How I do it: operative nuances of the Encephalo-Duro-Mio-Synangiosis (EDMS) technique for pediatric moyamoya disease and syndrome.

BACKGROUND: Moyamoya disease, a progressive occlusive arteriopathy mainly affecting the supraclinoid internal carotid artery, leads to abnormal "Moyamoya vessels" and ischemic events in children due to decreased cerebral blood flow. Surgery, especially indirect revascularization, is suggested for pediatric Moyamoya cases. METHOD: We present the Encephalo-Duro-Mio-Synangiosis (EDMS) technique, illustrated with figures and videos, based on 14 years' experience performing 71 surgeries by the senior author (SGJ) and the Moyamoya Interdisciplinary Workteam at "Prof. Dr. J. P. Garrahan" Pediatric Hospital. CONCLUSION: EDMS is a simple and effective treatment for Moyamoya disease, enhancing procedure precision and safety, reducing associated risks, complications, and improving clinical outcomes.

Measuring global cerebrovascular pulsatility transmission using 4D flow MRI.

Pulse wave encephalopathy (PWE) is hypothesised to initiate many forms of dementia, motivating its identification and risk assessment. As candidate pulsatility based biomarkers for PWE, pulsatility index and pulsatility damping have been studied and, currently, do not adequately stratify risk due to variability in pulsatility and spatial bias. Here, we propose a locus-independent pulsatility transmission coefficient computed by spatially tracking pulsatility along vessels to characterise the brain pulse dynamics at a whole-organ level. Our preliminary analyses in a cohort of 20 subjects indicate that this measurement agrees with clinical observations relating blood pulsatility with age, heart rate, and sex, making it a suitable candidate to study the risk of PWE. We identified transmission differences between vascular regions perfused by the basilar and internal carotid arteries attributed to the identified dependence on cerebral blood flow, and some participants presented differences between the internal carotid perfused regions that were not related to flow or pulsatility burden, suggesting underlying mechanical differences. Large populational studies would benefit from retrospective pulsatility transmission analyses, providing a new comprehensive arterial description of the hemodynamic state in the brain. We provide a publicly available implementation of our tools to derive this coefficient, built into pre-existing open-source software.

Management of Incidental Carotid Cave Aneurysm.

BACKGROUND: Incidental diagnosis of saccular aneurysms is more common with the advent of imaging techniques. Because of the severe morbidity and mortality that they can cause, treatment is chased for them, either microsurgical treatment or endovascular, even when they are diagnosed incidentally. Carotid cave aneurysms are rare, and they seem to have a more benign course compared to other intracranial aneurysms, probably related to the physical enveloping effect of the surrounding structures. Yet, their microsurgical treatment is a serious challenge technically for the neurosurgeon, with its severe morbidity and mortality for the patient. Endovascular techniques have their risks, too. PURPOSE: In this paper, we analyzed and presented our series of incidentally diagnosed carotid cave aneurysms. MATERIALS AND METHODS: The age, gender of patients, the size, laterality, and MR angiographic follow-up of aneurysms were reported. Their clinical results were noted. RESULTS: Fifty-six patients who had incidentally been diagnosed with 59 carotid cave aneurysms were followed up. No patient was microsurgically treated, but 15 patients had endovascular treatment for 15 aneurysms. The mean size of 15 treated aneurysms was 4.6 ± 2.1 (range = 2-10) mm, and it was 3.0 ± 1.5 (range = 1.7-10) mm for the untreated aneurysms (n = 44). There was no significant difference between the follow-up times of the treated and untreated groups (P = 0.487). The median follow-up of 59 aneurysms in 56 patients was 52 (mean = 49.6 ± 27.9, range = 1-124) months, with a total follow-up of 244 aneurysm years. None of the patients had subarachnoid hemorrhage related to carotid cave aneurysms during follow-up, and none of the aneurysms had shown growth. Two patients who had endovascular treatment had ischemic complications with minor neurologic deficits. CONCLUSION: Follow-up can be a reasonable option for the incidental aneurysms that are located and confined to the carotid cave. Additionally, TOF might be a reliable method for follow-up imaging of carotid cave aneurysms.

Acute Glaucoma Following Internal Carotid Artery Stenting: A Rare But Serious Complication of Ocular Ischemic Syndrome.

Acute glaucoma following carotid artery recanalization is a rare but severe complication of underlying ocular ischemic syndrome. We present a case of a 71-year-old woman with ocular ischemic syndrome and severe stenosis of the right internal and external carotid artery undergoing carotid artery stenting. Immediate postprocedural angiography showed pronounced reperfusion of the ophthalmic artery. Subsequently, the patient developed vision-threatening acute glaucoma despite treatment with acetazolamide. Monitoring of intraocular pressure is important in patients who are at risk of developing ocular ischemic syndrome because of internal carotid artery stenosis. Interventionalists should also assess the degree of vascular collateralization from the external carotid artery.

[Dynamic functional assessment of internal carotid artery tortuosity in patients with multifocal atherosclerosis]. / Dinamicheskaya funktsional'naya otsenka patologicheskikh izvitostei vnutrennikh sonnykh arterii u bol'nykh s mul'tifokal'nym aterosklerozom. Klinicheskii sluchai.

A personalized approach with attention to anamnesis and specific symptoms is necessary in patients with internal carotid artery tortuosity. Neuroimaging (especially before elective surgery) or functional stress tests following ultrasound of supra-aortic vessels may be necessary depending on medical history and complaints. In addition to standard Doppler ultrasound, these patients should undergo rotational and orthostatic transformation tests. We analyze changes in shape and hemodynamic parameters within the tortuosity area in various body positions. This is especially valuable for patients with concomitant carotid artery stenosis. The article presents a clinical case illustrating the importance of such approach.

[Functional assessment of internal carotid artery tortuosity in patients with multifocal atherosclerosis]. / Vazhnost' dinamicheskoi funktsional'noi otsenki patologicheskoi izvitosti vnutrennikh sonnykh arterii u bol'nykh s mul'tifokal'nym aterosklerozom.

The review is devoted to diagnosis and treatment of internal carotid artery tortuosity. The authors consider modern classification, epidemiology and diagnostic options using neuroimaging or ultrasound-assisted functional stress tests depending on medical history and complaints. In addition to standard Doppler ultrasound, rotational and orthostatic tests are advisable due to possible changes of local shape and hemodynamic parameters following body position changes, especially in patients with concomitant atherosclerotic stenosis. Thus, a personalized approach is especially important for treatment and diagnostics of internal carotid artery tortuosity.

Ischemic stroke due to stylocarotid artery syndrome: a case report and review.

Stylocarotid artery syndrome (SAS) is a rare variant of Eagle's syndrome that may lead to transient ischemic attack or stroke. The underlying pathophysiological mechanism involves compression of the internal carotid artery by an elongated styloid process (ESP), potentially resulting in vascular occlusion or dissection. An ESP exceeding 2.5 cm is deemed elongated, with a length of 3.0 cm considered clinically significant. Although the prevalence of ESP ranges from 4.0% to 7.3%, symptomatic cases are rare; symptoms are present in only approximately 4.0% of individuals with an ESP. Unlike the typical symptoms of Eagle's syndrome, SAS may not cause pharyngeal discomfort, the sensation of a foreign body in the throat, dysphagia, or facial pain. This absence of characteristic symptoms as well as the development of central nervous system symptoms often leads patients to seek care from neurologists instead of otolaryngologists, increasing the likelihood of misdiagnosis or underdiagnosis. We herein report a unique case of ischemic stroke caused by SAS and present a literature review on cases of SAS-associated ischemic stroke published in the past decade. The reporting of this study conforms to the CARE guidelines.

Using DFT on ultrasound measurements to determine patient-specific blood flow boundary conditions for computational hemodynamics of intracranial aneurysms.

Boundary conditions (BCs) is one pivotal factor influencing the accuracy of hemodynamic predictions on intracranial aneurysms (IAs) using computational fluid dynamics (CFD) modeling. Unfortunately, a standard procedure to secure accurate BCs for hemodynamic modeling does not exist. To bridge such a knowledge gap, two representative patient-specific IA models (Case-I and Case-II) were reconstructed and their blood flow velocity waveforms in the internal carotid artery (ICA) were measured by ultrasonic techniques and modeled by discrete Fourier transform (DFT). Then, numerical investigations were conducted to explore the appropriate number of samples (N) for DFT modeling to secure the accurate BC by comparing a series of hemodynamic parameters using in-vitro validated CFD modeling. Subsequently, a comprehensive comparison in hemodynamic characteristics under patient-specific BCs and a generalized BC based on a one-dimensional (1D) model was conducted to reinforce the understanding that a patient-specific BC is pivotal for accurate hemodynamic risk evaluations on IA pathophysiology. In addition, the influence of the variance of heart rate/cardiac pulsatile period on hemodynamic characteristics in IA models was studied preliminarily. The results showed that N ≥ 16 for DFT model is a decent choice to secure the proper BC profile to calculate time-averaged hemodynamic parameters, while more data points such as N ≥ 36 can ensure the accuracy of instantaneous hemodynamic predictions. In addition, results revealed the generalized BC could overestimate or underestimate the hemodynamic risks on IAs significantly; thus, patient-specific BCs are highly recommended for hemodynamic modeling for IA risk evaluation. Furthermore, this study discovered the variance of heart rate has rare influences on hemodynamic characteristics in both instantaneous and time-averaged parameters under the assumption of an identical blood flow rate.

Distal normal vessel diameter might be associated with silent brain infarcts after stenting for symptomatic carotid stenosis.

BACKGROUND: Carotid artery stenting (CAS) has been the standard treatment for carotid stenosis because it is less invasive; however, the risk of periprocedural thromboembolism is high. We investigated the predictors for silent brain infarcts (SBIs), focusing on embolic protection in CAS. METHODS: This study was single-center retrospective study, and we obtained baseline demographics and clinical, laboratory, and periprocedural variables of patients who underwent CAS. Also, methods used for embolic protection (no EPD, distal EPD, or proximal balloon guiding catheter) during CAS were obtained. Distal normal vessel diameter was defined as the diameter of cervical internal carotid artery where the artery wall becomes parallel. Diffusion-weighted imaging was performed before and after procedure to detect SBIs. The primary outcome was stented territory SBIs, and the secondary outcomes were any territories SBIs and stented territory SBIs in cases with EPD. RESULTS: A total of 196 CAS procedures with mean age 69.1 ± 9.9 years were included. After CAS, stented territory SBIs occurred in 53 (27.0 %) cases and any territories SBIs in 60 (30.6 %) cases. Univariable analyses revealed that distal normal vessel diameter (odds ratio = 1.71, 95 % confidence interval = 1.20-2.43, P = 0.003) was associated with the occurrence of stented territory SBIs after CAS. After adjusting for potential variables, larger distal normal vessel diameter (1.61 [1.10-2.36], P = 0.014) increased the occurrence of SBIs after CAS. Consistent results were obtained when the outcome was any territories SBIs or stented territory SBIs in cases with EPD. CONCLUSIONS: Distal normal vessel diameter was a predictor for the occurrence of SBI after CAS. The passable pore size of EPDs may vary depending on vessel diameter, and may impact the occurrence of SBIs.

Internal carotid artery bulb width: a novel potential parameter for the prediction of cerebral vascular diseases.

OBJECTIVE: To investigate the relationship between the width of the internal carotid artery (ICA) bulb and cerebral vascular diseases including stroke and intracranial aneurysms. MATERIAL AND METHODS: In total 300 patients who had supra-aortic computed tomography angiography (CTA) were enrolled in this study from 2015 to 2021. The study groups consisted of 100 ischemic stroke patients, 100 patients with intracranial aneurysms, and 100 control subjects. The intracranial aneurysm patient group was divided into two subgroups according to the presence of subarachnoid hemorrhage (SAH). The largest diameters of the ICA C1 (cervical) and C2 (petrous) segments in all individuals were measured bilaterally on CTA images. The ICA diameter ratios of the cases were measured using the formula C1-C2C1. The relationship between the age and ICA vessel analysis was evaluated as well. RESULTS: The mean ICA bulb width values in the ischemic stroke patient group and the intracranial aneurysm patient group were significantly higher than the control group (p < 0.001). The ICA C1 and C2 segment diameter values and ICA diameter ratio were smaller in the intracranial aneurysm patients with SAH than those who had not (p = 0.7). There was a statistically significant but weak relationship between the age and ICA diameter ratios in all study groups (R-squared value of 0.26, p = 0.03). CONCLUSION: ICA bulb width is a parameter that can be easily evaluated with neuroimaging modalities and is a successful method that may be used for predicting the risk of ischemic stroke or the presence of an intracranial aneurysm.

Dynamic cerebral autoregulation is preserved during orthostasis and intrathoracic pressure regulation in healthy subjects: A pilot study.

Resistance breathing may restore cardiac output (CO) and cerebral blood flow (CBF) during hypovolemia. We assessed CBF and cerebral autoregulation (CA) during tilt, resistance breathing, and paced breathing in 10 healthy subjects. Blood velocities in the internal carotid artery (ICA), middle cerebral arteries (MCA, four subjects), and aorta were measured by Doppler ultrasound in 30° and 60° semi-recumbent positions. ICA blood flow and CO were calculated. Arterial blood pressure (ABP, Finometer), and end-tidal CO2 (ETCO2) were recorded. ICA blood flow response was assessed by mixed-models regression analysis. The synchronization index (SI) for the variable pairs ABP-ICA blood velocity, ABP-MCA velocities in 0.005-0.08 Hz frequency interval was calculated as a measure of CA. Passive tilting from 30° to 60° resulted in 12% decrease in CO (p = 0.001); ICA blood flow tended to fall (p = 0.04); Resistance breathing restored CO and ICA blood flow despite a 10% ETCO2 drop. ETCO2 and CO contributed to ICA blood flow variance (adjusted R2: 0.9, p < 0.0001). The median SI was low (<0.2) indicating intact CA, confirmed by surrogate date testing. The peak SI was transiently elevated during resistance breathing in the 60° position. Resistance breathing may transiently reduce CA efficiency. Paced breathing did not restore CO or ICA blood flow.

Usefulness of "AcT ratio" in diagnosis of internal carotid artery stenosis: a multicenter, retrospective, observational study.

PURPOSE: The ratio of the internal carotid artery (ICA) to the common carotid artery (CCA), especially the "AcT ratio," which is a modified measurement method of acceleration time, is useful for diagnosing ICA-origin stenosis. However, previous studies were single-center studies. Therefore, this multicenter, retrospective, cross-sectional study aimed to determine whether a method using the AcT ratio is useful for estimating stenosis rates. METHODS: This study included 461 vessels subjected to carotid artery ultrasonography and evaluation for ICA-origin stenosis via NASCET at four hospitals. The duration from the steep rise point to the inflection point or the first peak was defined as AcT on pulsed wave Doppler. The AcT ratio was calculated as AcT of ICA/AcT of ipsilateral CCA. The AcT ratio and rate of ICA-origin stenosis were analyzed using Pearson's correlation coefficient, simple regression analysis, and ROC curve. RESULTS: A significant positive correlation was observed between the AcT ratio and NASCET stenosis. NASCET stenosis of ≥ 50% had a sensitivity, specificity, and negative predictive value (NPV) of 70.2%, 71.6%, and 91.5%, respectively, when the cut-off value of the AcT ratio was 1.17. NASCET stenosis of ≥ 70% had a sensitivity, specificity, and NPV of 70.5%, 72.1%, and 95.9%, respectively, when the cut-off value of the AcT ratio was 1.22. CONCLUSIONS: The findings of this multicenter, retrospective, cross-sectional study suggest that the AcT ratio is useful for diagnosing ICA-origin stenosis, especially for diagnosis by exclusion. NASCET stenosis of ≥ 50% was considered unlikely if the Act ratio was ≤ 1.17, whereas NASCET stenosis of ≥ 70% was considered unlikely if it was ≤ 1.22.

Natural history of asymptomatic cervical internal carotid artery stenosis in diabetes mellitus patients.

INTRODUCTION: Diabetes mellitus (DM) is known to be a cause of cervical internal carotid artery stenosis (ICS). In this study, we investigated the natural history of asymptomatic ICS in DM patients without surgical intervention. METHODS: We conducted a retrospective study of 148 DM patients with asymptomatic ICS treated medically at the Kansai Electric Power Hospital from April 2013 to March 2023, inclusive. We examined the incidence of ischemic stroke with ICS and evaluated the patients' clinical characteristics and imaging findings. RESULTS: Ischemic stroke with ICS occurred in 7 patients (4.7 %), and only smoking history was significantly correlated with the incidence of ischemic stroke (p = 0.04). DISCUSSION: The incidence rate of ischemic stroke with ICS in this study (4.7%) was comparable to the previous report. The result that, the correlated factors of the incidence of ischemic stroke in DM patients with ICS was only smoking history, seemed acceptable. However, prospective studies with a larger number of cases may be needed in the future to determine the correlated factors more eligibly.

Synchronous subarachnoid haemorrhage and ischaemic stroke as a result of complete internal carotid artery occlusion.

A previously healthy man in his 60s presents with a one-day history of insidious onset headache and 'walking into doors'. He reported transient right arm pain and tingling but no weakness. A CT brain showed a right middle cerebral artery (MCA) infarct as well as a synchronous right frontal lobe convexal subarachnoid haemorrhage (cSAH). An arch to vertex CT angiogram demonstrated right MCA occlusion and complete right internal carotid artery (ICA) occlusion from its origin. Reconstitution of flow was seen within the distal right ICA at the level of the distal foramen lacerum. A repeat CT of the brain after one week showed a stable appearance of the bleeding and infarct. He was commenced on antiplatelet therapy for the treatment of the ischaemic stroke as well as secondary prevention.This is a rare case of synchronous right MCA infarct as well as a right frontal cSAH secondary to ipsilateral carotid artery occlusion.

Factors related to vessel displacement due to stent retriever retraction: An in vitro study.

BACKGROUND: Thrombectomy with a stent retriever (SR) may lead to intracranial hemorrhage due to vessel displacement. We aimed to explore factors related to vessel displacement using an in vitro vessel model. METHODS: A vessel model mimicking two-dimensional left internal carotid angiography findings was used in this study. Six SR types (Solitaire 3 × 40, 4 × 40, and 6 × 40; Embotrap 5 × 37; Trevo 4 × 41; and Tron 4 × 40) were fully deployed in the M2 ascending, M2 bend, or M1 horizontal portion. Subsequently, the SR was retracted, and the vessel displacement, maximum SR retraction force, and angle of the M2 bend portion were measured. A total of 180 SR retraction experiments were conducted using 6 SR types at 3 deployment positions with 10 repetitions each. RESULTS: The mean maximum distance of vessel displacement for Embotrap Ⅲ 5 × 37 (6.4 ± 3.5 mm, n = 30) was significantly longer than that for the other five SR types (p = 0.029 for Solitaire 6 × 40 and p < 0.001 for the others, respectively). Vessel displacement was significantly longer in the M2 ascending portion group (5.4 ± 3.0 mm, n = 60) than in the M2 bend portion group (3.3 ± 1.6 mm, n = 60) (p < 0.001) and it was significantly longer in the M2 bend portion group than in the M1 horizontal portion group (1.1 ± 0.7 mm, n = 60) (p < 0.001). A positive correlation existed between the mean maximum SR retraction force or mean angle of the M2 bend portion due to SR retraction (i.e., vessel straightening) and the mean maximum distance of vessel displacement (r = 0.90, p < 0.001; r = 0.90, p < 0.001, respectively). CONCLUSIONS: Vessel displacement varied with the SR type, size, and deployment position. Moreover, vessel displacement correlated with the SR retraction force or vessel straightening of the M2 bend portion.

Rare combo: moyamoya and lupus in men.

Moyamoya syndrome (MMS) is a rare, chronic, progressive cerebrovascular disorder characterized by stenosis at the apices of the intracranial internal carotid arteries, including the proximal anterior cerebral arteries and middle cerebral arteries. Cerebral angiography images are used for detection through measurement. Systemic lupus erythematosus (SLE) is an autoimmune disease that can cause multisystemic involvement. The coexistence of SLE and MMS has been rarely reported in the literature. A 46-year-old male patient with malar rash, Raynaud phenomenon presented to the hospital with a complaint of weakness in the left lower extremity, which began 3 days before the date of the visit. In the diffusion magnetic resonance imaging, multiple diffusion restrictions were observed in the right frontal region. The patient underwent MR angiography, revealing stenosis in the terminal and supraclinoid segments of the right internal carotid artery, which made us consider moyamoya disease. This patient, with a malar rash and Raynaud's, a positive antibody profile, was diagnosed as a male with SLE accompanied by MMS.

Diagnostic Performance of Carotid Ring Sign on CT-Angiography in Internal Carotid True Occlusion.

BACKGROUND: To differentiate between pseudo occlusion (PO) and true occlusion (TO) of internal carotid artery (ICA) is important in thrombectomy treatment planning for patients with acute ischemic stroke. Although delayed contrast filling has been differentiated carotid PO from TO, its application has been limited by the implementations of multiphasic computed tomography angiography. In this study, we hypothesized that carotid ring sign, which is readily acquired from single-phasic CTA, can sufficiently differentiate carotid TO from PO. METHODS: One thousand four hundred and twenty patients with anterior circulation stroke receiving endovascular therapy were consecutively recruited through a hospital- and web-based registry. Two hundred patients with nonvisualization of the proximal ICA were included in the analysis after a retrospective screening. Diagnosis of PO or TO of the cervical segment of ICA was made based on digital subtraction angiography. Diagnostic performances of carotid ring sign on arterial-phasic CTA and delayed contrast filling on multiphasic computed tomography angiography were evaluated and compared. RESULTS: One-hundred twelve patients had ICA PO and 88 had TO. Carotid ring sign was more common in patients with TO (70.5% versus 6.3%; P<0.001), whereas delayed contrast filling was more common in PO (94.9% versus 7.7%; P<0.001). The sensitivity and specificity of carotid ring sign in diagnosing carotid TO were 0.70 and 0.94, respectively, whereas sensitivity and specificity of delayed contrast filling was 0.95 and 0.92 in judging carotid PO. CONCLUSIONS: Carotid ring sign is a potent imaging marker in diagnosing ICA TO. Carotid ring sign could be complementary to delayed contrast filling sign in differentiating TO from PO, in particular in centers with only single-phasic CTA.