Association between Carotid Bifurcation Angle and Vulnerable Plaque Volume Using Black Blood Magnetic Resonance Imaging

The morphology of the internal carotid artery (ICA) bifurcation is increasingly being recognized as the cause of atherosclerosis and vulnerable plaque leading to cerebral infarction. In this study, we investigated the relationship between carotid bifurcation angle and carotid plaque volume evaluated using black blood magnetic resonance imaging (BB-MRI). Among the 90 patients who underwent revascularization for atherosclerotic symptomatic carotid stenosis between April 2016 and October 2022 using BB-MRI, carotid plaque was evaluated in 57 patients. Relative overall signal intensity (roSI) was defined as the signal intensity of the plaque on T1-weighted images relative to the signal intensity of the sternocleidomastoid muscle in the same slice as the common carotid bifurcation. Regions showing roSI ≥ 1.0 were defined as plaque, and the plaque volume and relative plaque volume were measured from roSI ≥1.0 to ≥2.0 in 0.1 increments. We calculated the angles between the common carotid artery (CCA) and the ICA and between the CCA and the external carotid artery (ECA) on magnetic resonance angiography. We classified two groups according to carotid bifurcation angles based on the ICA angle: Group A = <35° and Group B = ≥35°. Compared with Group A (n = 42), Group B (n = 15) showed a greater relative plaque volume between roSI ≥ 1.3 and roSI ≥ 1.5. A significant correlation was identified between relative plaque volume with roSI ≥ 1.4 and ICA angle (p = 0.049). Vulnerable plaque was significantly more frequent in the group with an ICA angle of ≥35. Moreover, the ICA angle was significantly greater in patients with a roSI of ≥1.4.

Preoperative Embolization of Primary Juvenile Nasopharyngeal Angiofibroma: Is Embolization of Internal Carotid Artery Branches Necessary?

PURPOSE

To determine the effects of blood supply from internal carotid artery (ICA) on the surgical outcomes of primary juvenile nasopharyngeal angiofibroma (JNA) after transarterial embolization (TAE).

METHODS

A retrospective analysis was performed on primary JNA patients who underwent TAE and endoscopic resection in our hospital between December 2020 and June 2022. The angiography images of these patients were reviewed, and then they were divided into ICA + external carotid artery (ECA) feeding group and ECA feeding group according to whether the ICA branches were part of the feeding arteries. Tumors in ICA + ECA feeding group were fed by both ICA and ECA branches, while tumors in ECA feeding group were fed by ECA branches alone. All patients underwent tumor resection immediately after ECA feeding branches embolization. None of the patients underwent ICA feeding branches embolization. Data on demographics, tumor characteristics, blood loss, adverse events, residual and recurrence were collected, and case-control analysis was performed for the two groups. Differences in characteristics between the groups were tested using Fisher's exact and Wilcoxon tests.

RESULTS

Eighteen patients were included in this study: nine in ICA + ECA feeding group and nine in ECA feeding group. The median blood loss was 700 mL (IQR 550-1000 mL) in ICA + ECA feeding group versus 300 mL (IQR 200-1000 mL) in ECA feeding group, with no significant statistical difference (P = 0.306). Residual tumor was found in one patient (11.1%) in both groups. Recurrence was not observed in any patient. There were no adverse events from embolization and resection in either group.

CONCLUSION

The results of this small series suggest that the presence of blood supply from ICA branches in primary JNA has no significant effect on intraoperative blood loss, adverse event, residual and postoperative recurrence. Therefore, we do not recommend routine preoperative embolization of ICA branches.

LEVEL OF EVIDENCE

Level 4, Case-control.

Detailed Arterial Anatomy and Its Anastomoses of the Sphenoid Ridge and Olfactory Groove Meningiomas with Special Reference to the Recurrent Branches from the Ophthalmic Artery

BACKGROUND AND PURPOSE

Detailed arterial anatomy of the sphenoid ridge and olfactory groove meningiomas is complicated due to the fine angioarchitecture and anastomoses between each feeder. Herein, we present details of the arterial anatomy and the relationships of feeders in these lesions.

MATERIALS AND METHODS

This study included 20 patients admitted to our department between April 2015 and March 2020. Conditions of subjects consisted of 16 sphenoid ridge meningiomas and 4 olfactory groove meningiomas. We mainly analyzed arterial anatomy using 3D rotational angiography and slab MIP images of these lesions. We also analyzed the anastomoses of each feeder.

RESULTS

We found that 19 (95%), 15 (75%), and 15 (75%) lesions had feeders from the ophthalmic, internal carotid, and external carotid arteries, respectively. As feeders from the ophthalmic artery, recurrent meningeal arteries were involved in 18 lesions (90%). Fifteen lesions (75%) had anastomoses between each feeder.

CONCLUSIONS

Most of the meningiomas in the sphenoid ridge and olfactory groove had feeders from the ophthalmic and internal carotid arteries. There were various anastomoses between each feeder. This is the first report to demonstrate the detailed arterial anatomy and frequency of recurrent branches from the ophthalmic artery and their anastomoses using detailed imaging techniques.

Genome-wide analysis of carotid plaque burden suggests a role of IL5 in men

BACKGROUND

Carotid artery plaque is an established marker of subclinical atherosclerosis with pronounced sex-dimorphism. Here, we aimed to identify genetic variants associated with carotid plaque burden (CPB) and to examine potential sex-specific genetic effects on plaque sizes.

METHODS AND RESULTS

We defined six operationalizations of CPB considering plaques in common carotid arteries, carotid bulb, and internal carotid arteries. We performed sex-specific genome-wide association analyses for all traits in the LIFE-Adult cohort (n = 727 men and n = 550 women) and tested significantly associated loci for sex-specific effects. In order to identify causal genes, we analyzed candidate gene expression data for correlation with CPB traits and corresponding sex-specific effects. Further, we tested if previously reported SNP associations with CAD and plaque prevalence are also associated with CBP. We found seven loci with suggestive significance for CPB (p<3.33x10-7), explaining together between 6 and 13% of the CPB variance. Sex-specific analysis showed a genome-wide significant hit for men at 5q31.1 (rs201629990, β = -0.401, p = 5.22x10-9), which was not associated in women (β = -0.127, p = 0.093) with a significant difference in effect size (p = 0.008). Analyses of gene expression data suggested IL5 as the most plausible candidate, as it reflected the same sex-specific association with CPBs (p = 0.037). Known plaque prevalence or CAD loci showed no enrichment in the association with CPB.

CONCLUSIONS

We showed that CPB is a complementary trait in analyzing genetics of subclinical atherosclerosis. We detected a novel locus for plaque size in men only suggesting a role of IL5. Several estrogen response elements in this locus point towards a functional explanation of the observed sex-specific effect.

[Simultaneous operation in a patient with stenosis of the extracranial portion and an intracranial aneurysm of the internal carotid artery]

Presented herein is a clinical case report concerning surgical treatment of a patient with a rare combination of two pathologies, i. e., a haemodynamically significant stenosis of the extracranial portion and a sacciform aneurysm of the communicative portion of the right internal carotid artery on the background of multifocal atherosclerosis. The patient underwent a simultaneous operation consisting in clipping of the sacciform arterial aneurysm of the communicative portion of the right internal carotid artery and carotid endarterectomy on the right. The chosen surgical policy ensured effective prevention of the development of ischaemic stroke and rupture of the arterial aneurysm, whose risks would have been high in staged treatment and sequentially performing two operations.

Intra-Arterial MR Perfusion Imaging of Meningiomas: Comparison to Digital Subtraction Angiography and Intravenous MR Perfusion Imaging

BACKGROUND AND PURPOSE

To evaluate the ability of IA MR perfusion to characterize meningioma blood supply.

METHODS

Studies were performed in a suite comprised of an x-ray angiography unit and 1.5T MR scanner that permitted intraprocedural patient movement between the imaging modalities. Patients underwent intra-arterial (IA) and intravenous (IV) T2* dynamic susceptibility MR perfusion immediately prior to meningioma embolization. Regional tumor arterial supply was characterized by digital subtraction angiography and classified as external carotid artery (ECA) dural, internal carotid artery (ICA) dural, or pial. MR perfusion data regions of interest (ROIs) were analyzed in regions with different vascular supply to extract peak height, full-width at half-maximum (FWHM), relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and mean transit time (MTT). Linear mixed modeling was used to identify perfusion curve parameter differences for each ROI for IA and IV MR imaging techniques. IA vs. IV perfusion parameters were also directly compared for each ROI using linear mixed modeling.

RESULTS

18 ROIs were analyzed in 12 patients. Arterial supply was identified as ECA dural (n = 11), ICA dural (n = 4), or pial (n = 3). FWHM, rCBV, and rCBF showed statistically significant differences between ROIs for IA MR perfusion. Peak Height and FWHM showed statistically significant differences between ROIs for IV MR perfusion. RCBV and MTT were significantly lower for IA perfusion in the Dural ECA compared to IV perfusion. Relative CBF in IA MR was found to be significantly higher in the Dural ICA region and MTT significantly lower compared to IV perfusion.

Splaying of the Carotid Bifurcation Caused by a Cervical Sympathetic Chain Schwannoma

Splaying of the carotid bifurcation revealed by an imaging study is usually indicative of a carotid body tumor, but there are other possibilities. To promote awareness of a cervical sympathetic chain schwannoma as another cause of splaying of the carotid bifurcation, we present a case of cervical sympathetic chain schwannoma, with an additional 7 cases in the English-language literature, and discuss the relationship between the great vessels of the neck and a carotid body tumor or a schwannoma of the cervical sympathetic chain or vagus nerve from an anatomic viewpoint. We conclude that splaying of the carotid bifurcation with hypervascularity suggests a carotid body tumor, whereas in cases without hypervascularity, a cervical sympathetic chain schwannoma is another possibility. Vagus nerve schwannomas can separate the internal jugular vein and internal carotid artery, but seldom widen the carotid bifurcation.

Sympathetic Chain Schwannoma Resembling Carotid Body Tumour

Schwannomas are rare, benign nerve sheath tumours of parapharyngeal space. Differential diagnosis should include salivary gland tumours, paragangliomas, neurofibromas, and metastatic lymph nodes. The tumours may arise from vagus nerve and cervical sympathetic chain (CSC). Diagnosis is usually made by imaging techniques: contrast CT, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Fine needle aspiration cytology (FNAC) is useful diagnostic procedure but poor results are seen in neurogenic tumours. Rarely, a vascular CSC schwannoma at the level of carotid arteries bifurcation may mimic carotid body tumour (CBT) on imaging techniques, especially if they are vascular, causing splaying of internal and external carotid arteries. Clinically patient was asymptomatic except for a pulsatile swelling in neck for 5 years. The presented case resembled CBTclinically, on ultrasound and on imaging techniques causing splaying of carotid arteries. FNAC was inconclusive and was always hemorrhagic. During operation, it was found to be CSC schwannoma just posterior to carotid body. CSC was sacrificed and patient developed Horner syndrome postoperatively.

Internal and external carotid artery embolism following facial injection of autologous fat

Autologous fat injection is a common aesthetic procedure for soft-tissue augmentation of the face. Although this procedure is generally regarded as safe, several patients have experienced acute visual loss or cerebral infarction after these injections. We describe a case of internal and external carotid artery fat embolism that occurred following injection of autologous fat into the face. It appeared that the injected fat entered a branch of the left external carotid artery and that the embolus likely migrated into the left internal carotid artery and distally into the left ophthalmic artery, left anterior artery, and middle cerebral artery. LEVEL OF EVIDENCE 5:

[Structural and functional changes of external and intracranial arteries in elderly patients of different ethnic groups with ischemic heart disease]

The present article discusses the problem of structural and functional changes in extra-and intracranial arteries in elderly patients with ischemic heart disease (CHD) belonging to different ethnic groups before the upcoming coronary arteriography research and planned operative intervention. We examined 120 elderly patients with ischemic heart disease, including 50 patients of Korean nationality and 70 patients of Slavic ethnicity. Average values of IMT of the right and left CCA patients of South Asian group were significantly lower than those of Slavic ethnicity. Elderly patients with CHD the violation of cerebral circulation were due to atherosclerotic lesions of the extracranial vessels and local hemodynamic disturbances in their area of pathological tortuosity. Korean ethnicity elderly patients with CHD were observed more pronounced signs of stenosis and deformation of the main arteries of the neck, as well as lower collateral reserve of cerebral circulation.

Concurrence of bilateral kinking of the extracranial part of the internal carotid artery with coiling and tortuosity of the external carotid artery--a case report

Anatomical variations of the carotid arterial system have a great impact on surgical approaches to the neck and radiological imaging interpretation. Although reports on internal carotid artery dolichoarteriopathy (kinking, tortuosity, coiling) have been reported, no report on dolichoarteriopathy of the external carotid artery has been described. Herein, we report a case with concurrent bilateral kinking of the extracranial part of the internal carotid artery associated with extensive calcifications in the relatively high-located carotid bifurcation and coiling with tortuosity of the external carotid artery in a male cadaver - an entity that has not yet been reported. The variation presented should be kept in mind during various surgical procedures in order to decrease possible iatrogenic or surgical complications.

The influence of obesity on the assessment of carotid intima-media thickness

BACKGROUND

The assessment of carotid intima-media thickness (CIMT) may improve cardiovascular risk prediction. The optimal protocol for CIMT measurement is unclear. CIMT may be measured in the common carotid artery (CCA), carotid bifurcation (CB), and internal carotid artery (ICA), but measurements from CB and ICA are more difficult to obtain. We studied the influence of body mass index (BMI) and atheroma plaques on the capacity to obtain CIMT measurements at different carotid sites.

METHODS

Using an automatic system, CIMT was measured in 700 subjects aged 45-75, in the near and far walls of CCA, CB, and ICA bilaterally. The presence of atheroma plaques, BMI and vascular risk factors were recorded.

RESULTS

CIMT measurements in CCA were possible in all except one subject. It was not possible to obtain CIMT measurements at CB or ICA in 24.1% of normal weight and 58.8% of obese subjects. The likelihood of obtaining CIMT measurement at all carotid sites decreased as the BMI increased. Atheroma plaques in a carotid segment did not preclude CIMT measurement at this site.

CONCLUSIONS

CIMT measurements in distal carotid segments are more challenging in obese subjects. Measuring CIMT at CCA remains feasible in obese subjects and should be the primary endpoint in these subjects. Nevertheless, CB and ICA measurements, when feasible, would improve risk classification.

Quantitative assessment of external carotid artery territory supply with modified vessel-encoded arterial spin-labeling

BACKGROUND AND PURPOSE

In patients with carotid stenosis or occlusion, cerebral blood could be supplied through collateral pathways to improve regional blood flow and protect against ischemic events. The contribution of collaterals from the ICA can be assessed by depiction of vascular perfusion territories with ASL. However, so far there is no method available to evaluate the collateral perfusion territory from the ECA in MR imaging. In this study, we present a new labeling scheme based on VE-ASL to quantitatively assess the perfusion territory of the ECA.

MATERIALS AND METHODS

A new labeling approach with a Hadamard encoding scheme was developed to label major arteries, especially the ECA. Twelve healthy subjects with normal cerebrovascular anatomy were examined to demonstrate their perfusion territories. Eight patients with carotid artery stenosis or occlusion were assessed before and after surgery to show changes of their collateral blood supply.

RESULTS

The proposed method enables assessment of the perfusion territories of the ECA. Good agreement was found between the vascular territories and normal cerebrovascular anatomy in healthy subjects. For the patients with carotid stenosis or occlusion, our noninvasive results provided information on collateral flow comparable with that from DSA. Their collateral flows from the ECA, moreover, could be quantitatively estimated pre- and postoperatively.

CONCLUSIONS

The modified approach has been validated by the consistency of collateral perfusion territories with cerebrovascular anatomy, and quantitative assessment of collaterals proved useful for assisting in evaluating therapeutic interventions.

Shear stress-induced activation of Tie2-dependent signaling pathway enhances reendothelialization capacity of early endothelial progenitor cells

Although endothelial progenitor cells (EPCs) play a pivotal role in the endothelial repair following arterial injury and shear stress has a beneficial effect on EPCs, however, the molecular mechanism underlying the influence of EPCs on the endothelial integrity and the regulation of shear stress on the EPC signaling remained to be studied. Here, we investigated the effects of laminar shear stress on the tyrosine kinase with immunoglobulin and epidermal growth factor homology domain-2 (Tie2)-dependent signaling and its relation to in vivo reendothelialization capacity of human early EPCs. The human early EPCs were treated with shear stress. Shear stress in a dose-dependent manner increased angiopoietin-2 (Ang2)-induced migratory, adhesive and proliferatory activities of EPCs. Transplantation of EPCs treated by shear stress facilitated in vivo reendothelialization in nude mouse model of carotid artery injury. In parallel, the phosphorylation of Tie2 and Akt of EPCs in response to shear stress was significantly enhanced. With treatment of Tie2 knockdown or Akt inhibition, shear stress-induced phosphorylation of Akt and endothelial nitric oxide synthase (eNOS) of EPCs was markedly suppressed. After Tie2/PI3K/Akt/eNOS signaling was blocked, the effects of shear stress on in vitro function and in vivo reendothelialization capacity of EPCs were significantly inhibited. The present findings demonstrate for the first time that Tie2/PI3k/Akt/eNOS signaling pathway is, at least in part, involved in the EPCs-mediated reendothelialization after arterial injury. The upregulation of shear stress-induced Tie2-dependent signaling contributes to enhanced in vivo reendothelialization capacity of human EPCs.

[The management of carotid reestenosis--an experience with the conventional surgery]

The authors report a series of 26 consecutive patients, 20 men and 6 women, age range 47-80 years, average age of 66 years, who underwent conventional surgery for the treatment of carotid reestenosis. The surgical management consisted in the resection of a segment of the common carotid-internal carotid arteries and interposition of a prosthetic graft, followed by ligation of the external carotid, in 3 patients; in the remainder 23 cases a venous bypass graft was interposed from the common carotid to the internal carotid artery, above the lesion, with preservation of the external carotid artery flow and ligation of the internal carotid, just below the anastomosis. There was no operative mortality and the significant morbility consisted in a cervical hematoma in one patient, transient disphonia in two cases and transient disphagia in one patient. During the mean follow up time of 43 months, one patient developed a significant reestenosis of the venous graft and another patient developed an aneurysm of the venous graft, both conditions requiring surgical repair. Based on the early and late results of this experience, the authors elect the open conventional surgery as the method of choice for the treatment of carotid reestenosis.

Compensatory collateral circles in vertebral and carotid artery occlusion

The obstructive disease of the supraaortic trunks has considerable clinical importance. Patients with the same grade of obstruction can display a wide spectrum of symptoms. Apart from the grade, etiology and localization of the obstruction, the presence of collateral circles plays an essential role in the determination of the symptoms. We selected all asymptomatic patients, undergoing a diagnostic investigation with EchoColorDoppler in a period of 13 years, in whom an occlusion of the common carotid artery, of the internal carotid artery or of the vertebral artery was present, and we studied the compensatory collateral circles. We considered 8 subjects affected by common carotid occlusion, 66 subjects with internal carotid occlusion and 24 subjects with vertebral artery occlusion. In the 8 subjects affected by common carotid occlusion, before the bifurcation, the collateral circle was realized by the superior thyroid arteries through the supraisthmic thyroid artery. All of the 66 subjects with internal carotid disease showed collateral circles through the ophthalmic branches and through the communicating arteries. In the 24 subjects with vertebral artery occlusion, the compensatory collateral circle was realized by the cervical, costocervical and occipital branches. In conclusion, the presence of an adequate hemodynamic compensation through a collateral circle represents an important positive prognostic factor and can avoid invasive procedures, thus avoiding possible complications.

Bilateral variation of facial artery: a case report

Dissection of a 65-year-old male cadaver revealed bilateral anomalous facial artery. The right facial artery taking origin from the external carotid artery did not make any loop in the submandibular region, entered the face by winding round the lower border of mandible, and terminated as the inferior labial artery. The upper part of the right side face in this case was supplied by various branches of transverse facial artery, infra orbital artery and dorsal nasal artery. The origin, course and branching pattern of the left facial artery was normal except the inferior labial artery was missing from it. The venous drainage of the face was normal on both sides. This case may provide useful information for clinical applications in different fields of oral and maxillofacial surgery.

Endosurgical repair of an iatrogenic facial arteriovenous fistula due to percutaneous trigeminal balloon rhizotomy

A 56-year-old woman with right-sided trigeminal neuralgia (TN), who underwent technically uneventful percutaneous balloon rhizotomy, developed significant bilateral pulsatile tinnitus on the first post-operative day. Although the patient reported significantly improved neuralgia, auscultation revealed a right facial bruit. Magnetic resonance angiography (MRA) of the face and brain demonstrated prominent right facial and jugular venous vascularity. Catheter angiography confirmed the suspected facial arteriovenous fistula (AVF). A transarterial approach was used to explore the AVF which arose from a laceration of the right internal maxillary artery and which fistulized directly with the pterygoid venous plexus. Endosurgical repair utilizing three non-fibered platinum coils was done under conscious sedation at the same setting as the diagnostic angiogram. Angiographically, the fistula was obliterated, and the patient's bruit and tinnitus immediately resolved. Follow-up MRA at 3.5 months was normal, and, the patient had no clinical symptoms of recurrent AVF. In conclusion facial AVF can complicate percutaneous trigeminal rhizotomy. Iatrogenic facial AVF can be repaired via an endovascular approach.

Stroke in patients with human immunodeficiency virus infection

What is the impact of HIV and HIV therapy on the nature of stroke and stroke management?

Rosai-Dorfman disease presenting as an isolated extranodal mass of the carotid sheath: a case report

Rosai-Dorfman disease is a rare, benign granulomatous disease that typically presents with massive cervical lymphadenopathy. In less than 50% of cases, other soft-tissue manifestations may also be found in the head and neck. Rosai-Dorfman disease can be difficult to diagnose because of its rarity and its ability to mimic, both clinically and radiologically, more common diseases such as lymphoma. The histopathologic diagnosis can also be difficult to make, particularly when the disease exhibits extranodal manifestations. We present a case of isolated extranodal Rosai-Dorfman disease involving the carotid sheath, without the typical massive adenopathy.

Lower blood flow velocity, higher resistance index, and larger diameter of extracranial carotid arteries are associated with ischemic stroke independently of carotid atherosclerosis and cardiovascular risk factors

PURPOSE

To investigate the association between diameter and flow velocity of the carotid arteries and ischemic stroke.

METHODS

Peak systolic velocity, end diastolic velocity, Pourcelot resistance index, blood flow volume, luminal diameter, and carotid plaque burden were measured and compared in 240 ischemic stroke (IS) patients without history of stroke, 163 chronic stable IS patients, and 236 nonstroke controls (age, >or=40 years). Data were also compared between stroke subtypes (large artery atherosclerosis, lacunar, cardioembolic, or undetermined origin).

RESULTS

Acute as well as chronic stable IS patients had significantly lower flow velocities and flow volume, higher resistance index than nonstroke controls in the common carotid artery (CCA), internal carotid artery and external carotid artery, and larger common carotid artery diameter. The differences were found across all IS subtypes and in stroke patients with as well as without carotid plaque. Comparisons between these subgroups showed significant differences in end diastolic velocity, resistance index, flow velocity, and diameter that were more prominent in the CCA. After adjusting for carotid plaque and cardiovascular risk factors, the associations between the above-mentioned parameter and stroke remained significant.

CONCLUSIONS

Stroke patients in acute as well as chronic stable phase appeared to have larger CCA diameters, lower carotid flow velocities and volume, and higher resistance index than nonstroke patients independently of extracranial carotid atherosclerosis. These findings need to be confirmed by a prospective study.

Thrombus organization and healing in the swine experimental aneurysm model. Part I. A histological and molecular analysis

Object

The authors describe the process of thrombus organization in the swine surgical aneurysm model.

Methods

Lateral carotid artery aneurysms with immediately induced thrombosis were created in 31 swine for a time-course study. Aneurysms were evaluated at 1, 3, 7, 14, 30, and 90 days after they were created. Histological analyses included quantitative immunohistochemical studies and evaluation of collagen deposition. Complementary DNA microarray analysis was performed for gene expression profiling. The lists of up- and downregulated genes were cross-matched with lists of genes known to be associated with cytokines or the extracellular matrix. The expression of selected genes was quantified using real-time polymerase chain reaction. Functional clustering was performed with the Expression Analysis Systematic Explorer (EASE) bioinformatics package.

Results

Histological analysis demonstrated leukocyte and macrophage infiltration in the thrombus at Day 3, myofibroblast infiltration at Days 7 to 14, and progressive collagen deposition and contraction thereafter. Tissue organization occurred in a centripetal fashion. A previously undescribed reticular network of connective tissue was observed at the periphery of the aneurysm at Day 3. Macrophages appeared critical to this thrombus organization. A total of 1109 genes were significantly changed from reference time zero during the time course: CXCL14, which produces a monocyte-specific chemokine, was upregulated over 100-fold throughout the time course; IGF1 was upregulated fourfold at Day 7, whereas IGFBP2 was downregulated approximately 50% at Days 7 and 14. Osteopontin (SPP1) upregulation increased from 30-fold at Day 30 to 45-fold at Day 14. The EASE analysis yielded eight functional classes of gene expression.

Conclusions

This investigation provides a detailed histological and molecular analysis of thrombus organization in the swine aneurysm model. The companion study will describe the effect of embolic bioabsorbable polymers on this process.

Cardioembolism: a rare cause of jaw claudication

Jaw claudication (JC) results from ischemia of the masticatory muscles, typically caused by temporal arteritis and other arteriopathies affecting the external carotid artery (ECA).

We documented a case of JC resulting from cardioembolic occlusion of the ECA and searched both English and French literature on the Medline database (1966-October 2006) to identify previous reports. We combined the keywords “jaw claudication” with either “cardiogenic embolism”, “cardiac embolism”, “cardioembolism”, “etiology”, “cause”, or “carotid occlusion”.

Differential effects of carotid artery stenting versus carotid endarterectomy on external carotid artery patency

PURPOSE

To determine the effect of stent coverage of the external carotid artery (ECA) after carotid artery stenting (CAS) compared to eversion endarterectomy of the ECA after carotid endarterectomy (CEA).

METHODS

The records of 101 CAS and 165 CEA procedures performed over 2 years were reviewed. Duplex velocities and history and physical examinations were taken prior to the procedure, at 1 month, and at 6-month intervals subsequently. CAS was performed by extending the stent across the internal carotid artery (ICA) lesion into the common carotid artery (CCA) thereby covering the ECA. CEA was performed with eversion endarterectomy of the ECA.

RESULTS

The mean peak systolic velocities (PSV) in the ICA pre-CAS and pre-CEA were 361 and 352 cm/s, respectively. In terms of CAS, there was a significant increase in ECA velocities versus baseline at 12 (p = 0.009), 18 (p = 0.00001), and 24 (p = 0.005) months. In the CEA group, there was a significant decrease in ECA velocities versus baseline at 1 (p = 0.01) and 6 (p = 0.004) months. There were 2 occluded ECAs in follow-up in the CAS group and none in the CEA group. No significant differences were noted when comparing preprocedural ICA or ECA velocities. However, at the 1-, 6-, and 12-month intervals, the ECA velocities in the CAS group were significantly higher than in the CEA group (p = 0.03, p = 0.001, and p = 0.0004, respectively). There were no neurological symptoms in any patients during the study period.

CONCLUSION

Although progressive stenosis of the ECA is noted during CAS, the ECA usually does not occlude. Furthermore, there are no associated neurological symptoms. Thus, apprehension for progressive ECA occlusion should not be a contraindication to CAS. In addition, concern for ECA coverage should not deter stent extension from the ICA to the CCA during CAS.

Tumefactive cyst with a vascular blush as a late complication after combined embolization and stereotactic radiosurgery treatments for a cerebral arteriovenous malformation

Cyst formation is a recognized late complication after stereotactic radiosurgery for cerebral arteriovenous malformations (AVMs). We report on a patient with delayed cyst formation after combined embolization and stereotactic radiosurgery treatments for a cerebral AVM. The true nature of the cyst was complicated by tumefactive magnetic resonance MR imaging characteristics. The tumefactive cyst was associated with an additional imaging finding suggestive of a neoplastic lesion - a 'blush' on conventional angiography.

Low levels of Nogo-B in human carotid atherosclerotic plaques are associated with an atheromatous phenotype, restenosis, and stenosis severity

OBJECTIVE

Reticulon-4/Nogo (Nogo-B) protects mouse arteries from lumen loss by reducing smooth muscle cell (SMC) migration and intimal thickening. Our goal was to determine plaque and circulating levels of Nogo-B in atherosclerotic and control subjects. Therefore, we studied the relationships between local Nogo-B, plaque characteristics, and clinical data in patients undergoing carotid endarterectomy.

METHODS AND RESULTS

Western blot analysis showed that endarterectomy specimens from the femoral (n=19) and carotid arteries (n=145) contained significantly less Nogo-B than nonatherosclerotic mammary arteries (n=8; P<0.003) and aortas (n=15; P=0.03). Immunohistochemistry revealed that in atherosclerotic lesions, Nogo-B was expressed by macrophage/foam cells, SMC rich, and neo-vascularized areas. Atheromatous plaques (>40% fat content) showed a significant reduction in Nogo-B expression (P=0.002). Nogo-B expression levels were significantly lower in patients with more than 90% of carotid stenosis (P=0.04) or restenotic lesions after prior carotid intervention (duplex; P=0.01). In contrast, plasmatic levels of Nogo-B (soluble Nogo-B) did not differ between atherosclerotic subjects (n=68) and risk-factor matched controls (n=63; P=0.5).

CONCLUSION

Our findings suggest that local reduction of Nogo-B in atherosclerotic tissue might contribute to plaque formation and/or instability triggering luminal narrowing. In contrast, plasma Nogo-B levels are not associated with clinically manifested atherosclerotic disease.

Stenosis of the Proximal External Carotid Artery in an Adult With Moyamoya Disease: Moyamoya or Atherosclerotic Change? -Case Report-

A 55-year-old woman presented with moyamoya disease manifesting as recurrent transient ischemic attacks despite taking aspirin and antihypertensive agent. Angiography showed the characteristic angiographic appearance with bilateral internal carotid artery occlusion and abnormal collateral vessels. Left external carotid angiography demonstrated moderate stenosis of the proximal external carotid artery (ECA). A self-expandable stent was successfully placed in the left ECA to improve ipsilateral cerebral perfusion. The patient had an uneventful outcome after a 1-year follow up. Involvement of the proximal ECA is very unusual in moyamoya disease, and might result from hemodynamic stress or degenerative atherosclerosis. Revascularization procedures for stenoses of proximal ECA may improve cerebral perfusion in patients with moyamoya disease.

Carotid artery plaque thickness is associated with increased serum calcium levels: the Northern Manhattan study

BACKGROUND

Elevated serum calcium concentrations are associated with vascular calcification and cardiovascular disease. It is unknown whether there is a relationship between high-normal serum calcium levels and sub-clinical vascular effects. We investigated the association between serum calcium and carotid plaque thickness, a powerful early predictor of clinical coronary and cerebrovascular events.

METHODS

Epidemiological study of 1194 subjects from the Northern Manhattan Study cohort, a prospective community-based study designed to investigate risk factors for vascular disease in different race-ethnic groups.

RESULTS

Subjects with carotid plaque had higher corrected serum calcium levels within the normal range than those without carotid plaque (2.21+/-0.09 mmol/L versus 2.19+/-0.09 mmol/L, p<0.002). The relationship between carotid plaque and serum calcium persisted after adjustment for traditional cardiovascular risk factors. Subjects in the top quintile of maximal carotid plaque thickness (>or=1.7 mm) were more likely to be in the highest quintile of serum calcium level (OR=1.64, 95% CI=1.17-2.29, p<0.004). The interaction of age and corrected serum calcium was the most significant predictor of carotid plaque thickness when traditional vascular risk factors were considered (p<0.001).

CONCLUSIONS

Serum calcium levels in a multi-ethnic population of older men and women were positively associated with carotid plaque thickness, a powerful early predictor of clinical coronary and cerebrovascular events.

Treatment of a superior sagittal sinus dural arteriovenous fistula with Onyx: technical case report

OBJECTIVE

The endovascular treatment of a complex superior sagittal sinus dural arteriovenous fistula with ethylene vinyl alcohol copolymer (Onyx) in one session is described.

CLINICAL PRESENTATION

A 54-year-old man presented with dizziness and a bruit. A cerebral angiogram demonstrated a superior sagittal sinus dural arteriovenous fistula with a patent superior sagittal sinus that was supplied via multiple branches of the external carotid arteries bilaterally and the left anterior and middle cerebral arteries. Drainage was mainly through the superior sagittal sinus and, only in part, retrogradely through the cortical veins. A decision was made to proceed with endovascular treatment followed by surgery.

INTERVENTION

Transarterial injection of one pedicle of middle meningeal artery on both sides with Onyx resulted in complete obliteration of the dural supply and some of the pial supply to the malformation without complications. The superior sagittal sinus remained patent. Based on this result, surgical treatment was cancelled. The residual pial supply had disappeared by the 10-month angiographic follow-up examination and the patient remained neurologically intact and without symptoms.

CONCLUSION

Definitive treatment may be attained with Onyx in dural arteriovenous fistulas. The potential of Onyx for use as a permanent embolic agent in dural arteriovenous fistulae needs to be investigated.

Anterior ethmoidal artery aneurysm and intracerebral hemorrhage

The association between the formation of intracranial aneurysms and situations of increased blood flow in certain areas of the brain is well accepted today. It has been seen in association with arteriovenous malformations of the brain, carotid occlusion, and Moyamoya disease. The occurrence of aneurysms in small arteries of the skull base, with the exception of the intracavernous carotid artery, however, is rare. We report a case of a 55-year-old woman who presented with an intracerebral hemorrhage caused by a ruptured anterior ethmoidal artery aneurysm. To the best of our knowledge, this is only the second case of documented intracranial bleeding from such a lesion.

A modified technique for bypass of the external carotid artery to the proximal posterior cerebral artery: an anatomical and technical study

CONCLUSIONS

Our results support the proposition that bypass between the external carotid artery (ECA) and proximal posterior cerebral artery (PCA) can be achieved by using a short saphenous venous graft. The diameters of the ECA and vein graft may provide an increased blood flow with a straighter course. This technique may be helpful for management of patients with vertebrobasilar insufficiency or those requiring a high volume blood flow to the posterior circulation.

OBJECTIVES

We aimed to describe a modified technique using a short saphenous vein graft for bypass between the ECA and the PCA in order to use a small length of graft material and increase the patency of the anastomosis.

MATERIALS AND METHODS

Ten sides of five cadavers were dissected bilaterally. After a frontotemporal craniotomy and zygomatic arch osteotomy, the middle cranial fossa was exposed. A hole located approximately 2-3 cm posterolateral to the foramen rotunda was created extradurally. The sylvian fissure and the interpeduncular and ambient cisterns were opened. The proximal P2 segment of the PCA was identified. The ECA was found through a cervical incision. A short interposition saphenous vein graft was conducted to pass just behind the ramus mandible to the infratemporal fossa. The bypass between the ECA and P2 segment of the PCA was performed by using a short saphenous vein graft. The diameters of the ECA, P2 segment of PCA and both ends of the saphenous vein graft and its length were measured using an electronic micrometer.

RESULTS

The mean cross-clamping time of the PCA was 10.4+/-1.8 min. The mean diameters of the P2 segment of the PCA and ECA were 2.2+/-0.15 mm and 3.83+/-0.28 mm, respectively. The mean length of the saphenous vein graft was 88.8+/-3.8 mm.

Cerebral arteriopathy with extracranial artery involvement in a patient with ulcerative colitis

Arteriopathy of the central nervous system (CNS) complicated with ulcerative colitis is a rare condition, moreover the involvement of extracranial arteries has not been documented. An 18-year-old female complained of a severe pulsatile headache and nausea. She had been diagnosed and treated for ulcerative colitis for four years. Magnetic resonance imaging of the brain showed normal results; however, magnetic resonance angiography (MRA) revealed severe irregularity of the intracerebral arteries. After treatment with prednisolone, the patient fully recovered and the irregularity of the intracerebral arteries was dramatically improved. Vasculitis was strongly suggested as the cause of arteriopathy of the CNS in the present case. Involvement of extracranial arteries such as the carotid artery was also incidentally discovered by duplex ultrasonography and the HLA typing suggested genetic susceptibility to Takayasu's arteritis. Findings from our patient suggest that extracranial arterial involvement should be considered in the case of arteriopathy of the CNS associated with ulcerative colitis.

Head-and-neck swelling: an under-recognized feature of giant cell arteritis. A report of 37 patients

OBJECTIVE

To describe the frequency of occurrence and characteristics of head-and-neck swelling (HNS) in temporal (giant cell) arteritis (TA).

METHODS

We analyzed the charts of patients with HNS retrieved from a single department series of 260 consecutive patients with TA and reviewed the published French-English literature. Patients with a swelling limited to the temporal fossa were excluded.

RESULTS

A history of HNS was elicited in 17 patients in our series (i.e. 6.5%) and in 20 previously published patients. The swelling was an inaugural feature in most cases and was often transient. Ear-nose-and-throat (ENT )symptoms were observed in 80% of the cases, including jaw claudication or pain upon opening mouth in 22, causing trismus in 10. Two patients had permanent visual impairment and 1 had sudden hearing loss. The temporal artery biopsy yielded giant cell arteritis (GCA) in all the patients but 2. The HNS was often painful and mainly involved mainly the orbital region and face, particularly the lower part of the cheeks and maxillae, less often the neck and, rarely, the forehead and tongue. Concurrent localized limb swellings were also observed in 3 patients. The HNS disappeared in all the patients, either spontaneously or under steroid treatment, and recurred only in 6 patients.

CONCLUSION

HNS is not exceptional in untreated TA and is strongly associated with ENT symptoms and a positive TAB, but not with visual loss or stroke. Such characteristics imply in these cases a prominent, widespread involvement of the external carotid artery system by giant cell arteritis.

The Occipital Artery:Amicroanatomical Study

OBJECTIVE:

We performed a systematic microanatomical study of the occipital artery (OA) and its branches to describe the course, diameter, and branches of this vessel as well as the presence and pattern of anastomotic channels between the OA and the vertebral artery.

METHODS:

Twelve occipital arteries (6 adult cadaveric heads injected with colored latex) were studied using the surgical microscope. Particular attention was given to the course and branching pattern of the artery as well as the presence and type of anastomotic channels between the occipital artery and vertebral artery.

RESULTS:

Based upon anatomical considerations, the course of the occipital artery was divided into three segments. The first, or digastric segment, extends from the origin to the exit off the occipital groove of the mastoid process. The second segment, or suboccipital, extends from the occipital groove to the superior nuchal line. The third, or terminal segment, corresponds to the subgaleal segment just above the superior nuchal line up to the vertex. Two main descending branches of the second segment or suboccipital were identified. The superficial descending branch (SDB) runs between the splenium capitis and semispinalis capitis while the deep descending branch (DDB) enters the suboccipital triangle. Anastomotic vessels between one of these two descending branches and branches of the vertebral artery were found in 11 out of the 12 OAs dissected (91%).

CONCLUSION:

Detailed knowledge of the OA anatomy is helpful in choosing this vessel as a donor for extra-intracranial bypasses. More importantly, knowledge and understanding of the type and pattern of anastomoses between the OA and the vertebral artery are critical to avoid disastrous complications (i.e., posterior circulation stroke) during embolization of vascular or neoplastic processes fed by distal OA branches.

[Sudden cervical hematoma after hypertensive crisis. Report of a case]

We report the case ofa 61 years old woman with multiple pathologies: HTA, diabetes, relapsing polychondritis, hypercholesterolemia, iatrogenic Cushing, cardiopathy, cystic fibrosis, etc. She began, an increment of TA (220/130 mm Hg) or hypertensive crisis, with a sudden left cervical hematoma located on the carotid bifurcation according to CT imaging. We oractice an arteriography that was informed as normal and the patient was admitted and controlled of an ORL as Vascular Surgeon. The bleeding stop spontaneously we treat the patient conservativity.

Ocular Ischemic Syndrome After Occlusion of Both External Carotid Arteries

The ocular ischemic syndrome (OIS) has been reported in association with high-grade stenosis or occlusion of the common carotid artery (CCA) or internal carotid artery (ICA) but never with high-grade stenosis or occlusion of the external carotid artery (ECA) alone. We describe two patients who developed OIS with bilateral occlusion of the ECAs yet patent CCAs and ICAs. In one case, unilateral OIS followed consecutive bilateral carotid endarterectomies. In the other case, OIS developed spontaneously OU but was exacerbated in one eye after ipsilateral carotid endarterectomy (CE) in the setting of pre-existing contralateral ECA occlusion. In some individuals, the ECA is the primary source of arterial blood flow to the eye. Because of this fact, the endarterectomy surgeon must avoid causing ECA occlusion by meticulously removing not only the ICA plaque, but also the entire ECA plaque.

Phenotypic modifications of vascular smooth muscle cells could be responsible for vascular hyporeactivity to contracting agent in mechanically injured rat carotid artery

Vascular smooth muscle cells (VSMCs) that accumulate in neointima after angioplastic injury show different phenotypic characteristics from those of medial layer and an impaired reactivity to contracting agents. The aim of the study was to correlate the vascular hyporesponsiveness to the changes in intracellular calcium concentration [Ca(2+)](i) and the expression of proteins necessary for its utilization in mechanically injured rat carotid arteries (IC) at 14 and 28 days after angioplastic balloon. IC showed a significant reduction (P<0.01) to PE- or KCl-induced contraction as compared to uninjured carotid (UC). Fura-2AM-loaded VSMCs isolated from IC revealed that this hyporeactivity to PE or KCl was accompanied by the impairment of the increase in [Ca(2+)](i) induced by contracting agents in both Ca(2+)-free or -containing medium. Similar results were observed following the ryanodine challenge in VSMC. Western blot analysis showed a significant (P<0.05) reduction in myosin heavy chain (MHC) and IP(3)-type III receptor expression in IC isolated at 14 days from injury compared to UC, while an improvement of these proteins expression was observed at 28 days after damage. On the other hand, in IC tissue, SERCA2 and alpha-actin expression, compared to UC was significantly higher at 14 days than at 28 days. These data indicate that vascular hyporeactivity induced by mechanical injury may be due to alterations of either [Ca(2+)](i) or contractile proteins. These modifications could be related to the changes of VSMC phenotypic characteristics, as supported by the observed modifications in MHC, SERCA2 and alpha-actin expression, proteins considered as biological markers of cellular differentiation.

De novo development of a remote arteriovenous fistula following transarterial embolization of a carotid cavernous fistula: case report and review of the literature

We report a case of a patient who developed a remote dural arteriovenous fistula involving the left sigmoid sinus 4 months after successful transarterial embolization of a carotid cavernous fistula. This rare occurrence has been reported after transvenous embolization, but this represents the first case, to our knowledge, after transarterial coil embolization. We present our findings along with a brief review of the literature.

Variation in the Carotid Bifurcation Geometry of Young Versus Older Adults

Background and Purpose— Retrospective analysis of clinical data has demonstrated major variations in carotid bifurcation geometry, in support of the notion that an individual’s vascular anatomy or local hemodynamics may influence the development of atherosclerosis. On the other hand, anecdotal evidence suggests that vessel geometry is more homogenous in youth, which would tend to undermine this geometric risk hypothesis. The purpose of our study was to test whether the latter is indeed the case.

Methods— Cross-sectional images of the carotid bifurcations of 25 young adults (24±4 years) and a control group of 25 older subjects (63±10 years) were acquired via MRI. Robust and objective techniques were developed to automatically characterize the 3D geometry of the bifurcation and the relative dimensions of the internal, external, and common carotid arteries (ICA, ECA, and CCA, respectively).

Results— Young vessels exhibited significantly less interindividual variation in the following geometric parameters: bifurcation angle (48.5±6.3° versus 63.6±15.4°); ICA angle (21.6±6.7° versus 29.2±11.3°); CCA tortuosity (0.010±0.003 versus 0.014±0.011); ICA tortuosity (0.025±0.013 versus 0.086±0.105); ECA/CCA diameter ratio (0.81±0.06 versus 0.75±0.13), ICA/CCA (0.81±0.06 versus 0.77±0.12) diameter ratio, and bifurcation area ratio (1.32±0.15 versus 1.19±0.35).

Conclusions— The finding of more modest interindividual variations in young adults suggests that, if there is a geometric risk for atherosclerosis, its early detection may prove challenging. Taken together with the major interindividual variations seen in older vessels, it suggests a more complex interrelationship between vascular geometry, local hemodynamics, vascular aging, and atherosclerosis, the elucidation of which now calls for prospective studies.

Magnetic resonance angiography evaluation of external carotid artery tributaries in moyamoya disease

BACKGROUND AND PURPOSE

High-resolution magnetic resonance (MR) image has been introduced to diagnose and follow-up moyamoya disease and visualized moyamoya vessels and internal carotid artery stenosis. This study was performed to assess the utility of MR angiography (MRA) for the evaluation of anastomotic channels through the external carotid artery (ECA) in moyamoya disease patients.

METHODS

Twenty patients with moyamoya disease were reviewed. The cortical anastomosis and superficial temporal artery (STA), middle meningeal artery, and deep temporal artery by MRA were evaluated and were compared with those by digital subtraction angiography if obtained. Fifteen patients (24 hemispheres) underwent bypass surgery, including encephaloduroarteriosynangiosis in 14 hemispheres and STA-middle cerebral artery anastomosis with encephalomyosinangiosis in 10 hemispheres. Five patients did not undergo any surgery.

RESULTS

MRA could show these vessels and the patency of anastomosis formed by the surgery and also showed naturally formed anastomosis and ECA tributaries in the patients who did not undergo any surgery.

CONCLUSION

MRA provides useful information for follow-up evaluation on the development of the ECA system in moyamoya disease.