Carotid Stump Syndrome: Outcome from Surgical Management

Sudden unilateral eye pain with vision loss related to carotid stump syndrome; A case report and literature review

INTRODUCTION AND IMPORTANCE

Carotid stump syndrome (CSS) is a rare cause of recurrent ipsilateral cerebrovascular accidents (CVAs) resulting from completely occluded internal carotid artery (ICA). In this condition, hemodynamic and embolic risks are related to cerebral and retinal ischemic strokes.

PRESENTATION OF CASE

A 65-year-old gentleman with multiple comorbidities, presented to our hospital with a sudden painful unilateral vision loss of the right eye. Head CT was done upon arrival, showing no evidence of ischemic or hemorrhagic brain insult and multiple right frontoparietal old infarct lesions were detected. Central retinal artery occlusion diagnosis was confirmed by an ophthalmologist. CT angiogram of the brain and carotids was done and revealed an obliterated, thrombosed, and non-opacified right internal carotid artery from the carotid bifurcation up to intracranial petrous/foramen lacerum. After taking the patient's surgical consent, right carotid stump endarterectomy and ligation of the stump under general anesthesia was done and the postoperative period was uneventful.

CLINICAL DISCUSSION

CSS is an uncommon underlying etiology, causing recurrent stroke events. The clinical features of this syndrome include cerebral and ophthalmology symptoms. Diagnosis of CSS relies on imaging modalities. Internal carotid artery stump surgical excision through the ipsilateral ECA endarterectomy is the gold standard for CSS treatment.

CONCLUSION

Despite being a rare entity, CSS is a treatable cause of retinal embolic events TIAs. Therefore, it is important to raise awareness of such condition. The presented case demonstrates the diagnosis, management and prognosis of CSS.

Carotid Stump Syndrome: An Uncommon Cause of Recurrent Ipsilateral Strokes

Carotid stump syndrome is a rare cause of recurrent cerebrovascular accidents. Carotid stump is the patent proximal remnant below the completely occluded internal carotid artery (ICA). Cerebral and retinal ischemic symptoms seen after complete occlusion of ipsilateral ICA is known as carotid stump syndrome. Known for causing recurrent ipsilateral cerebrovascular accidents, it is a potentially treatable entity. The therapeutic goal is medical management with a statin, dual anti-platelet therapy along with surgical intervention either with an endovascular repair or carotid endarterectomy. Herein, we present a case of carotid stump syndrome managed medically.

Interventional recanalization as a treatment of carotid stump syndrome caused by right internal carotid artery occlusion: A case report

RATIONALE

Carotid stump syndrome is a cerebral infarction caused by an embolus formed subsequent to the vortex of blood flow from the occluded stump, which then moves through the collateral vessels into the brain. The covered stent and stent-assisted coil embolization stump are the effective interventions for the carotid artery stump.

PATIENT CONCERNS

A 71-year-old man twice experienced left limb weakness; diffusion weighted imaging confirmed the diagnosis of cerebral infarction. Cervical computed tomography angiography, intracranial magnetic resonance angiography, and digital subtraction angiography were conducted to evaluate collateral circulation, intraluminal composition, and shape of the carotid stump.

DIAGNOSES

The patient was diagnosed with cerebral infarction and right carotid stump syndrome.

INTERVENTION

The patient underwent interventional recanalization of the occluded internal carotid artery, which relieved his symptoms and led to satisfactory therapeutic outcomes during the clinical follow-up.

OUTCOMES

A 9-month clinical follow-up revealed no stroke recurrence.

LESSONS

Interventional recanalization for the carotid artery stump syndrome is feasible. Accurate preoperative evaluation including collateral circulation, intraluminal composition, and shape of the carotid stump can assure a successful vascularization and guided management.

Outcome following open and endovascular intervention for carotid stump syndrome

Carotid stump syndrome is defined as the persistence of retinal or cerebral ischaemic events with complete occlusion of the ipsilateral internal carotid artery. The aim of this retrospective cases series was to assess the outcomes for patients with carotid stump syndrome managed with surgical intervention. A series of 11 cases of carotid stump syndrome in nine patients presented to our tertiary vascular centre from October 2004 to February 2016. Indications for intervention were amaurosis fugax, transient ischaemic attacks and stroke. In total, 11 procedures were performed on nine patients including carotid angioplasty and stenting or carotid endarterectomy with patching. The mean follow-up period was 56.6 months. One patient suffered a myocardial infarction 30 days, post-operatively, and one patient was lost to follow-up. In the remaining seven patients, there was a complete resolution of symptoms. There were no incidents of death, stroke, cranial nerve injury, wound haematoma or procedural bleeding. Surgical exclusion of carotid stumps combined with dual antiplatelet agents was found to be a safe and effective treatment method for carotid stump syndrome.

Vertebral Artery Stump Syndrome

Carotid stump syndrome is a well-documented embolic source for ischemic stroke. However, few cases have been reported of a similar condition - termed vertebral artery stump syndrome - which affects the posterior circulation after vertebral artery origin occlusion. We herein report a case of infarction of the right superior cerebellar artery and left posterior inferior cerebellar artery territories due to vertebral artery stump syndrome. In this interesting case, a turbulent flow at the distal side of the vertebral artery occlusion was captured on ultrasonography, and was identified as the probable mechanism of vertebral artery stump syndrome.

Carotid stump syndrome: A case report

Carotid stump syndrome (CSS) is known to be one of the causes of recurrent ipsilateral ischemic stroke following the occlusion of the internal carotid artery (ICA). The present study describes a case of left CSS in a 50-year-old patient presenting with a central retinal artery embolism following internal carotid and middle cerebral artery occlusion. The central retinal artery embolism was believed to be a consequence of microemboli, which originated from the stump of the occluded ICA, passing into the ophthalmic artery due to external carotid-internal carotid anastomotic channels, although the other possible pathophysiological causes of this condition are discussed. Digital subtraction angiography of the patient showed trickle flow in the occluded ICA during the venous phase, by which the stump emboli may have been transported to the ophthalmic artery. The patient was successfully treated with anticoagulation therapy without surgical or endovascular treatment.

Carotid Stump Syndrome: Case Report and Endovascular Treatment

Objectives. To highlight the case of a patient with multiple transient ischemic attacks and visual disturbances diagnosed with carotid stump syndrome and managed with endovascular approach. Case Presentation. We present the case of a carotid stump syndrome in an elderly patient found to have moderate left internal carotid artery stenosis in response to an advertisement for carotid screening. After a medical therapeutic approach and a close follow-up, transient ischemic attacks recurred. Computed tomographic angiography showed an occlusion of the left internal carotid artery and the presence of moderate stenosis in the right internal carotid artery, which was treated by endovascular stenting and balloon insertion. One month later, the patient presented with visual disturbances due to the left carotid stump and severe stenosis of the left external carotid artery that was reapproached by endovascular stenting. Conclusion. Considerations should be given to the carotid stump syndrome as a source of emboli for ischemic strokes, and vascular assessment could be used to detect and treat this syndrome.

Contralateral microemboli following carotid artery stenting in patients with a contralateral internal carotid artery occlusion

Subclinical microembolization identified on diffusion-weighted magnetic resonance imaging is recognized as an important outcome measure for carotid revascularization procedures. It is generally believed that arch manipulation is the primary reason for developing microemboli in the contralateral hemisphere during carotid artery stenting. However, we identified three patients who developed postprocedure microemboli of the contralateral hemisphere despite a known chronic contralateral internal carotid artery occlusion. Our cases highlight that ipsilateral microemboli may be an underappreciated but an important source of contralateral lesions through patent intracranial collateral pathways.

The current management of carotid atherosclerotic disease: who, when and how?

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Safety and efficacy of surgical treatment of carotid stump syndrome: pilot study

Surgical exclusion of the internal carotid artery (ICA) stump combined with endarterectomy of the external carotid artery is an established treatment approach. The aim of this pilot study was to compare the risk of cerebrovascular events between surgical treatment and best medical treatment in patients with ICA occlusion and carotid stump syndrome. Forty patients (23 males; age: 43-80 years; mean age: 61.1 ± 9.0 years) with carotid occlusion and carotid stump syndrome were enrolled. Ten patients with asymptomatic ICA occlusion and 10 patients with symptomatic ICA occlusion and carotid stump syndrome were enrolled to the best medical therapy group. Patients with chronic ICA occlusion, carotid stump syndrome, and one (15 patients) or recurrent (three patients) episodes of ipsilateral stroke or transient ischemic attack were enrolled to the surgical group. Neurological examination was undertaken on the day of randomization and then every 6 months in all patients for 4 years. All vascular events and death were recorded. Only one vascular event occurred in patients with symptomatic ICA occlusion without recurrent stroke or transient ischemic attack who were treated medically. No other vascular event was noted in the other subgroups. One patient with symptomatic carotid occlusion without recurrent stroke died due to myocardial infarction 6 months after surgery. Surgical treatment of carotid stump syndrome seems to be a safe procedure. Nevertheless, the benefit of a surgical approach in comparison with the best medical treatment is not clear.

Carotid stump syndrome: pathophysiology and endovascular treatment options

Carotid stump syndrome is one of the recognised causes of recurrent ipsilateral cerebrovascular events after occlusion of the internal carotid artery. It is believed that microemboli arising from the stump of the occluded internal carotid artery or the ipsilateral external carotid artery can pass into the middle cerebral artery circulation as a result of patent external carotid-internal carotid anastomotic channels. Different pathophysiologic causes of this syndrome and endovascular options for treatment are discussed.

Stroke as a manifestation of Takayasu's arteritis likely due to distal carotid stump embolism

The clinical symptoms of Takayasu's arteritis (TA), which mainly affects the aorta and major aortic branches, vary widely depending on the site and degree of arterial lesions. We present herein the case of a young man whose initial symptom was pulmonary artery occlusion and who manifested TA 6 years later as cerebral embolism. Angiography confirmed bilateral common carotid artery (CCA) occlusion and a well-developed collateral circulation. The stump of the occluded CCA has both proximal and distal ends. The possibility of emboli from the occluded CCA (distal stump) seems to be the most probable explanation, as turbulent flow was detected at distal stump on color Doppler sonography. The carotid stump can be a potential source of emboli in TA as well as in atherosclerosis.

Endovascular treatment of carotid stump syndrome

We present the case of a carotid stump syndrome in a 72-year-old woman with a 3-day history of recurrent transient ischemic attacks. Computed tomographic angiography showed the occlusion of the ipsilateral internal carotid artery, and the presence of an internal stump with ophthalmic reverse flow, confirming the suspect of a stump syndrome. The patient underwent stent-graft exclusion of the carotid stump; she was last seen 12 months after the procedure when she remained totally asymptomatic.

Vertebral artery injuries associated with cervical spine injuries: a review of the literature

STUDY DESIGN

Literature review.

OBJECTIVE

To determine the incidence of vertebral artery injuries (VAIs) in association with cervical spine trauma and investigate the optimum diagnostic and treatment protocols.

SUMMARY OF BACKGROUND DATA

VAIs may result from cervical spine trauma and have the potential to cause cerebral, brainstem, and even spinal cord ischemia. Screening and treatment for traumatic VAI are very controversial, with conflicting recommendations within the trauma and spine literature.

METHODS

A literature review was performed to identify publications pertaining to VAIs associated with cervical spine trauma. These publications were evaluated to determine the incidence, radiographic evaluation, and treatment options of VAIs.

RESULTS

Approximately 0.5% of all trauma patients will have a VAI, and 70% of all traumatic VAIs will have an associated cervical spine fracture. Cervical spine translation injuries and transverse foramen fractures are most commonly cited as having a significant association with VAIs. The incidence of neurologic deficits secondary to VAI ranges from 0% to 24% in published series that incorporate a screening protocol for asymptomatic patients. Catheter angiography has been the gold standard for the diagnosis of VAIs; however, new 16-slice computed tomography angiography seems to have sensitivity and specificity close to that of catheter angiography. Treatment options include observation, antiplatelet agents, anticoagulation, and endovascular treatments. Although some authors have advocated antithrombotic therapy for most asymptomatic VAIs, there is a lack of class I evidence to support any strong guidelines for treatment.

CONCLUSIONS

VAIs can occur in association with cervical spine trauma and have the potential for neurological ischemic events. Screening for and treatment of asymptomatic VAIs may be considered, but it is unclear based on the current literature whether these strategies improve outcomes.

Endovascular Treatment of the Carotid Stump Syndrome

In patients with an occluded internal carotid artery, the carotid stump syndrome is a potential source of microemboli that pass through the ipsilateral external carotid artery and the ophthalmic artery to the territory of the middle cerebral artery. Thus, the syndrome is associated with carotid territory symptoms although the internal carotid artery is occluded. Surgical exclusion of the internal carotid artery associated with endarterectomy of the external carotid artery has been described as the gold standard of treatment by many authors. This report is the second case, to our knowledge, of endovascular treatment of the carotid stump syndrome with the use of a stent-graft.

Large paraclinoid aneurysm with a calcified neck treated by tailored multimodality procedures

A 68-year-old woman presented with a large paraclinoid aneurysm with a calcified neck causing visual symptoms. Direct clipping was hazardous because of severe calcification of the neck. Endovascular internal trapping was difficult because of the short distance between the neck and the origin of the posterior communicating artery. Proximal occlusion was likely to be less effective because of large collateral back flow to the aneurysm via the ophthalmic artery (OphA). The aneurysm was successfully treated by a combination of a high-flow bypass, intraoperative coil embolization of the parent artery including the origin of the OphA, and clipping of the internal carotid artery distal to the aneurysm. Paraclinoid aneurysms may be difficult to treat by the simple application of direct clipping, endovascular coiling, or trapping. Multimodality procedures can be tailored to treat such aneurysms.

Management of the Near Total Internal Carotid Artery Occlusion

OBJECTIVES

The risk of stroke in patients with near total internal carotid artery (ICA) occlusion is perceived to be high as stroke risk increases with severity of the stenosis. The management of this entity has not been addressed specifically in the existing randomised trials and thus it remains controversial.

METHODS

Systematic review of the relevant literature.

RESULTS

The management of patients with near total ICA occlusion remains controversial: some favour intervention whereas others have condemned it as dangerous or of no benefit. A prospective multicentre randomised trial regarding intervention versus best medical treatment for patients with symptomatic near total ICA occlusion seems difficult because of the large number of patients required to power the study. Nevertheless, it appears hard to decline surgery based on the current evidence.

CONCLUSIONS

Because of the current controversy over the best management of the near total ICA occlusion, prospective observational studies are needed to demonstrate its prevalence in the symptomatic and asymptomatic population and any associated excess stroke risk. Based on the current evidence, surgery is the treatment of choice in most centres but its validity over best medical treatment remains untested.

Pseudo-occlusions of the internal carotid artery: a rationale for treatment on the basis of a modified carotid duplex scan protocol

PURPOSE

We report on a modified duplex scanning technique that may be a means of detecting a patent internal carotid artery (ICA) previously believed to be occluded by means of magnetic resonance angiography (MRA), standard duplex protocols, or both. In addition, we attempted to develop selection criteria for operability in this setting, on the basis of the lumen diameter and wall thickness of the post-stenotic ICA segment.

METHOD

In the past 22 months, 17 patients (12 men; 5 women) with ICA occlusions reported by means of MRA (10 patients) or by means of duplex scanning (7 patients) were found to have patent arteries when subjected to this duplex scanning protocol: (1) the use of low pulse repetition frequency (150-350 Hz), maximal persistence, and sensitivity of color and power angiography modes; (2) the use of an 8-MHz to 5-MHz probe as a means of visualizing the most distal extracranial segment of the ICA; and (3) measurements of the lumen diameter and wall thickness of the post-stenotic ICA. The age of patients ranged from 53 to 80 years (mean age, 71 years). Seven patients (41%) had no symptoms.

RESULTS

Extremely low peak systolic and end-diastolic velocities were detected distal to the stenotic segment in the ICA in all cases, and they varied from 5 to 30 cm/s (mean, 14 plus minus 8 cm/s) and 0 to 8 cm/s (mean, 4.5 plus minus 2.0 cm/s), respectively. The luminal diameter of the post-stenotic ICA varied from 0.7 to 3.6 mm (mean, 2.0 plus minus 1.1 mm), and the wall thickness ranged from 0.6 to 1.4 mm (mean, 0.9 plus minus 0.3 mm) in all patients. Twelve patients (71%) were examined with the intent of performing an endarterectomy. Of these, eight patients (47%) underwent successful operations with patches (3 vein; 5 synthetic), and four (29%) were found to have unreconstructable disease. The ICA lumen diameter and wall thickness in all eight patients who underwent endarterectomies were 2 mm or larger and 1 mm or thinner, respectively, whereas they were smaller than 2 mm and thicker than 1 mm, respectively, in the remaining four patients (P <.01). The last five patients were observed because they had small ICAs (lumen <2 mm) with thickened walls (>1 mm). Intraoperative and early postoperative duplex scanning examinations were performed in the eight ICAs that were successfully reconstructed. In these patients, the ICA lumen diameter increased from a mean of 2.9 plus minus 0.4 mm preoperatively to a mean of 4.4 plus minus 0.3 mm 2 weeks postoperatively (P <.001). Intraoperative ICA flow volumes were also measured after the endarterectomy, and they varied from 55 to 242 mL/min (mean, 115 plus minus 53 mL/min) and ranged from 122 to 220 mL/min (mean, 159 plus minus 34 mL/min) 2 weeks postoperatively. One patient who did not undergo surgical exploration died of chronic renal failure and congestive heart failure within the first month of follow-up. The remaining 16 patients had no neurological symptoms and were alive after a follow-up period of 2 to 22 months (mean, 8 plus minus 5 months).

CONCLUSION

The proposed duplex protocol appears to be an effective means of identifying some patients with patent ICAs that were believed to be occluded by means of standard examinations. In addition, such patients may be candidates for an endarterectomy if the ICA post-stenotic lumen diameter is 2 mm or larger and the wall thickness is 1 mm or thinner.