Endovascular treatment of carotid dissecting aneurysms

Ocular ischaemia due to a spontaneous carotid artery dissection

Internal carotid artery dissection (ICAD) is caused by the disruption of the tunica intima, with the formation of an intramural haematoma that can cause stenosis or occlusion of the artery's lumen, leading to reduced blood flow and secondary thrombus formation. Up to two-thirds of patients with ICAD show ophthalmological symptoms or signs, which are, frequently, the first manifestations of this clinical condition, often preceding for weeks the neurological signs of cerebral infarction. Central retinal artery occlusion (CRAO) is a rare complication of ICAD, secondary either to haemodynamic compromise, with ocular hypoperfusion and reverse flow within the ophthalmic artery, or to thromboembolic events, in rarer cases. We report a case of CRAO secondary to a spontaneous ICAD, in an otherwise healthy middle-aged patient.

Endovascular trapping for a giant aneurysm of the cervical internal carotid artery: a case report

SUMMARY

We describe a case of giant cervical internal carotid aneurysm successfully treated by endovascular trapping. A 57-year-old woman with a history of maxillary contusion seven years before presented with pharyngeal discomfort during swallowing. MRI revealed a 4 cm mass in the right parapharyngeal space. A common carotid angiogram revealed a giant aneurysm with a wide neck originating from the cervical internal carotid artery; kinking of the internal carotid artery was noted at a point distal to the carotid bifurcation. Analysis of cerebral blood flow by SPECT during a balloon occlusion test showed no hypoperfusion areas, and the patient underwent endovascular trapping. There were no neurological or other complications after the procedure. A follow-up MRI revealed complete thrombosis of the aneurysm. Our results show that endovascular trapping for pseudoaneurysm of the cervical internal carotid artery can be a reliable and effective treatment in patients who tolerate a balloon occlusion test.

Association of cervical internal carotid artery aneurysm with ipsilateral vertebrobasilar aneurysm in two children: a segmental entity?

INTRODUCTION

A combination of cervical and intradural aneurysm in children in the absence of systemic disorders has previously not been reported.

CASE REPORT

We report two boys with an identical combination of fusiform cervical internal carotid aneurysm and ipsilaterally located vertebrobasilar aneurysm. They had no history of trauma, they did not display any personal or familial signs of systemic disease, and the testing for collagen disease was negative. The location and appearance of the aneurysms and the identical anatomical disposition in the patients indicated a non-randomly distributed segmental vulnerability.

CONCLUSION

The cases demonstrate primary morphological signs of a developmental error being expressed in two seemingly separate segments but linked by the hypoglossal artery. It suggests a segmental error related to this embryonic vessel. They also show that few phenotypes are specific for a genotypic disorder and highlight the importance of analysing different etiologies for aneurysm formation and anatomical disposition when taking treatment strategy decisions.

Vascular Lesions of the Skull Base: Endovascular Prospective for the Otolaryngologist

With continual advances being made in endovascular equipment and techniques, the role that these image-guided, minimally invasive therapies play in the multidisciplinary management of vascular lesions of the skull base will probably continue to expand. The introduction of emerging technologies, including the development and implementation of implantable bioactive devices such as drug-eluting stents, bioactive embolic coils, and bioactive particulate embolic materials, will provide an increasing array of options for these patients. This article has reviewed the basic concepts of embolization and revascularization for vascular lesions of the skull base encountered by the practicing otolaryngologist. These concepts can provide a framework for collaboration between the otolaryngologist and neuroendovascular operator in a cooperative approach to these patients. The importance of detailed knowledge of the vascular anatomy of the skull base when dealing with these lesions, the concept of dangerous anastomoses, several clinically useful classification schemes for these lesions, and basic endovascular techniques of embolization and revascularization have been highlighted.

Interventional Neuroradiology Adjuncts and Alternatives in Patients with Head and Neck Vascular Lesions

Vascular lesions of the head and neck can result from a variety of neoplastic and traumatic conditions that may cause local neurologic symptoms or may compromise the carotid or vertebral arteries, leading to ischemic deficits. Management of lesions involving vascular structures at the skull base may require a temporary balloon occlusion tolerance test or endovascular transarterial embolization as part of the preoperative management. Endovascular techniques can also be used as a salvage measure for severe head and neck bleeding and can assist with the management of vascular injury occurring in the operative or perioperative setting. Familiarity with the role of endovascular techniques in this group of patients may favorably influence patient management and outcome.

Combined Surgical and Endovascular Treatment of Infected Pseudoaneurysm After Carotid Endarterectomy-Case Report-

A 67-year-old male presented with a rare pseudoaneurysm caused by infection after carotid endarterectomy (CEA) performed for stenosis of the left internal carotid artery (ICA). Wound infection and recurrent bleeding from the operated ICA developed 1 month after surgery. Serial angiography showed that the post-CEA pseudoaneurysm gradually increased in size. The carotid balloon occlusion test revealed that the patient could not tolerate permanent ICA occlusion because of poorly developed collaterals. Direct surgical exposure of the aneurysm was impossible due to tight adhesion of the surrounding tissue, so common carotid to middle cerebral artery bypass using a radial artery graft was performed followed by ligation of the distal common carotid artery. Subsequently, retrograde blood flow from the ICA to the aneurysm was interrupted by embolization of the external carotid artery coil through the facial artery. Combined surgical and endovascular treatment is a therapeutic option for patients with post-CEA pseudoaneurysm, if either direct or endovascular surgery is unfeasible.

Cervical Artery Dissection: A 5-Year Prospective Study in the Belluno District

BACKGROUND

Artery dissection is an unusual cause of ischemic stroke, particularly frequent among young patients. The aim of this study was to collect epidemiological data on artery dissection in a hospital-based community, set up a diagnostic protocol and discover outcome predictors.

METHODS

Among patients suffering from cerebral infarction resident in our country, those with clinical and radiological features suggestive of artery dissection were selected. Risk factors, investigative techniques and treatment were evaluated. Patients were subjected to clinical examinations and were regularly tested neuradiologically.

RESULTS

Out of 895 ischemic stroke patients, 10 patients with cervical artery dissection (1.1%) were found. Seven patients were treated with anticoagulants and 3 received antiplatelet agents. One posttraumatic artery dissection patient died within a few days of the stroke. None of the patients suffered from a recurrence, while serious disability occurred in 4 of them.

CONCLUSIONS

Artery dissection should be suspected in any cerebral infarction patient, especially in young patients without risk factors for cerebrovascular diseases. The treatment of choice consists of anticoagulants. An early clinical diagnosis, strongly supported by radiological tests, is mandatory to start the proper treatment and achieve the best possible outcome.

Risk of stroke and recurrent dissection after a cervical artery dissection: A multicenter study

OBJECTIVE

To assess the risk of stroke, TIA, or dissection recurrence after a first event of cervical artery dissection (CAD).

METHODS

The authors undertook a historical cohort study of consecutive patients with a first event of CAD who were admitted in 24 departments of neurology within a period of at least 1 year. Patients were retrospectively selected from a stroke data bank or from the local administrative data bank using the 10th revision of the International Statistical Classification of Diseases. A neurologist and a radiologist reviewed all charts to validate diagnosis and collect data. In 2002, patients were interviewed by phone or during a visit by the local investigators.

RESULTS

Four hundred fifty-nine patients (mean age 44.0 +/- 9.7 years) were included in the study. Among the 457 survivors, 25 (5.5%) could not be contacted in 2002 because they had moved. After a mean follow-up of 31 months, four (0.9%) patients presented a recurrent ischemic stroke attributable to either not yet completely recovered initial CAD (n = 2) or a recurrent CAD (n = 2). Eight (1.8%) patients had a TIA without CAD recurrence. Two TIA occurred at the acute stage of CAD. Of the six remaining TIA, only one was associated with chronic arterial stenosis. In addition, two patients had recurrent CAD without stroke, giving a total of four (0.9%) CAD recurrences.

CONCLUSIONS

Patients with a first event of CAD have a very low risk of ischemic events or dissection recurrences. Ischemic events seem rarely to be in relation with chronic arterial lesions.