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Wu G, Nong Y, Hong S, Wang S, Dai C, He C, Li C, Ma T, Yang Z, Zhang B, Gao Y, Ma G. Management of intervenable factors to reduce vascular complications in patients with internal carotid artery occlusion treated by non-emergency endovascular treatment. Front Neurol 2024; 15:1332940. [PMID: 38497036 PMCID: PMC10940403 DOI: 10.3389/fneur.2024.1332940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
Objective This study aims to identify risk factors for vascular complications during non-emergency endovascular treatment in patients with internal carotid artery occlusion (ICAO) and to propose potential interventions. Method A retrospective analysis of 92 patients with ICAO who received non-emergency endovascular treatment in our center from 1 January 2018 to 31 June 2023, was conducted. The correlation between intraoperative vascular complications and potential risk factors was studied, and interaction analysis was performed. Results Our findings revealed that the use of non-neurology guide wires to open vessels (adjusted OR: 4.1, 95%CI: 1.3-12.8; p = 0.014) and glycosylated hemoglobin (HbA1c) ≥ 6.5 mmol/L (adjusted OR: 3.2, 95%CI: 1.2-8.9; p = 0.023) was significantly associated with vascular complications in non-emergency endovascular treatment of ICAO patients. The restricted cubic spline (RCS) showed that the higher the HbA1c level, the higher the risk of vascular complications. Conclusion The use of non-neurology guide wires for vessel opening during non-emergency endovascular treatment in patients with ICAO increases the risk of vascular complications. Preoperative assessment and management of HbA1c levels can reduce the incidence of intraoperative vascular complications.
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Affiliation(s)
- Guangyu Wu
- Department of Neurology, Guangzhou Key Laboratory of Diagnosis and Treatment for Neurodegenerative Diseases, Guangdong Neuroscience Institute, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuxin Nong
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shaorui Hong
- Shantou University Medical College, Shantou, China
| | - Shuo Wang
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Chengbo Dai
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Chizhong He
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Changmao Li
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Tengyun Ma
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Zhexian Yang
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Bin Zhang
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Yuyuan Gao
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Guixian Ma
- Department of Neurology, Guangzhou Key Laboratory of Diagnosis and Treatment for Neurodegenerative Diseases, Guangdong Neuroscience Institute, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
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Wang S, Ouyang W, Zhang Y, Chen H. Branch retinal artery occlusion with congenital common carotid artery and internal carotid artery occlusion: A case report. Eur J Ophthalmol 2024; 34:NP60-NP65. [PMID: 38158829 DOI: 10.1177/11206721231165442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE To report a case of branch retinal artery occlusion (BRAO) of the left eye combined with left congenital common carotid artery occlusion (CCAO) and internal carotid artery occlusion (ICAO). METHODS Case report. RESULTS A 36-year-old man presented with sudden vision loss of only the left eye without any signs or symptoms of brain diseases. Fluorescein fundus angiography (FFA) showed left BRAO, and computed tomography angiography (CTA) of the head and neck showed entire left CCAO and ICAO. The patient's left vertebral artery was anastomosed with the left occipital artery via the muscular branch, supplying blood retrogradely to the left external carotid artery. The right internal carotid artery compensated for blood supply to the left anterior cerebral artery and middle cerebral artery via anterior communication, and the left posterior communication artery compensated for blood supply to the left middle cerebral artery. CONCLUSIONS To our knowledge, this study was the first to report a case of BRAO combined with congenital CCAO and ICAO with vision loss as the first symptom and proposed the importance of head and neck examination in retinal artery occlusion at the first visit to a doctor.
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Affiliation(s)
- Shoubi Wang
- The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Weijie Ouyang
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Eye Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Yidan Zhang
- The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Han Chen
- The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
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Aramaki K, Aihara M, Kanazawa Y, Kawashima T, Yamaguchi R, Matsumoto M, Tosaka M, Yoshimoto Y. Radiological features of internal carotid artery occlusion caused by pituitary apoplexy: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23484. [PMID: 38048571 DOI: 10.3171/case23484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/10/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Pituitary apoplexy rarely causes internal carotid artery (ICA) occlusion and acute ischemic stroke. Some cases have been reported, but the neuroimaging findings, including cerebral angiography, have not been discussed. OBSERVATIONS A 55-year-old male suffered the sudden onset of right cervical pain and left mild hemiparesis. Computed tomography indicated a pituitary mass, and magnetic resonance angiography showed a right ICA occlusion. The initial diagnosis was ICA occlusion caused by ICA dissection. His symptoms worsened and the region of cerebral infarction expanded, so the patient was transferred to our hospital. Magnetic resonance imaging and cerebral angiography showed the sudden stoppage of right ICA blood flow caused by local compression of the tumor near the distal dural ring. The diagnosis was acute ischemic stroke resulting from ICA pseudo-occlusion caused by pituitary apoplexy, and emergent endoscopic transsphenoidal resection was performed. Postoperatively, the right ICA was completely patent, and hemiparesis was improved with rehabilitation. LESSONS ICA occlusion caused by pituitary apoplexy is very rare, but emergent treatment is necessary. However, the pathology is difficult to diagnose quickly. Neuroimaging findings showing that the ICA is easily stenosed or occluded if rapidly compressed by the tumor near the distal dural ring may be useful to rapidly diagnose and treat.
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Affiliation(s)
- Keigo Aramaki
- 1Department of Neurosurgery, Hokushin General Hospital Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Nakano, Nagano, Japan
| | - Masanori Aihara
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
| | - Yu Kanazawa
- 3Department of Neurosurgery, Tatebayashi Kosei General Hospital, Tatebayashi, Gunma, Japan
| | - Takahiro Kawashima
- 3Department of Neurosurgery, Tatebayashi Kosei General Hospital, Tatebayashi, Gunma, Japan
| | - Rei Yamaguchi
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
| | - Masahiro Matsumoto
- 3Department of Neurosurgery, Tatebayashi Kosei General Hospital, Tatebayashi, Gunma, Japan
| | - Masahiko Tosaka
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
| | - Yuhei Yoshimoto
- 2Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; and
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Zhou B, Xu L, Sun S, Zhang H. Parent Artery Chronical Occlusion after Endovascular Treatment of a Unruptured "True" Posterior Communicating Artery Aneurysm. Neurol India 2023; 71:1241-1243. [PMID: 38174466 DOI: 10.4103/0028-3886.391389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
A case of a patient with a true large unruptured posterior communicating artery (PCoA) aneurysm in a distal segment of PCoA, who was treated by interventional therapy via an ipsilateral occlusion of the internal carotid artery (ICA), is reported. Although the treatment went very well and the patient recovered very well, angiography 6 months after the operation showed that left PCoA had occluded and the aneurysm disappeared. The temporary recanalization of occluded ophthalmic segment of ICA can be a pathway for interventional therapy. Mechanism and preventive measures for spontaneous occlusion of the PCoA harboring an aneurysm still needs further study.
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Affiliation(s)
- Baoyuan Zhou
- Department of Neurosurgery and Laboratory of Neurosurgery, Lanzhou University Second Hospital, Institute of Neurology, Lanzhou University, Lanzhou, Gansu, China
| | - Linjuan Xu
- Department of Anesthesia, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Shouyuan Sun
- Department of Neurosurgery and Laboratory of Neurosurgery, Lanzhou University Second Hospital, Institute of Neurology, Lanzhou University, Lanzhou, Gansu, China
| | - Hailin Zhang
- Department of Neurosurgery and Laboratory of Neurosurgery, Lanzhou University Second Hospital, Institute of Neurology, Lanzhou University, Lanzhou, Gansu, China
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Sarwar MU, Furrukh M, Tabrez MA, Kannar A, Sumbal MA, Haseeb M. Malignant Middle Cerebral Artery Infarct Caused by Eagle's Syndrome. Cureus 2023; 15:e47205. [PMID: 38022111 PMCID: PMC10653012 DOI: 10.7759/cureus.47205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Eagle's syndrome is characterised by elongation of the styloid process. The elongated styloid process can cause symptoms like dysphagia, facial or neck pain, syncope, visual changes, etc. In severe cases, it may cause a rupture or dissection of the carotid artery, which can lead to intracranial thrombo-embolism and ischemic stroke. We report a case of a 57-year-old male presenting with dysarthria and mild left-sided body weakness. An initial non-contrast computed tomography (CT) scan showed a possible right internal carotid artery thrombus. He developed worsening left-sided weakness and gaze palsy one day after the admission. Repeated CT brain and intracranial angiography were arranged, which showed significant oedema with mass effect and right internal carotid artery dissection with thrombus. He underwent decompressive craniectomy. An enlarged styloid process measuring 4.53 cm in close proximity to the cervical vasculature was also noted. He was not deemed an appropriate candidate for styloidectomy. Due to residual left-sided weakness, he had to take early retirement. He underwent extensive rehabilitation and was able to mobilize with the help of a quad stick after a period of nine months. At the five-year follow-up, there were no characteristic symptoms of Eagle's syndrome and he was mobilizing without support.
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Affiliation(s)
| | | | | | - Aqil Kannar
- General Medicine, Dorset County Hospital, Dorchester, GBR
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Zhang SY, Blacquiere D, Dewar B, Stotts G, Dowlatshahi D. Spontaneous Recanalization of Internal Carotid Artery Occlusion: A Case Report. Neurologist 2023; 28:324-325. [PMID: 36715668 PMCID: PMC10521796 DOI: 10.1097/nrl.0000000000000485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Spontaneous recanalization of an occluded internal carotid artery (ICA) is thought to be unlikely. However, there has been a growing number of reports describing this phenomenon. Despite this, the frequency, time course, and mechanism of spontaneous recanalization remain unknown. In this paper, we describe a patient with a symptomatic recanalization of an occluded left ICA. CASE REPORT A 70-year-old woman presented with transient speech arrest and right upper extremity weakness related to an occluded ICA. After 3 days, her weakness and aphasia reappeared and worsened transiently. A repeat computed tomography angiography revealed recanalization of the occluded ICA, as well as new ischemic changes in the previously hypoperfused left insular region. This finding changed the management from medical management to revascularization with a stent, after which the patient was discharged home with acetylsalicylic acid and clopidogrel. CONCLUSIONS Although previously thought to be a rare occurrence, spontaneous recanalization is not uncommon. Further research into this phenomenon as proper identification and characterization of this phenomenon can influence follow-up and management.
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Affiliation(s)
- Sarah Y. Zhang
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec
| | - Dylan Blacquiere
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Dewar
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grant Stotts
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Acciarri P, Camagni A, Bressan M, Zenunaj G, Casetta I, Bernardoni A, Gasbarro V, Traina L. Acute ischemic stroke: The role of emergency carotid endarterectomy in isolated extracranial internal carotid artery occlusion. Vascular 2023:17085381231192712. [PMID: 37594376 DOI: 10.1177/17085381231192712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVES The treatment of choice for acute and isolated extracranial internal carotid artery (eICA) occlusion remains, to date, controversial. Although intravenous thrombolysis is recommended, its effectiveness is generally low. This retrospective study aims to assess the clinical outcome and the role of CT perfusion in symptomatic patients who underwent carotid endarterectomy (CEA) for acute occlusion of the eICA. MATERIALS AND METHODS All the 21 patients presented with stroke-in-evolution, complete patency of intracranial circulation, no evidence of hemorrhagic transformation at CT and a minimum ASPECTS of 6. Clinical improvement was assessed by evaluating the variation of NIHSS and the mRS. We investigated the relationship between NIHSS and the timing of the surgery, the ASPECT score, and the volume of ischemic penumbra at CT perfusion. RESULTS Median NIHSS on admission was 9 (range 1-24) and it decreased to 4 (range 0-35) 24 h after surgery, improving in 76.2% of patients. Patients with an ASPECTS of 6 (3 patients) showed an improvement of 66.7%, while it was of 81.8% in those starting with a score of 9 or 10 (11 patients). A mRS between 0 and 2 after 3 months was achieved in 12 out of 21 patients. The average time elapsing between surgery and symptom onset was 410 min (range 70-1070 min). Fourteen patients treated within 8 h from symptoms onset showed a clinical improvement of 85.7%, compared to a 57.1% for those which underwent later surgery. Four patients underwent thrombolytic therapy before CEA showing postoperative clinical improvement and no intracranial hemorrhage. Among the 14 patients who underwent CT perfusion, the median ischemic penumbra volume was 112 cc in those with clinical improvement (10 patients) and only 84 cc in those with worse clinical outcomes (4 patients). CONCLUSIONS Emergency CEA in isolated eICA occlusion has proved to be a safe and effective treatment option in selected patients. CT perfusion, imaging the ischemic penumbra and quantifying the tissue suitable for reperfusion, offers a valid support in the diagnostic-therapeutic workup. Indeed, we can infer that the area of the ischemic penumbra is directly proportional to the margin of clinical improvement after revascularization, supposing that the appropriate intervention timing is respect.
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Affiliation(s)
| | - Alice Camagni
- Department of Vascular Surgery, Sant'Anna University Hospital, Cona, Italy
| | - Maddalena Bressan
- Department of Vascular Surgery, Sant'Anna University Hospital, Cona, Italy
| | - Gladiol Zenunaj
- Department of Vascular Surgery, Sant'Anna University Hospital, Cona, Italy
| | - Ilaria Casetta
- Department of Neurology, Sant'Anna University Hospital, Cona, Italy
| | | | - Vincenzo Gasbarro
- Department of Vascular Surgery, Sant'Anna University Hospital, Cona, Italy
| | - Luca Traina
- Department of Vascular Surgery, Sant'Anna University Hospital, Cona, Italy
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Jud S, Klövekorn R, van Niftrik CHB, Herzog L, Sebök M, Schweizer J, Luft AR, Fierstra J, Wegener S. High posterior cerebral artery flow predicts ischemia recurrence in patients with internal carotid artery occlusion. Front Neurol 2023; 14:1193640. [PMID: 37545725 PMCID: PMC10397388 DOI: 10.3389/fneur.2023.1193640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 06/28/2023] [Indexed: 08/08/2023] Open
Abstract
Recurrent stroke is a dreaded complication of symptomatic internal carotid artery occlusion (ICAO). Transcranial Duplex (TCD)-derived increased flow velocity in the ipsilateral posterior cerebral artery (PCA)-P2 segment indicates activated leptomeningeal collateral recruitment and hemodynamic impairment. Leptomeningeal collaterals are pial vascular connections between the anterior and posterior vascular territories. These secondary collateral routes are activated when primary collaterals via the Circle of Willis are insufficient. Our goal was to test the TCD parameter PCA-P2 flow for prediction of ipsilateral ischemia recurrence. We retrospectively analyzed clinical and ultrasound parameters in patients with ICAO. Together with clinical variables, we tested systolic PCA-P2 flow velocity as predictor of a recurrent ischemic event using logistic regression models. Of 111 patients, 13 showed a recurrent ischemic event within the same vascular territory. Increased flow in the ipsilateral PCA-P2 on transcranial ultrasound (median and interquartile range [IQR]: 60 cm/s [IQR 26] vs. 86 cm/s [IQR 41], p = <0.001), as well as previous transient ischemic attack (TIA) and low NIHSS were associated with ischemia recurrence. Combined into one model, accuracy of these parameters to predict recurrent ischemia was 89.2%. Our data suggest that in patients with symptomatic ICAO, flow increases in the ipsilateral PCA-P2 suggest intensified compensatory efforts when other collaterals are insufficient. Together with the clinical variables, this non-invasive and easily assessable duplex parameter detects ICAO patients at particular risk of recurrent ischemia.
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Affiliation(s)
- Simon Jud
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Robert Klövekorn
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Christiaan Hendrik Bas van Niftrik
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Lisa Herzog
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland
| | - Martina Sebök
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Juliane Schweizer
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Stadtspital Waid and Triemli, Zurich, Switzerland
| | - Andreas R. Luft
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Jorn Fierstra
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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Xu X, Ni C, Wu K, Zha M, Sun Y, Wang H, Xu J, Yang K, Guo Y, Huang X, Zhou Z. The relationship between occlusion patterns and outcomes after thrombectomy in patients with acute internal carotid artery occlusion. J Neuroradiol 2023; 50:455-461. [PMID: 37061029 DOI: 10.1016/j.neurad.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND AND PURPOSES Ischemic stroke caused by acute internal carotid artery occlusions (AICO) is usually associated with high disability and mortality. We aimed to investigate whether occlusion patterns significantly influence clinical outcome in patients receiving endovascular thrombectomy (EVT). PATIENTS AND METHODS We performed a retrospective analysis of databases from two comprehensive stroke centers and consecutively investigated patients who had underwent EVT. AICO was defined as acute internal carotid artery occlusions (cervical segment to terminal segment). The clinical characteristics, intervention parameters, and prognosis data were collected. Leptomeningeal collaterals (LMC) were assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale (ASITN/SIRs), graded on a 5-point scale. The occlusion patterns based on Willisian collaterals were categorized into I-type, L-type, and T-type by contralateral carotid artery injections at digital subtraction angiography. Multivariate regression models were applied to evaluate the relationship between occlusion patterns and the prognosis of patients at 90 days after stroke. RESULTS A total of 213 patients were included in the study. Of those,142 (66.7%) achieved successful reperfusion and 64 (30.0%) achieved favorable outcomes at 90 days. Overall, 26 (12.2%), 117 (54.9%), and 70 (32.9%) cases respectively suffered from I-type, L-type, and T-type occlusion. In addition, patients with I-type occlusions had a higher percentage of complete LMC compared with L-type or T-type occlusions (88.5% versus 30.8% versus 27.1%, P< 0.0167). In multivariable logistic regression, we found T-type occlusion was no longer an independent predictor of poor functional outcomes in AICO after adjusting LMC (T versus I, OR, 2.555, 95%CI: 0.717-9.103, P = 0.148; L versus I, OR, 0.815, 95%CI: 0.258-2.574, P = 0.727). CONCLUSIONS For ACIO, occlusion patterns are still a topic that needs attention. Furthermore, compensatory LMC may affect the association between occlusion patterns and functional prognosis in AICO. Occlusion patterns and LMC status distinguish the nature and impact of AICO on expected EVT and subsequent clinical outcomes.
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Affiliation(s)
- Xin Xu
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
| | - Chuyuan Ni
- Department of Neurology, Huangshan City People's Hospital, Huangshan, Anhui province, China
| | - Kangfei Wu
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
| | - Mingming Zha
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University
| | - Yi Sun
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
| | - Hao Wang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
| | - Junfeng Xu
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
| | - Ke Yang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
| | - Yapeng Guo
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China.
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital, Wannan Medical College, Wuhu, Anhui province, China
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10
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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11
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Li S, Zhao W, Liu G, Ren C, Meng R, Wang Y, Song H, Ma Q, Ding Y, Ji X. Chronic remote ischemic conditioning for symptomatic internal carotid or middle cerebral artery occlusion: A prospective cohort study. CNS Neurosci Ther 2022; 28:1365-1371. [PMID: 35702956 PMCID: PMC9344079 DOI: 10.1111/cns.13874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 01/05/2023] Open
Abstract
AIMS Remote ischemic conditioning (RIC) has been demonstrated to reduce recurrent stroke in patients with intracranial artery stenosis. This study aimed to evaluate the effects of RIC in patients with the symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion. METHODS This study is based on a high-volume single-center prospective cohort study in China, which included patients with symptomatic ICA or MCA occlusion with impaired hemodynamics and receiving chronic RIC. Clinical follow-up visits were performed regularly, and cardio-cerebrovascular events were assessed. RESULTS In total, 131 patients (68 with ICA occlusion and 63 with MCA occlusion; mean age, 52.6 ± 13.7 years; stroke, 73.5%; transient ischemic attack TIA, 26.5%) qualified for the analysis; the mean follow-up period was 8.8 years (range, 3-14 years). The compliance of RIC was 95.6 ± 3.7%, and no associated severe adverse events happened. The annual risk of ischemic stroke and ischemic cerebrovascular events was 2.4% and 3.3%, respectively. The cumulative probabilities of ischemic cerebrovascular events and major adverse cardiovascular and cerebrovascular events were 32.8% and 44.8% at 14 years, respectively. CONCLUSION In patients with symptomatic ICA or MCA occlusion with impaired hemodynamics, chronic RIC is well-tolerated, and it appears to be associated with a low annual risk of ischemic stroke and cardio-cerebrovascular events.
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Affiliation(s)
- Sijie Li
- Department of Emergency, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guiyou Liu
- Department of Emergency, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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12
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Chien CF, Tsai CY, Wu MN, Lai CL, Liou LM. Internal carotid artery occlusion related to poorly controlled rheumatoid arthritis presenting with continuous hand shaking: A case report and literature review. Medicine (Baltimore) 2022; 101:e29001. [PMID: 35244076 PMCID: PMC8896453 DOI: 10.1097/md.0000000000029001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 02/16/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Limb-shaking syndrome is a special manifestation of transient ischemic attack, resulting from internal carotid artery (ICA) occlusion. Extra-articular manifestations of rheumatoid arthritis (RA) are likely to occur in patients with severe or active RA. RA may accelerate atherosclerotic processes through inflammation. Here, we present a case of ICA occlusion related to poorly controlled RA that presented with continuous hand shaking. PATIENT CONCERNS A 73-year-old man with a history of poorly controlled RA developed total occlusion of the right ICA in recent 4 months. He presented with 2 days of continuous and rhythmic left-hand shaking before admission. DIAGNOSIS The patient was suspected to have transient ischemic attack resulting from ICA occlusion. INTERVENTIONS Antiplatelets and antiepileptic drugs were used for continuous nonepileptic focal myoclonus. A disease-modifying antirheumatic drug-based regimen for RA was developed to prevent further atherosclerosis. OUTCOMES Following the initial intervention, continuous hand shaking subsided on hospital day 7. Prednisolone was titrated as an active RA control. At the 6-month follow-up visit, neither painful wrist swelling nor recurrent shaking of the hand was noted. LESSONS Continuous hand shaking (nonepileptic focal myoclonus) can be the initial presentation of ICA occlusion in patients with poorly controlled RA. Every patient with RA should be treated aggressively with anti-rheumatic agents since RA is an independent risk factor for stroke. Additionally, every patient with RA should be surveyed for ICA stenosis, especially in those with poor control.
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Affiliation(s)
- Ching-Fang Chien
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chun-Yi Tsai
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Meng-Ni Wu
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chiou-Lian Lai
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Min Liou
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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13
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Chen C, Ling C, Luo L, Yang Y, Huang T, Wei L, Wang H. Multimodal recanalization for subacute symptomatic internal carotid artery occlusion due to atherosclerosis: Outcomes and notes on hybrid techniques. Ann Vasc Surg 2022; 84:114-125. [PMID: 35247538 DOI: 10.1016/j.avsg.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/20/2021] [Accepted: 01/16/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Subacute internal carotid artery occlusion (ICAO) is associated with ipsilateral recurrent stroke, and successful recanalization of ICAO can improve cerebral blood perfusion (CBP) and prevent stroke. However, the optimal treatment remains controversial. METHODS We conducted a retrospective analysis of patients with subacute symptomatic ICAO due to atherosclerosis treated at our center. The hybrid surgical procedures included carotid endarterectomy, Fogarty balloon catheter embolectomy, aspiration thrombectomy and percutaneous transluminal angioplasty/stenting. Recanalization rates, CBP improvement, stroke recurrence and restenosis/reocclusion were investigated. RESULTS Fourteen symptomatic atherosclerotic ICAO patients (type A, 4; type C, 10; men, 11; women, 3; average age, 68.1 ± 7.9 years) in the subacute phase were treated with a multimodal recanalization technique. Symptoms included mild cerebral infarction, transient ischemic attack (TIA) and amaurosis fugax. The average onset-to-treatment time was 18.1 ± 4.8 days. The successful recanalization (thrombolysis in cerebral ischemia grade 2 or 3) rate was 100%. The ipsilateral-to-contralateral mean transit time ratio was significantly lower at the 1-year follow-up than preoperatively (1.01 ± 0.05 vs. 1.26 ± 0.09, P < 0.0001). There was one case of restenosis detected 1 year after surgery and no cases of reocclusion. During the 28.3 ± 10.0 months of follow-up, only 2 cases of TIA occurred. The average modified Rankin Scale score and National Institute of Health Stroke Scale score were significantly lower at themost recent follow-up than before recanalization (1.21 ± 0.89 vs. 1.86 ± 0.66, P = 0.0003; 1.36 ± 1.55 vs. 2.00 ± 1.88, P = 0.0066). CONCLUSION Multimodal recanalization techniques performed in a hybrid operation theater can safely achieve high recanalization rates in atherosclerotic ICAO patients in the subacute phase, which can be beneficial for recovering CBP and preventing stroke.
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Affiliation(s)
- Chuan Chen
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China
| | - Cong Ling
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China
| | - Lun Luo
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China
| | - Yang Yang
- Department of Radiology, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China
| | - Tengchao Huang
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China
| | - Lei Wei
- Department of Neurology, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China
| | - Hui Wang
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China.
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14
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van den Brink H, Ferro DA, Bresser JD, Bron EE, Onkenhout LP, Kappelle LJ, Biessels GJ. Cerebral cortical microinfarcts in patients with internal carotid artery occlusion. J Cereb Blood Flow Metab 2021; 41:2690-2698. [PMID: 33899560 PMCID: PMC8504419 DOI: 10.1177/0271678x211011288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cerebral cortical microinfarcts (CMI) are small ischemic lesions that are associated with cognitive impairment and probably have multiple etiologies. Cerebral hypoperfusion has been proposed as a causal factor. We studied CMI in patients with internal carotid artery (ICA) occlusion, as a model for cerebral hemodynamic compromise. We included 95 patients with a complete ICA occlusion (age 66.2 ± 8.3, 22% female) and 125 reference participants (age 65.5 ± 7.4, 47% female). Participants underwent clinical, neuropsychological, and 3 T brain MRI assessment. CMI were more common in patients with an ICA occlusion (54%, median 2, range 1-33) than in the reference group (6%, median 0; range 1-7; OR 14.3; 95% CI 6.2-33.1; p<.001). CMI were more common ipsilateral to the occlusion than in the contralateral hemisphere (median 2 and 0 respectively; p<.001). In patients with CMI compared to patients without CMI, the number of additional occluded or stenosed cervical arteries was higher (p=.038), and cerebral blood flow was lower (B -6.2 ml/min/100 ml; 95% CI -12.0:-0.41; p=.036). In conclusion, CMI are common in patients with an ICA occlusion, particularly in the hemisphere of the occluded ICA. CMI burden was related to the severity of cervical arterial compromise, supporting a role of hemodynamics in CMI etiology.
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Affiliation(s)
- Hilde van den Brink
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Doeschka A Ferro
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther E Bron
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Laurien P Onkenhout
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Geert Jan Biessels
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
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15
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Yan C, Wang J, Guo R, Jin W, Zhao Y, Wang R. Vascular Diameters as Predictive Factors of Recanalization Surgery Outcomes in Internal Carotid Artery Occlusion. Front Neurol 2021; 12:632063. [PMID: 34552546 PMCID: PMC8451719 DOI: 10.3389/fneur.2021.632063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Revascularization surgery sometimes can achieve recanalization in patients with internal carotid artery occlusion (ICAO). High-resolution vessel wall magnetic resonance imaging (HRVWI) is a feasible technique to give detailed characteristics of the vessel wall, which may help to identify patients that carry higher success rates and more suitable for revascularization surgery. Objective: To examine the association between HRVWI characteristics of ICAO and the success rate of revascularization surgery in ICAO patients. Methods: We conducted a retrospective analysis of 31 ICAO recanalization patients enrolled from October 2017 to May 2019. The clinical data of patients and lesions were collected and analyzed. Results: A total of 31 ICAO patients were enrolled in this study. No significant differences were found between recanalization success and recanalization failure groups with regard to occlusion length, distal end of the occluded segment, and the treatment applied. The ipsilateral-to-contralateral diameter ratios (I/C ratios) of C1 or C2 and the diameter of C7 were positively related to recanalization success. A two-factor predictive model was constructed, and the I/C ratio of C2 < 0.86 and the diameter of C7 < 1.75mm were separately assigned 1 point. The ICAO patients who scored 0, 1, or 2 points had a risk of 5.6% (1/18), 55.6% (5/9), or 100% (4/4) to fail in the recanalization. Conclusions: The I/C ratios of C1 or C2 and the diameter of C7 are predictive factors of a revascularization surgery success in ICAO patients. A risk stratification model involving C2 and C7 was constructed for future clinical applications.
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Affiliation(s)
- Chengrui Yan
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Jiaru Wang
- Department of Radiology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ruohan Guo
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China
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16
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Deshpande G, Giri P. Acute monocular vision loss as presenting symptom of delayed stroke from internal carotid occlusion in COVID-19. Indian J Ophthalmol 2021; 69:1325-1327. [PMID: 33913892 PMCID: PMC8186595 DOI: 10.4103/ijo.ijo_439_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 12/01/2022] Open
Abstract
Covid-19 infection has been declared a pandemic by the World Health Organization. We present a unique case of a middle-aged gentleman, who recovered from asymptomatic Covid-19 infection and presented again with delayed stroke. He had vision loss secondary to internal carotid artery occlusion in the absence of neurological symptoms. To the best of our knowledge, this is the first case that describes cerebrovascular stroke due to delayed large vessel occlusion secondary to Covid-19 infection presenting as monocular vision loss.
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Affiliation(s)
| | - Pramod Giri
- Department of Neurosurgery Neuron Hospital, Nagpur, Maharashtra, India
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17
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Kikumoto M, Aoki S, Shiga Y, Kinoshita N, Nezu T, Ueno H, Arihiro K, Maruyama H. Giant Cell Arteritis with Internal Carotid Artery Occlusion in the Absence of Typical Clinical Features. Intern Med 2021; 60:1293-1297. [PMID: 33229803 PMCID: PMC8112973 DOI: 10.2169/internalmedicine.5592-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 65-year-old man presented with a slight headache and transient visual disturbance. Magnetic resonance imaging (MRI) revealed occlusion of the left internal carotid artery (ICA) and acute brain infarctions in both hemispheres, and a blood examination indicated inflammation. Gadolinium enhancement was observed in the walls of the temporal arteries and ICAs. After we diagnosed giant cell arteritis (GCA) by a temporal artery biopsy, aspirin and corticosteroids were administered. The typical symptoms of GCA, such as jaw claudication and temporal artery tenderness, were absent during the entire clinical course, and the findings of contrast-enhanced MRI contributed to the diagnosis.
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Affiliation(s)
- Mai Kikumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, Japan
| | - Yuji Shiga
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, Japan
| | - Naoto Kinoshita
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, Japan
- Department of Neurology, Hiroshima Prefectural Hospital, Japan
| | - Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, Japan
| | - Hiroki Ueno
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, Japan
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University, Graduate School of Biomedical and Health Sciences, Japan
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18
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Fuse Y, Tajima H, Kimura K, Nakamura S, Kurimoto F, Watanabe K. A Case of Mechanical Thrombectomy for Acute Occlusion of the Left Internal Carotid Artery Later than 24 Hours after Onset. J Neuroendovasc Ther 2021; 15:730-735. [PMID: 37502262 PMCID: PMC10371002 DOI: 10.5797/jnet.cr.2020-0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 01/29/2021] [Indexed: 07/29/2023]
Abstract
Objective Mechanical thrombectomy is performed on ischemic stroke patients with acute major cerebral artery occlusion within 24 hours of symptom onset. We report a case of delayed mechanical thrombectomy for acute left internal carotid artery occlusion. Case Presentation A 76-year-old woman suddenly presented with dysarthria and right hemiparesis was admitted to her previous hospital. She was treated by conservative therapy. The next day, she was transferred to our hospital 26 hours after onset with a diagnosis of ischemic stroke due to left carotid artery acute occlusion. Contrast CT revealed left carotid artery occlusion. Arterial fibrillation was detected. Mechanical thrombectomy through the right brachial artery was immediately performed. Complete recanalization was achieved without hemorrhagic complication. Her postoperative course was uneventful. Conclusion In this case, delayed mechanical thrombectomy for acute major cerebral artery occlusion was safely performed 24 hours after symptom onset.
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Affiliation(s)
- Yutaro Fuse
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Hayato Tajima
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Keisuke Kimura
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | | | - Futoshi Kurimoto
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
| | - Kazuhiko Watanabe
- Department of Neurosurgery, Handa City Hospital, Handa, Aichi, Japan
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19
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Elsharkawi M, Ghoneim B, Elsherif M, Sultan S. Bilateral external carotid artery stenting in symptomatic patient with complete occlusion of both internal carotid arteries. Clin Case Rep 2021; 9:540-542. [PMID: 33489211 PMCID: PMC7813021 DOI: 10.1002/ccr3.3577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022] Open
Abstract
Completely occluded ICA should not always turn a symptomatic patient down for surgical intervention especially if medical treatment fails. Where bilateral ECA intervention is required, endovascular approach should be considered if feasible.
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Affiliation(s)
- Mohamed Elsharkawi
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
| | - Baker Ghoneim
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
| | - Mohamed Elsherif
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
| | - Sherif Sultan
- Department of Vascular & Endovascular SurgeryGalway University HospitalNational University of IrelandGalwayIreland
- Department of Vascular and Endovascular SurgeryGalway ClinicGalwayIreland
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20
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Kimura R, Sakamoto Y, Aoki J, Katano T, Nishiyama Y, Kimura K. [A case of neurogenic pulmonary edema due to left internal carotid artery occlusion]. Rinsho Shinkeigaku 2020; 61:29-32. [PMID: 33328420 DOI: 10.5692/clinicalneurol.cn-001491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 79-year-old woman developed consciousness disturbance, left eye deviation, right hemiplegia and aphasia with hypoxemia. Chest X-ray showed bilateral pulmonary edema. MRI revealed the left internal carotid artery occlusion and entire left middle cerebral artery infarct including insular cortex. We performed mechanical thrombectomy therapy and TICI3 recanalization was obtained. During operation, the respiratory condition deteriorated and the ventilator was started after mechanical thrombectomy therapy. Chest X-ray showed butterfly shadow, which indicated pulmonary edema. Pulmonary edema improved on the 2nd day of onset, and disappeared on the 3rd day. There was no heart diseases such as Takotsubo myocardiopathy, acute cardiac failure and cardiomyopathy on echocardiography and electrocardiography. Therefore, we diagnosed her as having neurogenic pulmonary edema due to cerebral infarction including insular cortex. We consider that left insular cortex infarction was a trigger of neurogenic pulmonary edema. If hypoxemia associated with infarction including the insular cortex, neurogenic pulmonary edema should be considered for medical treatment.
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Affiliation(s)
| | - Yuki Sakamoto
- Department of Neurology, Nippon Medical School Hospital
| | - Junya Aoki
- Department of Neurology, Nippon Medical School Hospital
| | | | | | - Kazumi Kimura
- Department of Neurology, Nippon Medical School Hospital
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21
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Arif S, Arif S, Liaqat J, Slehria AUR, Palwa AR. Central Nervous System Vasculitis Secondary to Sarcoidosis: A Rare Case of Lupus Pernio With Complete Occlusion of Right Internal Carotid Artery. Cureus 2020; 12:e10274. [PMID: 33042710 PMCID: PMC7538030 DOI: 10.7759/cureus.10274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Sarcoidosis is a systemic inflammatory disorder resulting from an inappropriate immune response to ubiquitous environmental stimuli. It has a predilection for African Americans and people of Northern European countries. The classic histology is that of a non-caseating granuloma. Central nervous system involvement is a rare occurrence in sarcoidosis and even in this manifestation, the presence of vasculitis is comparatively uncommon. We present a case of a 35-year-old female, who presented with complaints of persistent headache of moderate intensity and had a violaceous plaque on nose, being treated by a dermatologist. The patient on further workup had mildly raised proteins on cerebrospinal fluid analysis. MRI brain showed multiple foci in bilateral frontoparietal regions and centrum semiovale, while digital subtraction angiography brain depicted vasculitis of small vessels of brain and complete occlusion of right internal carotid artery at its origin. Biopsy of lesion on nose was performed that showed chronic granulomatous inflammation. A diagnosis of brain vasculitis secondary to sarcoidosis was made. The patient was treated with plasmapheresis and pulse steroid therapy initially, and later on with cyclophosphamide and azathioprine. This resulted in resolution of headache and nose lesion.
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Affiliation(s)
- Saeed Arif
- Neurology, Pak-Emirates Military Hospital, Rawalpindi, PAK
| | - Shaheer Arif
- Neurology, Pak-Emirates Military Hospital, Rawalpindi, PAK
| | | | | | - Abdur Rahim Palwa
- Radiology, Armed Forces Institute of Radiology and Imaging, Rawalpindi, PAK
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22
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Mohammaden MH, Stapleton CJ, Brunozzi D, Hussein AE, Khedr EM, Atwal G, Alaraj A. Predictors of Poor Outcome Despite Successful Mechanical Thrombectomy of Anterior Circulation Large Vessel Occlusions Within 6 h of Symptom Onset. Front Neurol 2020; 11:907. [PMID: 33013629 PMCID: PMC7498572 DOI: 10.3389/fneur.2020.00907] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022] Open
Abstract
Background and Purpose: Successful reperfusion is a significant predictor of a good clinical outcome after mechanical thrombectomy (MT). However, some patients have a poor clinical outcome even with successful reperfusion. We aimed to study factors that predict a poor clinical outcome (90-day modified Rankin Scale ≥ 3) in patients with anterior circulation large vessel occlusion (LVO) treated by successful MT within 6 h of symptom onset. Methods: We performed a retrospective review of a prospectively maintained MT database of all patients who underwent MT within 6 h of symptom onset for an anterior circulation LVO at our institution from May 2016 to June 2018. Uni- and multivariable analyses were performed to identify predictors of poor outcome. Results: A total of 56 patients met the criteria for inclusion in this study. A poor outcome occurred in 31 (55.4%) patients. On univariate analysis, compared to patients with good clinical outcome, patients with poor outcome had higher mean baseline NIHSS scores (23.3 vs. 13.8, P < 0.001), were more likely to have internal carotid artery (ICA) occlusions (38.7 vs. 8%, P = 0.008), and had a higher incidence of distal clot migration (DCM) (48.4 vs. 8%, P = 0.028). Age, gender, other baseline clinical characteristics, MT technique, and incidence of hemorrhagic transformation did not differ between the two cohorts. On multivariable regression analysis, baseline NIHSS score [OR; 1.3, 95%CI [1.11–1.52], P = 0.001], site of occlusion (ICA) [OR; 8.9, 95%CI [1.3–60.9], P = 0.026], and DCM [OR; 5.77, 95%CI [1.09–30.69], P = 0.04] were independent predictors of poor outcome at 90-days. Conclusion: Baseline NIHSS score, ICA occlusion, and DCM are independent predictors of a poor outcome after MT for anterior circulation LVO performed within 6 h of symptoms onset.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, South Valley University Qena Faculty of Medicine, Qena, Egypt.,Department of Neurology, Marcus Stroke and Neuroscience Center, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, United States
| | - Christopher J Stapleton
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Denise Brunozzi
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Ahmad E Hussein
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Eman M Khedr
- Department of Neurology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Gursant Atwal
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Ali Alaraj
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
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23
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Yang Y, Liu X, Wang R, Zhang Y, Zhang D, Zhao J. A Treatment Option for Symptomatic Chronic Complete Internal Carotid Artery Occlusion: Hybrid Surgery. Front Neurosci 2020; 14:392. [PMID: 32410953 PMCID: PMC7199050 DOI: 10.3389/fnins.2020.00392] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Background Internal carotid artery occlusion (ICAO) is a relatively uncommon but important cause of transient ischemic attack and cerebral infarction. The majority of cases of symptomatic ICAO requires surgical treatment. In this study we performed an investigation of the efficacy and safety of hybrid surgery which is a surgical method for symptomatic chronic complete ICAO. Methods Fifty-five patients with symptomatic chronic ICAO treated by hybrid surgery from 2016 to 2019 were included. We recorded and analyzed the patients’ clinical characteristics, angiographic data, recanalization rate, complications, and outcomes. Catheter angiography or computed tomography angiography was used to assess the patency of the recanalized ICA during follow-up. Results The total success rate of recanalization was 78.2% (43/55). The occlusions were significantly shorter in the success than failure group (5.40 ± 1.50 vs. 7.56 ± 0.99 cm, respectively; P < 0.001). The median duration of ICA occlusion was significantly shorter in the success than failure group (90 vs. 200 days, respectively). The success rates of distal ICA recanalization at the petrous segment or below, cavernous segment, and clinoid segment or above were 100, 33.3, and 14.3%, respectively (P < 0.001). Multivariate analysis showed that the level of distal ICA reconstitution was the only factor affecting the recanalization success rate. Periprocedural complications included hyperperfusion syndrome (n = 1) and laryngeal nerve injury (n = 1). ICA reocclusion occurred in one patient (2.3%). Significant postoperative improvement in symptoms was observed in the success group, with a median modified Rankin scale score of 0 at the 3-month follow-up compared with before recanalization (median, 1) (P<0.001). Conclusion Hybrid surgery might be safe and effective for patients with symptomatic chronic complete ICAO. The level of distal ICA reconstitution is a predictor of successful recanalization in hybrid operations.
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Affiliation(s)
- Yunna Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xingju Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Savaid Medical School, University of the Chinese Academy of Sciences, Beijing, China
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24
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Hause S, Oldag A, Breja A, Neumann J, Wilcke J, Schreiber S, Heinze HJ, Skalej M, Halloul Z, Goertler M. Acute symptomatic extracranial internal carotid occlusion - natural course and clinical impact. VASA 2019; 49:31-38. [PMID: 31621550 DOI: 10.1024/0301-1526/a000826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: To assess the vascular and clinical course of acute symptomatic extracranial internal carotid artery (ICA) occlusion. Patients and methods: Patients with an acute ischemic event in the anterior circulation and corresponding extracranial ICA occlusion at CT angiography and/or color-coded duplex sonography underwent recurrent duplex follow-up for detection of spontaneous recanalization. Stroke recurrence and functional outcome 4.5 months after the ischemic index event assessed by modified Rankin scale served as secondary outcome parameters. Results: 133 patients (91 men, mean age 62.3 years, SD 10.8) demonstrated symptomatic occlusion of the extracranial ICA with open intracranial ICA and open middle cerebral artery and were followed-up for spontaneous recanalization. Twenty-eight recanalized spontaneously, 25 to high-grade focal stenosis within 12 days, revealing an early cumulative recanalization rate of 23 %. Detection of recanalization was independently associated with de novo dual anti-platelet therapy (adjusted odds ratio [OR], 3.24; 95 % confidence interval [CI], 1.34 to 7.80). Ischemic recurrence occurred in 16 patients, of which 10 deemed to be embolic and 5 hemodynamic. Spontaneous ICA recanalization and an exhausted cerebrovascular reserve in the hemisphere distal to the occluded ICA were both independently associated with the occurrence of a recurrent ischemic event at Cox regression. An increasing NIHSS score at admission, a decreasing middle cerebral artery flow velocity and an ischemic recurrence independently predicted poor outcome (modified Rankin scale 3 to 6) in multivariate analysis. Conclusions: Acute symptomatic extracranial ICA occlusion is an unstable condition with frequent spontaneous recanalization to severe stenosis and early embolic stroke recurrence, demanding appropriate prevention especially in those patients with only mild deficit.
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Affiliation(s)
- Stephan Hause
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Andreas Oldag
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Andrea Breja
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Jens Neumann
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Juliane Wilcke
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Stefanie Schreiber
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Hans-Jochen Heinze
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
| | - Martin Skalej
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Institute of Neuroradiology, Magdeburg University Hospital, Magdeburg, Germany
| | - Zuhir Halloul
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of General, Abdominal and Vascular Surgery, Magdeburg University Hospital, Magdeburg, Germany
| | - Michael Goertler
- Vascular and Stroke Center, Magdeburg University Hospital, Magdeburg, Germany.,Department of Neurology, Magdeburg University Hospital, Magdeburg, Germany
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25
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Hiramatsu R, Furuse M, Yagi R, Ohnishi H, Ikeda N, Nonoguchi N, Kawabata S, Miyachi S, Kuroiwa T. Limit of intraoperative near-infrared spectroscopy monitoring during endovascular thrombectomy in acute ischemic stroke. Interv Neuroradiol 2017; 24:57-63. [PMID: 29183174 DOI: 10.1177/1591019917740101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Endovascular thrombectomy is recommended for a persistent ischemic penumbra if recanalization cannot be achieved by the intravenous (IV) administration of recombinant tissue-plasminogen activator (rt-PA) alone. Although endovascular thrombectomy is a powerful treatment for major cerebral artery occlusion, the monitoring of recanalization and reperfusion during acute ischemic stroke presents a therapeutic challenge, and a previous study reported the usefulness of near-infrared spectroscopy (NIRS) for intraoperative monitoring during emergency endovascular thrombectomy for acute large ischemic stroke. Here we present our experience with a relevant case series. We applied NIRS monitoring during endovascular thrombectomy in two patients with large ischemic stroke following carotid artery occlusion and one patient with a non-large ischemic stroke caused by a distal middle cerebral artery (MCA) occlusion. In the patients with large ischemic stroke, complete recanalization of the internal carotid artery was achieved, and NIRS revealed a very good regional oxygen saturation (rSO2) response. By contrast, in the patient with non-large ischemic stroke, the rSO2 did not change, despite complete recanalization of the distal MCA. Our findings suggest the limited usefulness of intraoperative NIRS monitoring during emergency endovascular thrombectomy for non-large acute ischemic stroke caused by a distal MCA occlusion. However, intraoperative NIRS monitoring could be used practically to detect recanalization of the major artery during thrombectomy and early IV rt-PA administration in cases involving major artery occlusion.
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Affiliation(s)
- Ryo Hiramatsu
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Motomasa Furuse
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Ryokichi Yagi
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Hiroyuki Ohnishi
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Naokado Ikeda
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Shigeru Miyachi
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
| | - Toshihiko Kuroiwa
- Department of Neurosurgery and Endovascular Therapy, Osaka Medical College, Osaka, Japan
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26
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Lee SH, Chung I, Choi DS, Shin IW, Kim S, Kang S, Kim JY, Chung YK, Sohn JT. Visual loss due to optic nerve infarction and central retinal artery occlusion after spine surgery in the prone position: A case report. Medicine (Baltimore) 2017; 96:e7379. [PMID: 28767569 PMCID: PMC5626123 DOI: 10.1097/md.0000000000007379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Visual loss after spine surgery in the prone position is a serious complication. Several cases of central retinal artery occlusion with ophthalmoplegia after spine surgery have been reported in patients with ophthalmic arteries fed by the internal carotid artery (ICA) in a normal manner. PATIENT CONCERNS A 74-year-old man developed visual loss after undergoing a spinal decompression and fusion operation in the prone position that lasted approximately 5 hours. DIAGNOSES We detected an extremely rare case of visual loss due to optic nerve infarction and central retinal artery occlusion through fundoscopic examination, fluorescein angiogram, brain magnetic resonance imaging, and magnetic resonance angiography. The patient's visual loss may have been caused by compromised retrograde collateral circulation of the ophthalmic artery from branches of the external carotid artery in the presence of proximal ICA occlusion after a spinal operation in the prone position. INTERVENTIONS To recover movement of the left extraocular muscles, the patient received intravenous injections of methylprednisolone for 3 days and then oral prednisolone for 6 days. OUTCOMES Twenty days after the treatment, the motion of the left extraocular muscles was significantly improved. However, recovery from the left visual loss did not occur until 4 months after the operation. LESSONS In high-risk patients with retrograde collateral circulation of the ophthalmic artery from the external carotid artery due to proximal ICA occlusion, various measures, including the use of a head fixator to provide a position completely free of direct compression of the head and face, should be considered to decrease the risk of postoperative visual loss.
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Affiliation(s)
- Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
| | - Inyoung Chung
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Dae Seob Choi
- Department of Radiology & Gyeongnam Cerebrovascular Center, Gyeongsang National University Hospital
| | - Il-Woo Shin
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Sunmin Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
| | - Sebin Kang
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
| | - Ji-Yoon Kim
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
| | - Young-Kyun Chung
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
| | - Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, Gyeongsangnam-do, Republic of Korea
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27
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Xie D, Hu D, Zhang Q, Sun Y, Li J, Zhang Y. Increased high-sensitivity C-reactive protein, erythrocyte sedimentation rate and lactic acid in stroke patients with internal carotid artery occlusion. Arch Med Sci 2016; 12:546-51. [PMID: 27279846 PMCID: PMC4889675 DOI: 10.5114/aoms.2014.47879] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 09/12/2014] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Internal carotid artery occlusion (ICAO) causes high annual rates of mortality and morbidity. It has been established that atherosclerosis is the normal cause of ICAO. As the pathogenesis of atherosclerosis may involve blood lipids, inflammatory factors and other biomarkers, the aim of this study was to assess the changes in these biomarkers and investigate the relationship between these biomarkers and the development of ICAO in stroke patients. MATERIAL AND METHODS A total of 89 ischaemic stroke inpatients with ICAO (ICAO group) and 89 without ICAO (control group) were studied, retrospectively. The serum was collected from each patient on the 3(rd) day of admission, to measure the lipid parameters and biomarkers, e.g. high-sensitivity C-reactive protein (hs-CRP), erythrocyte sedimentation rate (ESR), and lactic acid (LA). Histories were taken including age, gender, smoking history, and disease history. Additional analysis was carried out to compare between the genders and evaluate the association between certain biomarkers and ICAO. RESULTS Among the 89 ICAO cases in this study, the serum levels of hs-CRP, ESR and LA were significantly higher than those in the control group (p ≤ 0.001). No significant differences were found in the mean levels of total cholesterol, triacylglycerol, HDL cholesterol or glucose, or the known risk factors. Gender also had no influence on these biomarkers. Logistic regression analysis indicated that hs-CRP, ESR and LA were significantly associated with ICAO (p ≤ 0.05). CONCLUSIONS These results suggest that hs-CRP, ESR and LA are associated with ICAO in ischaemic stroke patients, but gender has no effect. Therefore, Hs-CRP, ESR and LA may be useful in the early detection of patients with ICAO.
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Affiliation(s)
- Dan Xie
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Di Hu
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qin Zhang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yufang Sun
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jimei Li
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yongbo Zhang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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28
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Bigliardi G, Dell'Acqua ML, Vallone S, Barbi F, Pentore R, Picchetto L, Carpeggiani P, Nichelli P, Zini A. "Opening the Unopenable": Endovascular Treatment in a Patient with Three Months' Internal Carotid Artery Occlusion and Hemispheric Symptomatic Hypoperfusion. J Stroke Cerebrovasc Dis 2016; 25:2016-8. [PMID: 27241576 DOI: 10.1016/j.jstrokecerebrovasdis.2016.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/20/2016] [Accepted: 04/27/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Internal carotid artery occlusion (ICAO) is defined as "untouchable" by all specialists; no treatment is indicated because intervention risks (carotid endarterectomy (CEA) or endovascular treatment) are usually much more than benefits.(1,2) We report the case of a patient admitted to our hospital with an atherothrombotic ischemic stroke due to symptomatic acute ICAO, who developed a recurrent stroke with hemispheric hypoperfusion and was treated in the emergency department with ICAO revascularization after 60 days of occlusion finding. CASE DESCRIPTION D.G., a 62-year-old man, came to our attention for a transient episode of left weakness and hypoesthesia. The electrocardiogram revealed a new diagnosis of atrial fibrillation. CT angiography showed right ICAO; computed tomography and magnetic resonance imaging studies with perfusion imaging revealed a severe hemispheric hypoperfusion. Full anticoagulation therapy was started, and antihypertensive therapy was reduced to help collateral circulation. Some weeks later, the patient was readmitted to the stroke unit for 2 episodes of left-hand weakness. Cerebral angiography confirmed right ICAO from the proximal tract to the siphon. After some days, the patient suffered a femoral hemorrhagic lesion, with active bleeding, and was treated with surgical intervention. On the following day, the patient presented with left hemiplegia with hemianesthesia (National Institutes of Health Stroke Scale score = 14). The patient was treated in the emergency department with a complex endovascular treatment with complete recanalization of ICAO by positioning 3 stents through the intravenous infusion of abciximab. After intensive rehabilitation, at the 3- and 6-month follow-up evaluations, the patient regained autonomy. CONCLUSION In literature, treatment of chronic ICAO is not indicated. Endovascular recanalization may be beneficial to patients with chronic cerebral hypoperfusion due to ICAO, when all conservative medical therapies have failed.
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Affiliation(s)
- Guido Bigliardi
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy.
| | - Maria Luisa Dell'Acqua
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
| | - Stefano Vallone
- Neuroradiology Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
| | - Filippo Barbi
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
| | - Roberta Pentore
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
| | - Livio Picchetto
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
| | - Paolo Carpeggiani
- Neuroradiology Unit, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
| | - Paolo Nichelli
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
| | - Andrea Zini
- Stroke Unit-Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, AUSL Modena, Modena, Italy
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29
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Fukushima Y, Miyawaki S, Inoue T, Shimizu S, Yoshikawa G, Imai H, Saito N, Tsutsumi K. Repeated de novo aneurysm formation after anastomotic surgery: Potential risk of genetic variant RNF213 c.14576G>A. Surg Neurol Int 2015; 6:41. [PMID: 25883833 PMCID: PMC4392556 DOI: 10.4103/2152-7806.153709] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 12/19/2014] [Indexed: 11/24/2022] Open
Abstract
Background: De novo aneurysm formation after intracranial anastomotic surgery is a relatively rare complication with fewer than 20 reported cases, and the mechanism is still unclear. Case Description: A 63-year-old male treated for symptomatic internal carotid artery occlusion developed de novo aneurysms twice after anastomoses first of the superficial temporal artery-middle cerebral artery and second of the external carotid artery-radial artery-middle cerebral artery over a 10-year period. The first de novo aneurysm was successfully resected with pathological diagnosis of true aneurysm. The second de novo aneurysm thrombosed naturally after gradual growth. Genetic testing of the patient revealed the c.14576G>A (p.R4859K) variant in ring finger protein 213, which is a susceptibility gene for moyamoya disease. Conclusions: This genetic variant was probably involved in the repeated de novo aneurysm formation, and this case represents a rare phenotype of the genetic variant.
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Affiliation(s)
- Yuta Fukushima
- Department of Neurosurgery, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | | | - Gakushi Yoshikawa
- Department of Neurosurgery, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Hideaki Imai
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuo Tsutsumi
- Department of Neurosurgery, Showa General Hospital, Kodaira, Tokyo, Japan
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30
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Omodaka S, Endo H, Doi H, Shimizu H, Fujimura M, Aizawa N, Nakazawa T, Tominaga T. Usefulness of laser speckle flowgraphy for the assessment of ocular blood flow in extracranial-intracranial bypass. J Stroke Cerebrovasc Dis 2014; 23:e445-e448. [PMID: 25238922 DOI: 10.1016/j.jstrokecerebrovasdis.2014.06.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/12/2014] [Accepted: 06/20/2014] [Indexed: 11/26/2022] Open
Abstract
Laser speckle flowgraphy (LSFG) is a noninvasive technique that can measure relative blood flow velocity in the optic fundus. The authors present a case of symptomatic internal carotid artery occlusion treated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in which an improvement of ocular circulation was confirmed by LSFG. A 47-year-old man presented with a 1-month history of repeated left blurred vision and motor weakness of the right leg. Diffusion-weighted magnetic resonance imaging revealed a small infarction in the left frontal lobe. Carotid angiography revealed that the left internal carotid artery was occluded at the C4 portion. Single-photon emission computed tomography indicated that the cerebral blood flow in the left MCA territory was markedly impaired. Ophthalmologic examination revealed ischemic change of the left optic fundi, and LSFG revealed decreased blood flow around the left optic disc. Left STA-MCA bypass was successfully performed. Both ischemic ocular symptoms and the ischemic symptoms of the right leg were completely recovered after surgery. Postoperative ophthalmologic examination revealed improvement of both ischemic changes of the left optic fundi. Moreover, LSFG revealed improvement of the blood flow around the left optic disc. LSFG can be a promising clinical tool for the assessment of ocular circulation before and after bypass surgery for occlusive cerebrovascular disease.
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Affiliation(s)
| | - Hidenori Endo
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan.
| | - Hiroshi Doi
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Hospital, Akita, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoko Aizawa
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toru Nakazawa
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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31
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Abstract
Moyamoya syndrome (MMS) is a rare, chronic progressive cerebrovascular occlusive disease that is characterized by a stenosis or occlusion of the bilateral internal carotid arteries and the circle of Willis arteries leading to the development of collateral vessels as visualized by cerebral angiography. We report a case of a 24-year-old woman with nephrotic syndrome whose biopsy showed membranous nephropathy. Ten months after the diagnosis she suffered sudden right hemiplegia and seizure. She was diagnosed with MMS by angiogram seven months ago and received decompressive craniotomy. The patient was admitted to our hospital and a diagnosis of systemic lupus erythematosus (SLE) was made. Glucocorticoids and tacrolimus were used to control the symptoms of SLE. Following one month of immunosuppressant treatment, the patient died of brain hemorrhage. This case alongside another six reviewed cases shows that an underlying cerebrovascular lesion of moyamoya in the vessels of patients with SLE is susceptible to cerebrovascular accidents.
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Affiliation(s)
- R Wang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, People's Republic of China
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32
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Miyaji Y, Koyama K, Kurokawa T, Mitomi M, Suzuki Y, Kuroiwa Y. Vascular corticobasal syndrome caused by unilateral internal carotid artery occlusion. J Stroke Cerebrovasc Dis 2012; 22:1193-5. [PMID: 22938697 DOI: 10.1016/j.jstrokecerebrovasdis.2012.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 06/12/2012] [Accepted: 07/09/2012] [Indexed: 11/15/2022] Open
Abstract
A 65-year-old man developed progressive worsening of right-sided limb-kinetic apraxia and extrapyramidal dysfunction. His left internal carotid artery was found to be occluded, and there was general atrophy and severely decreased cerebral blood flow in the left hemisphere. He had experienced an acute infarction in the left watershed area before superficial temporal artery to middle cerebral artery bypass surgery. After surgery, the cerebral blood flow in the left hemisphere was remarkably improved. Unilateral internal carotid artery occlusion may result in clinical manifestations similar to corticobasal degeneration.
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Affiliation(s)
- Yosuke Miyaji
- Department of Neurology, Fujisawa City Hospital, Fujisawa, Yokohama City, Japan.
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33
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Kodama A, Sugioka K, Kuniyoshi K, Okuyama S, Matsumoto C, Shimomura Y. Intravitreal bevacizumab injection and carotid artery stent replacement for neovascular glaucoma in internal carotid artery occlusion. Clin Ophthalmol 2010; 4:1177-80. [PMID: 21060668 PMCID: PMC2964954 DOI: 10.2147/opth.s13899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Neovascular glaucoma (NVG) secondary to internal carotid artery (ICA) occlusion is usually resistant to treatment. We report a case of NVG with ICA occlusion improved by intravitreal bevacizumab (IVB) injection and carotid artery stent replacement (CAS), even though we did not perform panretinal photocoagulation. A 67-year-old male with NVG noted visual loss in his left eye. Magnetic resonance angiography showed left ICA occlusion. He was diagnosed with NVG secondary to ICA occlusion. The next day, we carried out IVB injection in his left eye, following which the iris and angle neovascularization regressed, and the intraocular pressure decreased to normal within a day after the injection. CAS was performed on his left ICA at a month post injection. Two months later, we reinjected bevacizumab in his left eye. His condition remained stable with no recurrence over two years. This case indicates that IVB injection and CAS are useful for early-stage NVG secondary to ICA occlusion.
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Affiliation(s)
- Aya Kodama
- Department of Ophthalmology, Kinki University Faculty of Medicine, Osaka-Sayama City, Osaka, Japan
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