Unmasking the hidden culprit: Recurrent syncope in a 62-year-old man linked to severe internal carotid artery stenosis.

Syncope, a brief loss of consciousness, has many potential causes, with internal carotid artery (ICA) stenosis being a relatively uncommon but serious one. We present the case of a 62-year-old man from Dhaka, Bangladesh, who experienced recurrent syncope over 6 months, characterized by a brief loss of consciousness, occasional dizziness, and blurred vision. Despite a history of hypertension and hyperlipidemia, initial cardiac and neurogenic investigations were inconclusive. Magnetic resonance angiography revealed 90% stenosis of the right ICA, which was confirmed by digital subtraction angiography. The patient was treated with antiplatelet therapy, statins, and antihypertensives, and underwent carotid artery stenting. His postoperative recovery was uneventful, and he remained symptom-free during follow-up. This case underscores the importance of considering ICA stenosis in patients with recurrent syncope and comorbid vascular disease, particularly in resource-limited settings where timely diagnosis and intervention can prevent serious cerebrovascular complications.

Ischemic vascular accident revealing hypoplasia of the internal carotid artery in a narrowed bony canal: A case report.

Hypoplasia of the internal carotid artery is a rare congenital abnormality that can present with an ischemic stroke or transient ischemic attacks. We present the case of a 17-year-old male who presented with right hemiparesis and dysarthria. The imaging revealed hypoplasia of the left internal carotid artery and narrowing of the left carotid duct. The patient was managed conservatively. This case highlights the importance of considering ICA hypoplasia as a cause of ischemic stroke in patients with a narrowed osseous canal. Early diagnosis and management can help prevent recurrent strokes.

Carotid single- and dual-layer stents reduce the wall adhesion of platelets by influencing flow and cellular transport.

An ongoing thrombosis on a ruptured atherosclerotic plaque in the carotid may cause stroke. The primary treatment for patients with tandem lesion is stenting. Dual-layer stents have been introduced as an alternative to single-layer stents for elective and emergent carotid artery stenting. While the dual-layer structure shows promise in reducing plaque prolapse through the stent struts and with it the occurrence of post-procedural embolism, there are early signs that this newer generation of stents is more thrombogenic. We investigate a single- and a dual-layer stent design to assess their influence on a set of thrombosis-related flow factors in a novel setup of combined experiments and simulations. The in vitro results reveal that both stents reduce thrombus formation by approximately 50% when human anticoagulated whole blood was perfused through macrofluidic flow chambers coated with either collagen or human atherosclerotic plaque homogenates. Simulations predict that the primary cause is reduced platelet presence in the vicinity of the wall, due to the influence of stents on flow and cellular transport. Both stents significantly alter the near-wall flow conditions, modifying shear rate, shear gradient, cell-free zones, and platelet availability. Additionally, the dual-layer stent has further increased local shear rates on the inner struts. It also displays increased stagnation zones and reduced recirculation between the outer-layer struts. Finally, the dual-layer stent shows further reduced adhesion over an atherosclerotic plaque coating. The novel approach presented here can be used to improve the design optimization process of cardiovascular stents in the future by allowing an in-depth study of the emerging flow characteristics and agonist transport.

Metrics of retinal vasculature detected on OCTA in carotid artery stenosis: a systematic review and meta-analysis.

BACKGROUND: Carotid artery stenosis (CAS) is a major cause of cerebral microcirculation dysfunction, contributing to 15-20% of ischemic strokes. Retinal vessel changes is associated with several systemic diseases, including CAS. This systematic review investigates retinal microvascular alterations measured using optical coherence tomography angiography (OCTA) in patients with CAS. METHODS: We comprehensively searched the electronic databases, namely PubMed, Cochrane Library, Embase, and Web of Science. Macular and optic nerve head vascular density (VD) in patients with CAS were compared to controls. Pooled data for each outcome were calculated as standardized mean difference (SMD) and 95% confidence interval. OCTA parameters were analyzed using Review Manager Version 5.4.1 software. RESULTS: Seven articles were included in this meta-analysis. Whole macular enface superficial and deep VD were significantly lower in patients with CAS than in controls (SMD = -0.97, P = 0.002; SMD = -1.05, P = 0.006, respectively). Additionally, the parafoveal superficial VD was significantly lower in the CAS group than in the healthy group (SMD= -0.71, P= 0.001). Radial peripapillary capillary (RPC) whole-image VD (SMD= -0.90, P< 0.0001), RPC inside disc VD (SMD= -0.49, P= 0.02), and RPC peripapillary VD (SMD= -0.64, P= 0.0003) were also significantly lower in patients with CAS compared to healthy individuals. CONCLUSION: These findings suggest that patients with CAS are prone to decreased VD in the macular and optic nerve head areas. Hence, OCTA shows potential as a promising tool for the early detection of cerebral microcirculation disorders due to CAS.

Amalric choroidal infarction, retinal artery occlusion, and ischemic optic neuropathy: Delayed presentations of traumatic internal carotid artery dissection.

Purpose: This case report describes the delayed, uncommon ophthalmic presentations of monocular choroidal ischemia (Amalric triangular sign), ischemic optic neuropathy, central retinal artery occlusion (CRAO), and extraocular motility restriction caused by traumatic internal carotid artery dissection (ICAD) in a young individual. Observations: A 29-year-old man presented with sudden vision loss in his left eye which had started 7 h earlier. His medical history included a motorcycle accident six months prior, where he struck his chin on the ground and lost consciousness. At that time, he had completely recovered with no complications. On the day the patient reported with vision problem, an ophthalmic examination of the affected eye revealed visual acuity of no perception of light (NPL), restriction of extraocular movement, and relative afferent pupillary defect. Fundus examination showed slightly pale optic disc swelling, macular whitening with a cherry red spot appearance indicating the presence of CRAO, and several whitish triangular patches in the peripheral retina. Fundus fluorescein angiography revealed delayed arm to choroidal and retinal circulations in the early phase, with hyperfluorescence and hyperfluorescent staining along the areas of whitening triangular patches in the later phase. Carotid doppler ultrasonography and magnetic resonance angiography confirmed an extracranial left ICAD. After the 3-month follow up, the patient's vision remained NPL with hypo/hyperpigmentation changes along the previous whitish patches in the peripheral retina. Conclusion and importance: This case underscores the delayed onset of ocular ischemic symptoms associated with ICAD following head and neck trauma in young individuals. Despite the low risk, patients may need to be informed about the possibility of these late occurring ophthalmic complications and physicians need to stay vigilant for these conditions, which may arise months after the initial trauma.

In-stent Restenosis after Carotid Artery Stent Placement Comparing Maximum Plaque Predilation and Postdilation.

OBJECTIVE: To compare the incidence of in-stent restenosis (ISR) and ipsilateral neurological symptoms in patients treated with maximum plaque dilation before stent deployment (max-pre-D) and stent placement followed by angioplasty (post-D) technical variants of carotid artery stenting (CAS) at mid-term follow-up. METHODS: Single-center, real-world, retrospective comparative study of 307 patients treated in a single Vascular Surgery Unit between 2014 and 2018. The follow-up protocol consisted of duplex ultrasound performed at 1-, 6-, 12-months and annually thereafter. The primary outcome was to compare the incidence of ISR ≥ 70% in patients treated with post-D and max-pre-D. Secondary outcomes included between-group comparison of: i) symptomatic ISR, ii) reinterventions and iii) ipsilateral neurological events. RESULTS: 270 patients (121 max-pre-D, 149 post-D) fulfilling the inclusion criteria were included in the statistical analysis. Mean follow-up was 30.5 months (SD 25.6). The ISR rate was 4.1% (n=5) in max-pre-D group and 2.7% (n=4) in post-D group, with no significant difference in the survival analysis (log-rank p=0.664). Symptomatic ISR and retreatment occurred in three patients (33.3% of the total ISR for each outcome). Twenty-one ipsilateral neurological events occurred, 7 in the max-pre-D group (5.8%) and 14 in the post-D group (9.9%), with no statistically significant difference in survival analysis (log-rank p=0.315). CONCLUSION: ISR and major neurological events did not differ significantly between the max-pre-D and post-D groups. Max-pre-D seems to be as effective as post-D technique in mid-term follow-up.

Stroke and Mortality Following Carotid Endarterectomy or Carotid Artery Stenting: A 10 Year Nationwide Study in France.

OBJECTIVE: This retrospective, nationwide cohort study aimed compare periprocedural stroke or death within 30 days of the procedure (PPSD30) in patients who underwent carotid endarterectomy (CEA) or carotid stenting (CAS). METHODS: This retrospective cohort study used data from the French hospital database PMSI. All patients who underwent CEA or CAS between 2010 and 2019 in France were included. Information on individual patients and hospital characteristics was retrieved. A random effects logistic regression model compared the occurrence of PPSD30 after CEA or CAS. High surgical risk was accounted for by using propensity score matching and adjusted for patient and hospital characteristics. Analyses were also stratified to consider symptomatic and asymptomatic patients separately. RESULTS: Between 2010 and 2019, 164 248 patients underwent a carotid artery procedure in France: 156 561 CEA and 7 687 CAS (including about 25.0% asymptomatic women and 40.0% high risk patients). The PPSD30 rate was 1.5% overall (n = 2 514 patients) (1.5% after CEA vs. 2.4% after CAS), 1.3% in asymptomatic patients (1.2% after CEA vs. 1.8% after CAS), and 3.3% in symptomatic patients (3.1% after CEA vs. 6.5% after CAS). After matching and adjustment, the risk of PPSD30 was statistically significantly greater in patients who underwent CAS than in patients who underwent CEA (adjusted OR [aOR] 1.4, 95% CI 1.1 - 1.8 in overall patients; aOR 1.4, 95% CI 1.1 - 1.8 in asymptomatic patients; and aOR 2.7, 95% CI 1.8 - 4.0 in symptomatic patients). CONCLUSION: This nationwide real life study showed that CEA performed better than CAS, more markedly in symptomatic patients, but also in asymptomatic patients. Moreover, many patients received procedures that were more likely to be harmful than beneficial according to conclusions from past randomised trials (i.e., all asymptomatic women, all high surgical risk patients, and all who had undergone CAS).

External Carotid Artery Entrapment by the Hyoid Bone Associated with an Atherosclerotic Stenosis of the Internal Carotid Artery.

The mechanical compression of an external carotid artery (ECA) is a rare pathology. The compression of the carotid bifurcation can be positional, induced by anatomical elements, or provoked by volumetric formation in the neck area. In this study, we describe a rare case of an entrapment of the ECA. A 67-year-old man who had two episodes of transient ischemic attack (TIA) demonstrated by loss of consciousness was transferred to our hospital. Ultrasonography and computed tomography revealed the atherosclerotic stenosis (80%) of a right internal carotid artery (ICA) and, at the same time, entrapment of the right ECA by the elongated right greater horn of the hyoid bone (GHHB). A 1 cm section of the GHHB was resected. After clamping of the carotid arteries, longitudinal arteriotomy and endarterectomy surgeries were performed from the right ICA. At the two months follow-up examination, the patient's condition was reported as normal, with no episodes of TIA, dysphagia, or pharyngeal discomfort.

Super Learner Algorithm for Carotid Artery Disease Diagnosis: A Machine Learning Approach Leveraging Craniocervical CT Angiography.

This study introduces a machine learning (ML) approach to diagnosing carotid artery diseases, including stenosis, aneurysm, and dissection, by leveraging craniocervical computed tomography angiography (CTA) data. A meticulously curated, balanced dataset of 122 patient cases was used, ensuring reproducibility and data quality, and this is publicly accessible at (insert dataset location). The proposed method integrates a super learner model which combines adaptive boosting, gradient boosting, and random forests algorithms, achieving an accuracy of 90%. To enhance model robustness and generalization, techniques such as k-fold cross-validation, bootstrapping, data augmentation, and the synthetic minority oversampling technique (SMOTE) were applied, expanding the dataset to 1000 instances and significantly improving performance for minority classes like aneurysm and dissection. The results highlight the pivotal role of blood vessel structural analysis in diagnosing carotid artery diseases and demonstrate the superior performance of the super learner model in comparison with state-of-the-art (SOTA) methods in terms of both accuracy and robustness. This manuscript outlines the methodology, compares the results with state-of-the-art approaches, and provides insights for future research directions in applying machine learning to medical diagnostics.

Understanding perioperative risk determinants in carotid endarterectomy: the impact of compromised circle of Willis morphology on inter-hemispheric blood flow indices based on intraoperative internal carotid artery stump pulse pressure and backflow patterns.

Carotid artery stenosis (CAS) often requires surgical intervention through carotid endarterectomy (CEA) to prevent stroke. Accurate cerebrovascular risk assessments are crucial in CEA, as poor collateral circulation can lead to insufficient interhemispheric blood flow compensation, resulting in ischemic complications. Therefore, understanding perioperative risk determinants is vital. This study aims to determine the impact of compromised circle of Willis (CoW) morphology on inter-hemispheric blood flow, focusing on indices based on intraoperative internal carotid artery stump pulse pressure and backflow patterns. In 80 CAS patients who underwent CEA, preoperative CT angiography for CoW was conducted. Patients were categorized into five subgroups based on their CoW anatomy and three additional groups based on intraoperative internal carotid artery (ICA) stump backflow patterns evaluated by the surgeon. Continuous blood pressure signals, including systolic, diastolic, mean, and pulse pressure values, were recorded during the procedure. The relationship between CoW anatomical variants and the systolic and diastolic segments of the averaged pressure waveforms, particularly diastolic pressure decay, was analyzed. The correlation between CoW anatomy and stump backflow intensity was also examined. Significant variability in ICA stump backflow and pressure values was evident across CoW variants. Patients with compromised CoW morphology exhibited weaker backflow patterns and lower ICA stump pulse pressure values, consistent with impaired interhemispheric blood flow. Notably, ICA stump diastolic pressure decay was consistent across most CoW variant groups, indicating developed collateral circulation in cases with CoW anomalies. Thus, impaired CoW integrity is associated with compromised interhemispheric blood flow indices based on intraoperative ICA stump pulse pressure and backflow patterns during CEA. Integrating intraoperative pulse waveform analysis with preoperative CT angiography provides a more detailed assessment of cerebrovascular risk, guiding the selective use of shunts. This combined approach may improve surgical outcomes and patient safety by identifying patients at increased risk of perioperative neurological events due to CoW anomalies.

Histological Validation of 3D Variable Flip Angle TSE Multi-Contrast Magnetic Resonance Vessel Wall Imaging in Characterizing Carotid Vulnerable Atherosclerotic Plaques.

BACKGROUND: Accurate assessment of the vulnerability of carotid atherosclerotic plaques is crucial for stroke prevention. The three-dimensional (3D) magnetic resonance (MR) vessel wall imaging (VWI) has been increasingly employed to evaluate carotid plaques due to its extensive coverage and isotropic high spatial resolution. However, the accuracy of such technique lacks validation by histology. OBJECTIVE: This study aims to validate the accuracy of 3D multi-contrast MR VWI used variable-flip-angle (VFA) and turbo spin echo (TSE) readout in identifying vulnerable carotid plaques, using histological analysis as a reference. METHODS: Twenty-one male patients (mean age: 64.4 ± 7.2 years) scheduled for carotid endarterectomy (CEA) were recruited for this study. All patients underwent carotid multi-contrast MR VWI, including 3D T1- and T2-weighted variable flip angle-based turbo spin echo (VFA-TSE) sequences, as well as 3D time of flight (TOF) MR angiography (MRA), using a 3.0T MR system. Histological processing was performed for carotid plaque specimens. The presence or absence, along with the area measurements, of lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), and calcifications (CA) were independently evaluated on both MR images and histological sections. Cohen's kappa (κ) analysis was utilized to determine the agreement between 3D multi-contrast MR VWI and histology in identifying carotid plaque compositions before and after excluding compositions bellow certain size threshold. Spearman's correlation analysis was also conducted to assess the agreement in quantifying plaque compositions. RESULTS: A total of 81 slices of MR images were successfully matched with histological sections. Moderate to almost perfect agreements were observed between 3D MR VWI and histology in the identification of LRNC (κ: 0.85 and 0.89), IPH (κ: 0.65 and 0.69), and CA (κ: 0.46 and 0.62) before and after excluding compositions smaller than 0.79 mm2. Strong to very strong correlations were found in the quantification of plaque compositions including LRNC (r=0.88), IPH (r=0.80), and CA (r=0.74) between MR imaging and histology. CONCLUSION: The 3D VFA-TSE multi-contrast MR VWI is capable of accurately characterizing vulnerable carotid atherosclerotic plaques.

Prognosis and factors related to anti-VEGF therapy in patients with retinal vein occlusion and concomitant carotid artery disease.

To evaluate the prognosis and influencing factors of retinal vein occlusion (RVO) in patients with concomitant carotid artery disease receiving anti-vascular endothelial growth factor (VEGF) treatment. Patients diagnosed with RVO and receiving anti-VEGF treatment were included. Eye and clinical data were collected. The patients were divided into a group with concomitant carotid artery disease (Group A) and a group without concomitant carotid artery disease (Group B). The risk factors affecting the visual prognosis of RVO patients with concomitant carotid artery disease were analyzed. Among 177 eligible patients with RVO, 101 had concomitant carotid artery disease (Group A), while 76 did not (Group B). Group A had a significantly lower treatment effectiveness rate than Group B (P < 0.001). The age and platelet distribution width of Group A were significantly higher than Group B (P < 0.001). Multivariate logistic regression analysis showed that baseline best-corrected visual acuity (BCVA), disorganization of retinal inner layers (DRIL), external limiting membrane (ELM) disruption, and red blood cell distribution width (RDW) were significantly associated with the posttreatment visual prognosis of RVO patients with concomitant carotid artery disease(P < 0.05). RVO patients with concomitant carotid artery disease had a significantly lower treatment effectiveness rate than RVO patients without carotid artery disease. The poor baseline BCVA, DRIL, ELM disruption, and a greater RDW are risk factors for low anti-VEGF treatment efficacy among RVO patients with concomitant carotid artery disease.

An International, Expert-Based Delphi Consensus Document on Controversial Issues about TransCarotid Artery Revascularization (TCAR).

OBJECTIVE: TransCarotid Artery Revascularization (TCAR) has emerged as an alternative therapeutic modality to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS) for the management of patients with carotid artery stenosis. However, certain issues regarding the indications and contraindications of TCAR remain unanswered or unresolved. The aim of this international, expert-based Delphi Consensus document was to attempt to provide some guidance on these topics. METHODS: A 3-Round Delphi Consensus process was performed including 29 experts. The aim of Round 1 was to investigate the differing views and opinions of the participants. Round 2 was carried out after the results from the literature on each topic were provided to the participants. During Round 3, the participants had the opportunity to finalize their vote. RESULTS: Most participants agreed that TCAR can/can probably/possibly be performed within 14 days of a cerebrovascular event, but it is best to avoid it in the first 48 hours. It was felt that TCAR cannot/should not replace TFCAS or CEA, as each procedure has specific indications and contraindications. Symptomatic patients >80 years should probably be treated with TCAR rather than with TFCAS. TCAR can/can probably be used for the treatment of restenosis following CEA/TFCAS. Finally, there is a need for a randomized controlled trial to provide better evidence for the unresolved issues. CONCLUSIONS: This Delphi Consensus document attempted to assist the decision-making of physicians/interventionalists/vascular surgeons involved in the management of carotid stenosis patients. Furthermore, areas requiring additional research were identified. Future studies and randomized controlled trials should provide more evidence to address the unanswered questions regarding TCAR.

Advancements in Endovascular Treatment of Extracranial Carotid Artery Aneurysms.

OBJECTIVE: Traditionally, extracranial carotid artery aneurysms or pseudoaneurysms (ECCAs) have been managed through open surgical repair. Recent literature highlights the increasing success of endovascular techniques in treating ECCAs. Our study explores our center's experience with endovascular management of ECCAs, including the innovative use of Transcarotid Artery Revascularization (TCAR) at a tertiary care center. METHODS: We performed a retrospective analysis of patients with ECCAs who underwent endovascular intervention at a single institution. We examined our database from the period of 2010 to 2024. Our treatment modalities have expanded to include covered stenting, stent-assisted coil embolization, braided stents, overlapping closed-cell stents, and most recently Transcarotid Artery Revascularization (TCAR). RESULTS: There were 29 extracranial carotid artery aneurysms in 27 patients treated with various endovascular modalities. The average age was 67.6 years, with 17 (63.0%) males and 10 (37.0%) females. 8 (29.6%) patients had prior ipsilateral carotid intervention. 9 (31.0%) aneurysms were symptomatic. The most common etiology was idiopathic, with 16 (55.2%) aneurysms being spontaneous. Treatment modalities included: 2 (6.9%) treated with covered stents, 2 (6.9%) with stent-assisted embolization, 3 (10.3%) with flow-diverting braided stents, 3 (10.3%) with embolization or ligation alone, 17 (58.6%) with overlapping bare metal stents via femoral or radial access, and 2 (6.9%) with overlapping bare metal stents via TCAR. Technical success was achieved in all patients. The mean follow-up duration was 236 days (range: 2 to 3039 days). No perioperative or post-operative complications occurred, including no neurological deficits or embolic events. All patients were discharged on post-operative day 1 or 2. All 29 (100%) stents maintained vessel patency on follow-up imaging, and exclusion of ECCAs was confirmed on post-procedure surveillance imaging. CONCLUSION: Our study highlights that endovascular therapy is effective in managing ECCAs, with high patency rates and a favorable procedural safety profile.

Prognostic impact of intracranial arteriosclerosis subtype after endovascular treatment for acute ischaemic stroke.

BACKGROUND AND PURPOSE: The influence of intracranial arteriosclerosis (ICAR) on acute ischaemic stroke (AIS) prognosis is unclear. This study explored its impact, focusing on ICAR subtypes categorized by intracranial carotid artery calcification (ICAC) patterns: intimal or atherosclerotic versus internal elastic lamina calcification or non-atherosclerotic. The aim was to determine their effect on AIS prognosis in patients undergoing endovascular treatment (EVT). METHODS: This prospective cohort study included consecutive AIS patients with anterior circulation large vessel occlusion undergoing EVT. ICAC, the hallmark of ICAR, was assessed using non-contrast computed tomography to quantify volume and establish the predominant ICAR subtype. The primary outcome was long-term functional outcome, measured by the 90-day modified Rankin Scale score. Secondary outcomes included first-pass effect, revascularization degree, symptomatic intracranial haemorrhage and 24-h infarct volume. Multivariate-adjusted linear and logistic regression models were used to assess the association of ICAC volume and subtype with these outcomes. RESULTS: From January 2021 to February 2022, 181 patients were included, of whom 172 (95%) had ICAC. Internal elastic lamina calcification was the predominant subtype in 103 (57%), intimal in 52 (29%) and mixed in 17 (9%). The intimal or atherosclerotic ICAC pattern was linked to poorer functional outcomes (adjusted odds ratio 2.12, 95% confidence interval [CI] 1.10-4.09), decreased first-pass effect probability (adjusted odds ratio 0.42, 95% CI 0.21-0.84) and higher infarct volume (adjusted ß value 22.11, 95% CI 0.55-43.67). CONCLUSIONS: A predominant intimal ICAC subtype, linked to underlying atherosclerosis, correlated with larger infarct volume and poorer 90-day functional outcomes in EVT-treated AIS patients. Intracranial atherosclerosis appears to be a relevant factor hampering clinical benefits post-EVT.

Angioinvasive Rhino-Orbital-Cerebral Mucormycosis in a Patient with Type 2 Diabetes Mellitus: A Complex and Lethal Cause of Stroke.

Rhino-orbital-cerebral mucormycosis is a rapidly progressive and often fatal fungal infection caused by molds of the order Mucorales, particularly affecting immunocompromised individuals. This infection is notorious for its angioinvasive properties, enabling the fungi to invade blood vessels and leading to tissue necrosis. We report the clinical course of a 59-year-old Caucasian man with poorly controlled type 2 diabetes (HbA1c 16.8%) who presented with unilateral headache, left-sided facial numbness, and incomplete left ocular motor paresis. Initial presentation raised suspicion of orbital phlegmon, leading to antibiotic and later corticosteroid pulse therapy, which worsened the patient's condition. Subsequent imaging demonstrated extensive inflammatory changes, including wall irregularities of the left intracranial internal carotid artery, accompanied by ocular protrusion and periorbital enhancement. New palatal lesions indicated mucormycosis, which was confirmed by molecular analysis of a palatal biopsy, leading to Amphotericin B treatment. Pre-surgery imaging revealed a malignant middle cerebral artery infarction, and the patient died 16 days after symptom onset and 12 days after initial presentation under palliative care due to a poor prognosis. This case of angioinvasive mucormycosis underscores the severe and often fatal course of rhino-orbital-cerebral mucormycosis in an immunocompromised individual. The rapid progression from initially vague and unspecific symptoms to extensive vascular involvement and stroke highlights the critical need for early and accurate diagnosis, as well as prompt intervention to prevent further disease progression. Additionally, this case also illustrates the potential risks associated with corticosteroid therapy in the presence of undiagnosed fungal infections, which can exacerbate the condition and lead to serious complications. Clinicians should maintain a high index of suspicion for mucormycosis in similar clinical scenarios, prioritizing adequate antifungal treatment and careful monitoring to improve patient outcomes. Early interdisciplinary collaboration is essential for the effective management of such complex cases.

Clinical characteristics of lean metabolic-associated fatty liver disease and the impact of concurrent diabetes mellitus.

Objectives: Metabolic-associated fatty liver disease (MAFLD) was proposed in 2020 to replace the original term nonalcoholic fatty liver disease (NAFLD) with new diagnostic criteria. The disease risks of lean and overweight/obese MAFLD patients remain controversial. Materials and Methods: The participants from the Taiwan biobank cohort were included. Advanced liver fibrosis is defined as NAFLD fibrosis score (NFS) >0.675. We use carotid plaques of duplex ultrasounds to diagnose atherosclerosis. Results: A total of 20,058 participants (age 55.67 ± 10.32; males 37.6%) were included in the final analysis. Seven thousand eight hundred and forty-three (39.1%) participants were diagnosed with MAFLD. Of them, 965 (12.3%) were lean MAFLD patients. Among lean MAFLD patients, 25.6% were comorbid with diabetes mellitus (DM). Lean MAFLD patients were older and had higher percentages of females and DM than overweight/obese MAFLD patients. After propensity score matching for age and sex, they had lower levels of NFS but a higher percentage of carotid plaques. Among four subtypes of MAFLD including "lean with DM," "lean without DM," "overweight/obese with DM," and "overweight/obese without DM," logistic regression showed that "lean with DM" subjects had the highest risk of atherosclerosis and "overweight/obese with DM" subjects had the highest risk of advanced liver fibrosis in MAFLD patients. Conclusion: The population-based study revealed that lean MAFLD patients make up 12.3% of all MAFLD patients, and they have a higher proportion of coexisting diabetes. Among lean MAFLD patients concurrent with diabetes, they have the highest risk of atherosclerosis and should receive special attention clinically.

Carotid artery stenting for symptomatic carotid near occlusions: Feasibility, safety and outcome analysis.

INTRODUCTION: Extracranial internal carotid stenosis (EICS) is a well-established cause of stroke. Carotid near-occlusion (CNO), either distally collapsed or not, is a rare sub-type of EICS with conflicting data regarding the necessity for treatment. The aim of this study is to evaluate the results of carotid artery stenting (CAS) for patients with symptomatic CNOs. MATERIAL AND METHODS: Institutional review board (I06-420-23) approval was obtained for this retrospective study. Consecutive data from January 2019 to January 2023 was obtained. Sixty-five patients underwent 66 procedures for symptomatic CNOs. Diagnosis of CNOs were made with DSA images. Treatment decisions were made by a multidisciplinary team. Patient data including age, gender, clinical presentation, affected side, complications (initial/ follow-up), and pre and post mRS scores were recorded and analyzed. RESULTS: There were 22 female and 43 male patients with symptomatic CNOs (mean age: 71.52 ± 9.32 years). The mean time from symptom-to-treatment was 3.91 weeks ± 3.74 weeks (ranging from 0 to 20 weeks). There were eight events recorded in the 30 days period after CAS; five (7.7%) were cerebral hyperperfusion syndrome (one causing haemorrhage) and three (4.5%) ischemic complications. Permanent neurologic deficit rate was 6% and 61 patients (94%) mRS scores were unchanged during last follow-up. Mean follow-up period was 22.94 ± 16.67 months (ranging from 0.5 to 60 months). CONCLUSION: Our study demonstrated that in the complex population of patients with symptomatic CNOs, CAS is a feasible option with acceptable rate of permanent neurologic deficits. Further studies are needed to assess its safety and long-term efficacy.