in evaluation and management. Tertiary care pediatric referral center. Indications for admission were (1) concern about neurologic injury, (2) concern about vascular injury, (3) radiographic evidence of retropharyngeal free air or abscess, (4) pneumomediastinum, and (5) unreliable adult supervision at home. Six patients required surgery; 3 underwent retropharyngeal aspiration or incision and drainage procedures; 2 required neck explorations; and 1, who had an impaled foreign body in the parapharyngeal space, underwent surgical extraction. There were no vascular, neurologic, or other permanent injuries. Oropharyngeal trauma may result in palatal and posterior pharyngeal wall injury requiring closure of lacerations and management of retropharyngeal free air. Rarely does an injury lead to retropharyngeal abscess or significant pneumomediastinum. Lateral oropharyngeal injuries require increased concern about potential neurovascular impairment. However, neither the mechanism of injury nor the degree of injury correlates with the potential for neurovascular sequelae. Since neurovascular involvement may not become clinically apparent until days or weeks after the incident, admission for observation alone should be based on the distance from the patient's home to the hospital and on the level of reliable adult supervision. Indications for medical and surgical treatment of internal carotid artery thrombosis remain controversial.

Concurrent aneurysm rupture and thrombosis of high grade internal carotid artery stenosis: Report of two cases

The simultaneous presentation of aneurysmal subarachnoid hemorrhage and thrombosis of a high-grade internal carotid artery stenosis is rare, and their management raises several treatment dilemmas. Two such patients with ruptured aneurysms are presented: one with high-grade internal carotid artery stenosis that progressed to occlusion and one with acute internal carotid artery occlusion. Both patients were treated with craniotomy for clipping of the ruptured aneurysm followed by carotid thromboendarterectomy. We advocate urgent surgical treatment of both lesions, dealing with the most symptomatic lesion first. These two cases demonstrate the importance of reestablishing blood flow in patients with an acutely thrombosed carotid artery.

Should heparin be reversed after carotid endarterectomy? A randomised prospective trial

To investigate whether heparin reversal after carotid endarterectomy reduces the incidence of haemorrhagic complications. A randomised prospective trial. Sixty-four patients randomised to reversal of heparin or no reversal, of whom 31 received protamine titrated to the residual circulating heparin at closure of arteriotomy. Measurements included serial activated clotting times (ACTs), wound drainage, neck swelling using duplex Doppler imaging to measure the depth from skin to carotid bifurcation, and the recording of all complications. Wound drainage volumes were significantly reduced by protamine reversal (68.5 ml compared to 35 ml, p < 0.001), but neck swelling was not (72 mm compared to 70 mm, p = 0.77). Two patients who were not reversed developed neck haematomas requiring evacuation. More importantly, two patients receiving protamine, thrombosed the operated internal carotid artery (ICA) postoperatively and died despite urgent thrombectomy. A further patient who was not randomised in this study but who received protamine also developed ICA thrombosis within the same 3 month period. Reversing heparin with protamine reduces postoperative wound drainage after carotid surgery but may predispose to ICA thrombosis and stroke. This is in keeping with a previous retrospective study published during our trial.

Internal carotid artery thrombosis in a child secondary to intraoral trauma

A case of intraoral trauma leading to thrombosis of the internal carotid artery in a child is reported. Presentation, evaluation, and treatment of this entity are reviewed. Sequelae of this injury include delayed neurological deficits and death.

Massive cerebral venous thrombosis associated with the bilateral catheterization of the internal jugular veins: a case report

The authors describe the occurrence of the thrombosis of the cerebral venous sinuses in a patient in coma due to a large hemispheric infarction attributed to the thrombosis of the left internal carotid artery. After his admission to the Intensive Care Unit, a fiberoptic catheter was advanced into the left internal jugular vein to monitor the jugular bulb blood oxygen saturation, and the controlater was catheterized In order to supply fluids and medications. Despite the aggressive treatment, the patient died and, at the autopsy a massive thrombosis of the internal jugular veins was found, which extended to all the sinuses, in the absence of evident carotideal abnormalities. The authors describe the possible mechanisms of the massive thrombosis.

Rhinocerebral Mucormycosis

Rhinocerebral Mucormycosis