Ovarian hyperstimulation syndrome with carotid artery dissection and cerebral infarction: a case report.

BACKGROUND AND PURPOSE: Ovarian hyperstimulation syndrome (OHSS) is one of the most serious iatrogenic complications in assisted reproductive technology, which seem rarely associated with cerebrovascular diseases. We reported a patient diagnosed with OHSS combined with carotid artery dissection and massive cerebral infarction. CASE PRESENTATION: We reported a unique case of a 31-year-old woman who experienced abdominal pain, blurred consciousness, and speech inability after 15-day continuous injection of human gonadotropin for infertility. Imaging examination showed hyperacute cerebral infarction in the left frontotemporal island parietal lobe and left internal carotid artery dissection. After therapeutic use of low-molecular-weight heparin calcium anticoagulation and other conventional cerebrovascular treatments, she eventually achieved a good prognosis. CONCLUSIONS: OHSS seemd rarely associated with cerebrovascular diseases, such as infarction and carotid artery dissection. Encountering abdominal symptoms combined with neurologic symptoms, a detailed history and a thorough examination are essential. It is necessary to comprehensively analyze the pathogenesis and formulate individualized therapy according to the specific conditions of patients.

Unilateral delayed post-hypoxic leukoencephalopathy: a case report.

BACKGROUND: Delayed post-hypoxic leukoencephalopathy is a rare entity following hypoxia. Clinical and radiological signs of delayed post-hypoxic leukoencephalopathy have not previously been reported following acute ischemic stroke. CASE PRESENTATION: We report a case of an 81-year-old Central European man who presented with a dissection-related occlusion of the left carotid artery. He showed clinical improvement immediately after endovascular stroke therapy, followed by a significant clinical and especially cognitive deterioration thereafter and a clinical recovery after several weeks. The clinical course of the patient was accompanied by morphological changes on magnetic resonance imaging characteristic of delayed post-hypoxic leukoencephalopathy; that is, strictly limited and localized unilaterally to the left anterior circulation. CONCLUSION: This case demonstrates that clinical symptoms and morphological changes on magnetic resonance imaging compatible with delayed post-hypoxic leukoencephalopathy do not necessarily only occur with global hypoxia, but can also occur in patients with a large vessel occlusion in the corresponding vascular territories.

Caracterización clínica e imagenológica de una serie de pacientes con disección de arterias cervicales e intracraneales / Cervicocranial arterial dissection: experience in 57 patients

Background: Cervicocranial arterial dissection (CIAD) is an important cause of stroke. Aim: To describe the clinical and imaging characteristics of patients with CIAD. Material and Methods: An anonymous registry was made including all patients admitted to a private hospital with a diagnosis of CIAD. Patients were subdivided as having an anterior or posterior circulation dissection (ACD or PCD, respectively). Results: Fifty-seven patients aged 40 ± 8 years (60% women) were included in the study, 39 with PCD and 18 with ACD. Cervical pain was the most common symptom. CIAD was diagnosed with no clinical or imaging signs of stroke in 49% of patients. Fifty one percent of patients had focal neurological deficits and 72% had a NIH stroke score below five. No significant differences between patients with ACD or PCD were found. Fifty patients received antiplatelet therapy (simple or dual), seven patients were anticoagulated and 13 were subjected to stenting due to progression of stenosis with hemodynamic involvement or bilateral dissection with scarce collaterals. The lesion was located in V3 segment in 27 patients and cervical segment of the internal carotid in 16 cases. A favorable Modified Rankin Scale (0-2) was achieved in 85.9%, with a trend towards achieving better functional prognosis in PCD. Conclusions: Due to the greater availability of non-invasive imaging methods, 50% of these patients with CIAD did not have a stroke. Thus, an earlier and more timely management is feasible.

[Experience of successful rescue from 5 cases of internal carotid artery injury during transnasal endoscopic skull base surgery].

Objective: To investigate the cause and urgent management of internal carotid artery injury during transnasal endoscopic skull base surgery. Methods: Five cases of internal carotid artery injury encountered during transnasal endoscopic skull base surgery in Department of Otorhinolaryngology Head and Neck Surgery, the First Affiliated Hospital of University of Science of Technology of China, Anhui Provincial Hospital from December 2010 to July 2017 were analysed retrospectively. There were 2 cases of adenoid cystic carcinoma, 1 case of salivary gland-type adenocarcinoma, 1 case of petrous apex cholesterol granulomas and 1 case of squamous carcinoma. The cause of internal carotid artery injury and subsequent treatment were analysed, in order to prevent internal carotid artery injury during transnasal endoscopic surgery. Results: Intraoperatively, all these 5 cases were packed with vaseline strip successfully. Two cases underwent subsequent intravascular covered stent graft implantation; 1 case underwent replacement of packing with muscle fascia graft; 1 case was packed with vaseline strip in nasal and nasopharyngeal cavity; 1 case accepted ligation of common carotid artery after failure of nasal packing. Four cases were successfully treated without craniocerebral or ocular complications. Otherwise, 1 case demonstrated with extremity paralysis after ligation. Follow up ranged from 6 to 84 months, no patient died. Conclusion: The injury of internal carotid artery is related with improper operative procedures and anatomic localization, which should be treated properly with emergent hemostasis, and an experienced multidisciplinary team to repair vascular damage is very important.

Experience of successful rescue from 5 cases of internal carotid artery injury during transnasal endoscopic skull base surgery / 中华耳鼻咽喉头颈外科杂志

Objective@#To investigate the cause and urgent management of internal carotid artery injury during transnasal endoscopic skull base surgery.@*Methods@#Five cases of internal carotid artery injury encountered during transnasal endoscopic skull base surgery in Department of Otorhinolaryngology Head and Neck Surgery, the First Affiliated Hospital of University of Science of Technology of China, Anhui Provincial Hospital from December 2010 to July 2017 were analysed retrospectively. There were 2 cases of adenoid cystic carcinoma, 1 case of salivary gland-type adenocarcinoma, 1 case of petrous apex cholesterol granulomas and 1 case of squamous carcinoma. The cause of internal carotid artery injury and subsequent treatment were analysed, in order to prevent internal carotid artery injury during transnasal endoscopic surgery.@*Results@#Intraoperatively, all these 5 cases were packed with vaseline strip successfully. Two cases underwent subsequent intravascular covered stent graft implantation; 1 case underwent replacement of packing with muscle fascia graft; 1 case was packed with vaseline strip in nasal and nasopharyngeal cavity; 1 case accepted ligation of common carotid artery after failure of nasal packing. Four cases were successfully treated without craniocerebral or ocular complications. Otherwise, 1 case demonstrated with extremity paralysis after ligation. Follow up ranged from 6 to 84 months, no patient died.@*Conclusion@#The injury of internal carotid artery is related with improper operative procedures and anatomic localization, which should be treated properly with emergent hemostasis, and an experienced multidisciplinary team to repair vascular damage is very important.

[Risk factors of rupture of internal carotid artery during surgical resection of carotid body tumor].

Objective: To investigate risk factors of rupture of internal carotid artery resection during carotid body tumor resection and to summarize our treatment experience. Methods: During the period from 1991 to 2016, rupture of internal carotid artery occurred in 27 patients (28 tumors) during surgical resection of carotid body tumor in the First Affiliated Hospital of Sun Yat-sen University. Their clinical and follow-up data were retrospectively collected and analyzed. For all patients underwent surgical resection during this period, Logistic regression analysis was used to investigate the risk factors of intraoperative rupture of internal carotid artery. Results: Of these 28 tumors, there were 15 (53.6%) tumors with diameter≥5 cm and 20 (71.4%) Shamblin Ⅲ tumors. Intraoperatively, shunt was applied for 8 (28.6%) cases. Thirteen (46.4%) patients underwent ligation of external carotid artery, while 2 (7.1%) patients accepted resection of cranial nerves. Direct closure/patchplasty, autologous vessels or graft reconstruction was used in 16, 10 and 2 cases, respectively. Postoperatively, stroke occurred in 4(14.3%) cases and cranial nerve deficit in 15 (53.6%) cases. During a median length of 36 (14-125) months, cranial nerve deficit persisted in 5 cases. Follow-up radiologic examination indicated 3 (10.7%) cases of targeted vessel occlusion. However, no new-onset stroke was identified. Among all patients underwent surgical resection of carotid body tumor, female (OR=3.650, P=0.012), age≤25 years old (OR=3.710, P=0.013) and Shamblin Ⅲ tumor (OR=4.631, P=0.008) increase the risks of intraoperative carotid artery rupture. Conclusions: Shamblin Ⅲ tumor is the predictor of rupture of internal carotid artery. Intraoperative, properly increased blood pressure, intraoperative heparinization and use of shunt for those cases without well-compensated cranial collateral arteries are likely to decreasing the incidence of stroke.

Spontaneous carotid dissection / Dissecção espontânea de carótida

Summary Carotid dissection is a rare occurrence but it is the main cause of stroke in individuals aged less than 45 years, and can be the etiology in up to 25% of strokes in young adults. We report a case with classic image of ying yang on vascular ultrasound, which was treated according to the best available medical evidence, yielding a favorable outcome.

Resumo A dissecção de carótida é entidade rara, mas é a principal causa de acidentes vasculares cerebrais isquêmicos em menores de 45 anos e pode ser a etiologia de até 25% dos acidentes vasculares cerebrais em adultos jovens. Apresenta-se um caso com imagem clássica de ying yang à ultrassonografia vascular, que foi tratado de acordo com as melhores evidências médicas disponíveis e apresentou boa evolução.

Characteristics for Ischemic Stroke in 18–30 Years Old Patients, Multicenter Stroke Registry Study / 이화의대지

OBJECTIVES: Although there have been several reports that described characteristics for young age stroke, information regarding very young age (18–30 years old) has been limited. We aimed to analyze demographic factors, stroke subtype, and 3-month outcome in acute ischemic stroke patient who have relatively very young age in multicenter stroke registry. METHODS: We evaluated all 122 (7.1%) consecutive acute ischemic stroke (within 7 days after symptom onset) patients aged 18 to 30 from 17,144 patients who registered in multicenter prospective stroke registry, 1997 to 2012. Etiology was classified by Trial of Org 10172 in Acute Stroke Treatment criteria. Stroke severity was defined as National Institutes of Health Stroke Scale (NIHSS) and stroke outcome was defined by modified Rankin scale (mRS) at 3 months after index stroke. RESULTS: The mean age of all included patients was 25.1±3.7 years and 76 patients (62.2%) were male. The median NIHSS at admission was 4. Considering stroke subtype, 37 patients (30.3%) had stroke of other determined etiology (SOD), 37 (30.3%) had undetermined negative evaluation (UN) and 31 (25.4%) had cardioembolism (CE) were frequently noted. After adjusting age, sex and variables which had P<0.1 in univariable analysis (NIHSS and stroke subtype), CE stroke subtype (odds ratio, 4.68; 95% confidence interval, 1.42–15.48; P=0.011) were significantly associated with poor functional outcome (mRS≥3). CONCLUSION: In very young age ischemic stroke patients, SOD and UN stroke subtype were most common and CE stroke subtype was independently associated with poor discharge outcome.

The value of high-resolution magnetic resonance imaging of arterial walls in the diagnosis of cerebral artery dissection / 国际脑血管病杂志

Objective To investigate the value of high-resolution magnetic resonance imaging (HR-MRI) of arterial walls in the diagnosis of cerebral artery dissection (CAD).Methods The patients diagnosed as CAD and completed computed tomography angiography (CTA),magnetic resonance angiography (MRA),digital subtraction angiography (DSA),and HR-MRI were enrolled retrospectively.The detection rate and diagnostic value of the 4 imaging techniques were compared and analyzed.Results A total of 15 patients were enrolled,5 had internal carotid artery dissection,7 had vertebral artery dissection,2 had middle cerebral artery dissection,and 1 had basilar artery dissection.HR-MRI revealed 11 intramural hematoma,9 intimal flap,3 double lumen sign,and 2 pseudoaneurysm.A total of 18 CADs were detected in 15 patients,17 (94.44％),14 (77.78％),5 (27.78％) and 6 (33.33％) were detected with HR-MRI,DSA,CTA and MRA,respectively.There were significant difference in CAD detection rates of HR-MRI,DSA,CTA and MRA (x2 =24.939,P ＜ 0.001).The CAD detection rate of HR-MRI and DSA were significantly higher than those of CTA and MRA (all P ＜ 0.01 for HR-MRI,all P ＜ 0.05 for DSA),but there was no significant difference in CAD detection rate between HR-MRI and DSA.Conclusion HR-MRI is a diagnostic method for CAD with higher sensitivity.

Cervical artery dissection / 国际脑血管病杂志

Cervical artery dissection (CeAD) is characterized by an intramural hematoma of the internal carotid artery or the vertebral artery.CeAD is the major cause of ischemic stroke in young adults.Carotid artery dissection is a major cause of stroke.Early recognition and treatment of CeAD is important for the prevention of ischemic stroke.

Application of covered stent in treatment of carotid blowout after head and neck tumors resection / 中国耳鼻咽喉头颈外科

OBJECTIVE To assess the treatment reliability of covered stent for carotid artery blowout after head and neck tumors resection. METHODS Five cases with postoperative rupture of carotid artery invaded by the head and neck tumor were reviewed. They presented with life threatening massive neck or oral bleedings. All of them were treated with self expanding covered stents through intervention therapy approach. RESULTS The covered stent were successfully deployed in the target arteries in all cases,the instant isolation effect was quite satisfactory. After treatment, angiography showed successful occlusion of the pseudoaneurysm, patency of carotid artery lumen, and significant improvement of clinical symptoms without neurologic dysfunction. Following up 2 to 36 months, 3 patients were alive with no disease, two patients died of recurrence. CONCLUSION For the treatment of carotid blowout, endovascular occlusion with covered stent is a minimally-invasive, safe and reliable methods.

Treatment of cervical artery dissections / 国际脑血管病杂志

Cervical artery dissection (CeAD) is an important cause of ischemic stroke in young adults w ith ischemic stroke. The clinical manifestations are often local facial pain, Horner syndrome, and ischemic stroke. With the development of noninvasive imaging, many patients w ith CeAD have got early diagnosis. Thromboembolism is an important mechanism of its pathogenesis. Timely giving anticoagulation therapy is reasonable. How ever, anticoagulants may lead to intramural hematoma expansion; therefore, there are also people w ho support antiplatelet therapy. How ever, the effectiveness of the 2 regimens needs to be confirmed by randomized trials. The recently completed Cervical Artery Dissection in Stroke Study (CADISS) in patients w ith stroke is the first prospective study aiming at the problem. The results have show ed that there w as no significant difference in efficacy betw een the anticoagulants and the antiplatelet drugs. Thrombolysis in patients w ith acute CeAD can not increase the risks of hemorrhage, and the rate of good functional outcome is similar to that of the control group. Therefore, it can be used as a treatment method in acute phase. For patients w hose antithrombotic treatment is invalid or having contraindications and repeated recurrent stroke can conduct endovascular intervention or surgical treatment. Usualy, the prognosis of patients w ith CeAD is better. The stroke recurrence rate is low . The abnormal arterial w als in more than half of the patients w il disappear at 3 to 6 months.

Diagnostic analysis of 80 patients with spontaneous internal carotid artery and vertebral artery dissections / 中华神经科杂志

Objective To investigate the most sensitive methods for diagnosing spontaneous internal carotid artery dissection (sICAD) and spontaneous vertebral artery dissection (sVAD) respectively,for the sake of earlier and more accurate diagnosis.Methods Consecutive patients with sICAD and sVAD who visited the Department of Neurology and Radiology,Huashan Hospital Affiliated to Fudan University during 2008-2013 were retrospectively reviewed and the sensitivity of CT angiography (CTA),magnetic resonance T1-weighted fat-suppressed images (MR T1-FS) and digital subtraction angiography (DSA) for the diagnosis of sICAD and sVAD was compared.Results Eighty patients (62 male,18 female; mean age (45.7 ± 11.9) years) were included in the study.There were 99 arterial dissections in total,45 cases of sICAD,52 cases of sVAD and 2 cases of spontaneous middle cerebral artery dissections.The sensitivity of CTA,DSA and MR T1-FS for diagnosing sICAD was 97.5％ (39/40),90.0％ (36/40) and 69.6％ (16/23) respectively,while for sVAD was 89.8％ (44/49),84.6％ (44/52) and 100.0％ (27/27) respectively.Conclusions sICAD and sVAD have significant differences in many aspects including diagnostic strategies.CTA and MR T1-FS seem to be the most sensitive methods for the diagnosis of sICAD and sVAD respectively.Although DSA has been considered as the gold standard for the diagnosis of artery dissection,this imaging technique does not allow analysis of artery wall thickness,thus also has limitations.It is likely that the diagnostic sensitivity will be improved by combining CTA and MR T1-FS.

Vascular imaging findings in 43 patients with cerebral infarction due to spontaneous cerebral artery dissection / 国际脑血管病杂志

Objective To investigate the imaging characteristics of spontaneous cerebral artery dissection (CAD) causing cerebral infarction by analyzing the vascular imaging findings.Methods The neuroimaging and clinical data in patients with cerebral infarction due to spontaneous CAD were reviewed. The characteristic findings at different sites of CAD in all vascular imaging examinations were analyzed and summarized. Results A total of 43 patients (28 men, 15women; mean age, 45.1 + 12.3 years) with CAD were included in the study. Twenty-three patients with extracranial internal carotid artery dissection (ICAD), 5 with intracranial anterior circulation dissection, 7 with extracranial vertebral artery dissection (VAD), 6 with intracranial VAD, and 2 with basilar artery dissection (BAD). In patients with extracranial ICAD, occlusion (usually beginning about 1-2 cm above the bifurcation and tapering to a complete occlusion with a flame-like or mouse-tail appearance) was the common imaging findings, luminal stenosis (irregular, elongated, and tapered stenosis) and/or dissecting aneurysms were observed in partial patients, intimal flaps and double-lumen sign were found in a few patients, and vessel tortuosity of ipsilateral or bilateral ICA were observed in 6 patients. Characteristic signs of occlusion or stenosis of extracranial ICAD were observed in computed tomography angiography (CTA) or magnetic resonance angiography (MRA) in partial patients, and magnetic resonance imaging (MRI) could reveal the bright hyperintense crescent-shaped zone that represents the intramural hematoma, and resource imaging of CTA could reveal intimal flaps and double-lumen sign at the level of dissection. Occlusion (V1, V4 segment and V3 segment extending to V4 segment) was the common vascular imaging features in patients with VAD, V1 segment occlusion had a typical appearance: cut-off like or taped occlusion. MRA could reveal VA occlusion, and MRI could show the bright hyperintense of intramural hematoma at the level of VA occlusion. Concomitant dissecting aneurysms and stenosis of intracranial VA were found in 2 patients. Intracranial dissections of anterior circulation were verified mainly by digital subtraction angioraphy (DSA),if dissecting aneurysms or intimal flaps were observed, and intimal flaps were revealed by resource imaging of MRA in a patient. In patients with BAD, dissecting aneurysm was found in a patient, concomitant local stenosis in MRA and bright hyperintense of intramural hematoma on MRI were observed in another patients. Vascular imaging follow-up was performed in 7 patients, complete recanalization was found in a patient with extracranial ICA occlusion due to CAD, stenosis disappeared and dissecting aneurysm almost healed in a patient with extracranial ICAD, dissection lesions had no change in 2 patients with extracranial ICAD, dissecting aneurysm further expanded in a patient with extracranial ICAD, degree of stenosis reduced in a patient with intracranial ICAD, dissecting aneurysm healed after stenting in a patient with intracranial VAD. Conclusions Diagnosis of CAD mainly depends on vascular evaluations, and vascular imaging features of CAD, such as flame-like or taped occlusion, dissecting aneurysms,intimal flaps, irregular or/and elongated stenosis, MRI signals of intramural hematoma, doublelumen sign and so on, were the points for diagnosis of CAD. DSA was an important method for diagnosis of CAD, and MRA + MRA, or CTA and resource imaging were very valuable for diagnosis of CAD. CAD should be followed by methods of vascular imaging because the results of follow-up were very important for adjusting the treatment strategies in patients with CAD.

Diagnosis and management of cervical arterial dissection / 国际脑血管病杂志

Cervical arterial dissection is an important cause resulting in stroke, particularly in young adults. The clinical manifestation of cervical arterial dissection may be various, and imaging examinations have a great value in the diagnosis of cervical arterial dissection. At present, anticoagulation and anti-platelet aggregation are the most important medication, while intravascular intervention is a new option for patients failed to respond to medical treatment. This article reviews the recent progress in the diagnosis and treatment of cervical arterial dissection.

Dissecção espontânea das artérias carótidas e vertebrais em uma população multiétnica / Spontaneous carotid and vertebral arteries dissection in a multiethnic population

A dissecção espontânea das artérias carótidas e vertebrais (DEACV) é considerada uma causa rara de acidente vascular cerebral, particularmente em países com população multiétnica. O objetivo desse estudo foi avaliar características clínicas e de neuroimagem dos pacientes com DEACV em uma população multiétnica. Foram estudados 66 pacientes com diagnóstico de DEACV em dois hospitais terciários de São Paulo. Aplicou-se um questionário inicial e os pacientes foram seguidos prospectivamente. Dos pacientes estudados, 82 por cento eram brancos, 53 por cento eram homens e a média de idade foi 41,7 anos. Os fatores de risco cardiovasculares mais freqüentes foram hipertensão arterial e tabagismo. Outros aspectos avaliados foram história prévia de enxaqueca, tratamento inicial e prognóstico. Concluiu-se que apesar da população estudada ser multiétnica, houve um marcante predomínio de brancos. A análise das características clínicas e de neuroimagem dos pacientes com DEACV possibilita um melhor conhecimento da doença, levando a um diagnóstico precoce e tratamento mais adequado.

Spontaneous dissection of the carotid and vertebral arteries (SDCVA) is considered a rare cause of stroke, particularly in countries with multiethnic population. The objective was to evaluate the clinical and neuroimaging features of patients with SDCVA from a multiethnic population. Sixty-six patients diagnosed with SDCVA were studied at two tertiary hospitals at São Paulo. An initial questionnaire was completed and patients were followed prospectively. Among the patients studied, 82 percent were caucasian, 53 percent were male and the average age was 41.7 years old. The most frequent cardiovascular risk factors found were systemic hypertension and tobacco use. Other aspects evaluated were history of previous migraine, initial treatment and prognosis. In conclusion, although the population studied was multhiethnic, there was a marked predominance of caucasians. The analysis of clinical and neuroimaging data from patients with SDCVA allows a better understanding of the disease, leading to an earlier diagnosis and more appropriate treatment.

A Case of Internal Carotid Artery Dissection Presenting with Isolated Hypoglossal Nerve Palsy

Neurological manifestations of internal carotid aretry (ICA) dissection include amaurosis fugax, cerebral ischemia, oculosympathetic paresis, and various cranial nerve palsies. Isolated hypoglossal nerve palsy is a rare manifestation of ICA dissection. A 55-year-old man developed dysarthria following sudden pain in the left retroauricular area. His tongue was paralysed on the left side. Magnetic resonance image and carotid angiogram showed characteristic features of left ICA dissection, which may be the most plausible cause of hypoglossal nerve palsy in this patient. Expanding hematoma of dissecting aneurysm of ICA seems to have compressed the nutrient artery of the hypoglossal nerve, although the possibility of direct compression of the hypoglossal nerve itself is not completely ruled out.