Pediatric Case of Life-Threatening Stroke Caused by Reversible Cerebral Vasoconstriction Syndrome with Spontaneous Cervical Internal Carotid Artery Vasospasm: A Case Report.

Pediatric reversible cerebral vasoconstriction syndrome (RCVS) and spontaneous cervical internal carotid artery (ICA) vasospasm are rare conditions; the former is commonly associated with a favorable prognosis. A healthy 13-year-old girl presented with thunderclap headache, followed by left hemiparesis, during a curling match. Six days after onset, left hemiparesis worsened to hemiplegia. Magnetic resonance imaging showed progressive cerebral infarction caused by severe right middle cerebral artery and cervical ICA stenosis. She became comatose because of impending uncal herniation. Emergent surgical decompression was performed. Then, 59 days after onset, her multiple stenoses improved, which was consistent with RCVS concomitant with spontaneous cervical ICA vasospasm. This is the first case of RCVS that concurrently developed spontaneous cervical ICA vasospasm. The patient developed life-threatening stroke due to the hemodynamic impairment of the affected intracranial and cervical arteries. Spontaneous extracranial supra-aortic artery vasospasm can be a poor prognostic predictor of RCVS.

Identification of the Distal End of Carotid Plaque Using 3-Dimensional Fast Spin Echo T1-Weighted Magnetic Resonance Plaque Imaging.

BACKGROUND: Complete removal of the distal end of the plaque is an important requirement in carotid endarterectomy (CEA) to avoid postoperative complication. Preoperative identification of the distal end of plaque contributes to complete plaque removal. Three-dimensional (3D) magnetic resonance (MR) plaque imaging has been widely used to evaluate carotid plaque characterization. The purpose of the present study was to determine whether preoperative 3D fast spin echo (FSE) T1-weighted MR plaque imaging could identify the distal end of carotid plaque. METHODS: This study was designed as a prospective cohort study. We examined 50 patients with cervical internal carotid artery (ICA) stenosis who underwent CEA. 3D-FSE T1-weighted MR plaque imaging of the affected carotid bifurcation was preoperatively performed using a 1.5-T scanner. Identification of the distal end of plaque (DEMRI) on MR plaque imaging was performed and the distance from the baseline (DistanceMRI) was measured. Intraoperatively, the superimposed distal end of carotid plaque (Esim) was marked on the ICA according to the measurement on MR plaque imaging. The actual distal end of plaque (DECEA) was then identified after arteriotomy and the difference (DifferenceCEA-MRI) between Esim and DECEA was measured. Contrast ratio of carotid plaque and tortuosity of the ICA were calculated using MR plaque imaging. RESULTS: Interobserver agreements in measurement of DistanceMRI were excellent (intraclass correlation coefficient, .955; 95% confidence interval, .922-.974). In 28 patients (56%), Esim was identical to DECEA. Mean DifferenceCEA-MRI was 1.32 ± 1.77 mm. DifferenceCEA-MRI was significantly greater with fibrotic plaque (4.14 ± 1.21 mm) than with lipid-rich or necrotic plaque (.43 ± .87 mm; P < .05) or hemorrhagic plaque (1.27 ± 1.64 mm; P < .05). Mean DifferenceCEA-MRI was significantly greater in the group with tortuosity of the ICA less than 120° (3.86 ± 1.77 mm) than in the group with greater than or equal to 120° but less than or equal to 150° (1.15 ± 1.51 mm; P < .05) or greater than150° (0.50 ± 1.10 mm; P < .05). No patients showed residual stenosis after surgery on postoperative MR angiography. CONCLUSIONS: Using 3D-FSE T1-weighted MR plaque imaging allowed identification of the distal end of carotid plaque and contributed to complete removal of the plaque, although it may be reduced for cases with low-signal-intensity plaque or severe tortuosity of the ICA.

Relationship of stylohyoid chain and cervical internal carotid artery detected by 3D angiography.

OBJECTIVE: The calcification of the stylohyoid chain (SHC), elongated styloid process (SP), larger SP' angle and its shortened distance of cervical internal carotid artery (CICA) are risk factors for bony compression and the stylocarotid syndrome. METHODS: 3D-CTAs of 125 patients were analyzed in terms of the SP length, its angulations, type of the SHC and relationships of its proximity to the CICA. RESULTS: Elongated SP was observed frequently both in females (47%) and males (55%). The mean distance of the CICA to the SP was calculated as 8.2 ± 3.3 mm. This short distance between the CICA and the SP was observed more frequently in males (28.1%) and females (10.7%). The anterior and medial angulations of the SP were calculated as 71.2 ± 4.3°, and 57.3 ± 9.3°, respectively. In the present study, the SHC was determined as normal SP (54.2%), absence of the SP (1%), duplication of the SP (1%), elongated SP (26%), complete ossification of the SHC (1%), segmentation of the SHC (9%), fracture of ossification of the SHC (1.6%) and pseudo articulations of the SHC (5.6%). CONCLUSION: 3D-CTA was the most appropriate radiological investigation analyzing and measuring SHC (elongated, larger angle, shorter distances with CICA) and identifying types (duplicated, segmented, complete and fractured) resulting from pressures on the CICA. Our study also revealed the pressure on the artery not only arose from the tip of the SP but could also result from types stretching over the artery wall. In those specimens, there is a higher probability of formation of the stylocarotid syndrome due to the long-term pressure on the sympathetic chain around the CICA.

Effectiveness of S-Shaping of the Tip of the FUBUKI Guiding Catheter to Match the Shape of the Cervical Internal Carotid Artery in Anterior Circulation Cerebral Aneurysm Embolization.

Objective: During cerebral aneurysm embolization of the anterior circulation, the guiding catheter (GC) should be placed as distally as possible in the cervical internal carotid artery (ICA) to secure the maneuverability of the microcatheter and distal access catheter. However, if the shape of the tip of the GC does not appropriately match the course of the ICA, blood stasis might occur. We investigated whether shaping the tip of the GC into an S-shape would allow more stable catheterization to the distal ICA than the conventional GC with an angled tip. Methods: We included patients with cerebral aneurysms of the anterior circulation who were treated at our institution from April 2019 to April 2021. First, we evaluated the cervical ICA course in these patients through cerebral angiography and classified the courses into type S, type I, and type Z. Then, we focused on the most frequently encountered type-S cervical ICA to investigate the forging effect of the GC tip into an S-shape. We evaluated the lateral view of the carotid angiograms to examine whether the catheter tip reached the foramen magnum (FM) without interrupting ICA blood flow. The effects of age, sex, side, a history of hypertension and smoking, and an S-shape modification of the GC tip on the outcome of GC placement were analyzed. Results: A total of 67 patients were included in this study. The tip of the GC was placed at the FM in 27 cases. Among these factors, only the S-shape modification was significantly associated with whether the GC could be placed at the level of the FM (p <0.0001). Conclusion: By forging the tip of the GC into an S-shape, the GC can be safely advanced to the distal part of the cervical ICA, which may contribute to the improved maneuverability of microcatheters.

Balloon-mounted covered stent as endovascular management of a traumatic cervical internal carotid artery pseudoaneurysm in a 23-year-old: a case report.

Background: Distal cervical internal carotid artery (cICA) pseudoaneurysms are uncommon. They may lead to thromboembolic or hemorrhagic complications, especially in young adults. We report one of the first cases in the literature regarding the management via PK Papyrus (Biotronik, Lake Oswego, Oregon, USA) balloon-mounted covered stent of a 23-year-old male with an enlarging cervical carotid artery pseudoaneurysm and progressive internal carotid artery stenosis. Case Description: We report the management of a 23-year-old male with an enlarging cervical carotid artery pseudoaneurysm and progressive internal carotid artery stenosis. Based on clinical judgment and imaging analysis, the best option to seal the aneurysm was a PK Papyrus 5×26 balloon-mounted covered stent. A follow-up angiogram showed no residual filling of the pseudoaneurysm, but there was some contrast stagnation just proximal to the stent, which is consistent with a residual dissection flap. We then deployed another PK Papyrus 5×26 balloon-mounted covered stent, providing some overlap at the proximal end of the stent. An angiogram following this subsequent deployment demonstrated complete reconstruction of the cICA with no residual evidence of pseudoaneurysm or dissection flap. There were no residual in-stent stenosis or vessel stenosis. The patient was discharged the day after the procedure with no complications. Conclusions: These positive outcomes support the use of a balloon-mounted covered stent as a safe and feasible modality with high technical success for endovascular management of pseudoaneurysm.

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.

Adventitia Layer-Focused Microsurgical Flow Reconstruction for Long-Segment Tubular Stenosis of the Cervical Segment (C1) Internal Carotid Artery: Clinical Valuable Experience in 20 Cases.

To evaluate the efficacy of perivascular sympathectomy in managing adventitia layer-related long-segment tubular stenosis of cervical segment (C1) internal carotid arteries (ICAs) in a cohort where conventional medical and endovascular interventions were not viable options, we retrospectively analyzed 20 patients (8 males, 12 females, aged 41-63 years) who underwent perivascular sympathectomy for long-segment (>5 cm) tubular cervical ICA stenosis (non-atherosclerotic, non-intima related, and nondolichoarteriopathic) between 2017 and 2023. The procedure aimed to alleviate symptoms such as hemiparesis, pulsatile tinnitus, and migraines associated with transient ischemic attacks (TIAs). Preoperative and postoperative symptoms were assessed, and patient follow-up was conducted by MR angiography and perfusion studies. Postoperatively, 10 out of 11 migraine sufferers (90.9%) reported complete cessation of symptoms, while one patient (9.09%) experienced reduction in frequency and intensity. In cases of tinnitus, six out of nine patients (66.6%) reported complete resolution, two (22.2%) had reduced symptoms, and one (11.1%) saw no change. Regarding motor function, all 12 patients (100%) with initial hemiparesis (30-40% loss of motor function) showed complete recovery postoperatively. There was no TIA attack among the patients after the procedure in the mean two-year follow-up. Perivascular sympathectomy has shown promising results in alleviating symptoms and preventing recurrent cerebrovascular events in long-segment tubular stenosis of cervical ICAs.

Hyperacute stenting and angioplasty for acute extracranial non-tandem internal carotid artery strokes within the first 48†h: A 20-year experience and a systematic review and meta-analysis.

BACKGROUND: Acute strokes involving complete, isolated occlusion of the extracranial cervical internal carotid artery (EC-ICA) with no intracranial clot burden account for a minority of stroke cases that are managed variably. Here we present our two-decade experience and a systematic review of endovascular management of acute isolated EC-ICA strokes in the hyperacute phase (<48 h) and attempt to evaluate clinical effectiveness and safety. METHODS: Our prospectively maintained database was retrospectively searched for patients who presented between January 1, 2003 and December 31, 2022 with acute cervical ICA stroke confirmed on angiography. Only patients who had an isolated 100% occlusion of the cervical ICA segment and attempted acute stenting with/without angioplasty within the first 48 h of time since last known well were included. Demographics, procedural details, and outcomes were recorded. For the systematic review, a search of PubMed and Embase databases was conducted. RESULTS: Forty-six patients with acute, isolated EC-ICA occlusive stroke were included. Median presenting National Institutes of Health Stroke Scale (NIHSS) score was 8 (interquartile range 3-10) with a perfusion deficit in 78.3% of the 40 cases assessed with computed tomography perfusion imaging. Median time from symptom onset to intra-arterial puncture was 14.4 h. Immediate recanalization was achieved in 82.6% cases. Two cases (4.3%) of symptomatic intracranial hemorrhage (sICH) occurred postprocedure. Outcome measures were stable or improved discharge NIHSS score in 86.9% of cases, functional independence at 90 days (modified Rankin scale score ≤2) in 78.3%, and mortality in 6.5%. The systematic review included 167 patients from four articles. The estimated rate of immediate recanalization was 92.7% (95% confidence interval (CI), 88.77-96.77%), favorable outcome was 62.01% (95% CI, 55.04-69.87%), and sICH was 6.2% (95% CI, 3.41-11.32%). CONCLUSION: Stenting and angioplasty for acute cervical ICA occlusive strokes during the hyperacute phase can be performed successfully with favorable clinical outcomes and an acceptable recanalization rate.

Vessel wall imaging and carotid artery stenting for recurrent cervical internal carotid artery vasospasm syndrome: illustrative case.

BACKGROUND: Recurrent cervical internal carotid artery vasospasm syndrome (RCICVS) causes cerebral infarction, ocular symptoms, and occasionally chest pain accompanied by coronary artery vasospasm. The etiology and optimal treatment remain unclear. OBSERVATIONS: The authors report a patient with drug-resistant RCICVS who underwent carotid artery stenting (CAS). Magnetic resonance angiography revealed recurrent vasospasm in the cervical segment of the internal carotid artery (ICA). Vessel wall imaging during an ischemic attack revealed vascular wall thickening of the ICA, similar to that in reversible cerebral vasoconstriction syndrome. The superior cervical ganglion was identified at the anteromedial side of the stenosis site. Coronary artery stenosis was also detected. After CAS, the symptoms of cerebral ischemia were prevented for 2 years, but bilateral ocular and chest symptoms did occur. LESSONS: Vessel wall imaging findings suggest that RCICVS is a sympathetic nervous system-related disease. CAS could be an effective treatment for drug-resistant RCICVS to prevent cerebral ischemic events.

[Evaluation of cerebral hemodynamics using arterial spin labeling perfusion MR imaging in a patient with cervical internal carotid artery vasospasm].

57-year-old woman with sequelae of cerebral infarction was admitted to our hospital because her left-sided hemiparesis was worsened. The right internal carotid artery (ICA) was not visualized by carotid duplex sonography and brain MRA. Arterial spin labeling (ASL) perfusion MR images showed reduced signals in the bilateral ICA territories at post labeling delay 1,525 ms. Her neurological symptoms improved on the day after hospitalization. On day 3, the bilateral ICAs were well visualized on MRA, while cerebral perfusion in the ICA territories appeared to be normalized on ASL. We diagnosed cervical ICA vasospasm, based on the findings of cervical MRA and cerebral angiography. Three months later, the recurrence of ICA vasospasm occurred. ASL was useful for the serial non-invasive evaluation of cerebral hemodynamics from the onset to improvement in a patient with ICA vasospasm.

Treatment Strategy for Progressive Cervical Internal Carotid Artery Stenosis Under Restriction of the Use of Antiplatelet Drugs.

BACKGROUND: Acute ischemic stroke caused by cervical internal carotid artery stenosis (ICS) with altered consciousness and progressive paralysis leads to a poor neurologic prognosis. When such a patient is brought to the hospital in the hyperacute phase, intravenous tissue plasminogen activator is first administered. However, when an indwelling carotid artery stent is required after administration, physicians often hesitate to use antithrombotic drugs. In this report, we propose performing staged angioplasty (SAP) for such cases. METHODS: Four patients were retrospectively investigated. In all 4 patients, we immediately performed only percutaneous transluminal angioplasty (PTA) without antiplatelet drugs. If both cerebral perfusion on angiography and neurologic findings improved, no additional treatment was provided; otherwise, emergency carotid artery stenting (eCAS) was performed. In PTA-successful cases, eCAS or carotid endarterectomy (CEA) was performed with single or dual antiplatelet drugs at a later date. RESULTS: The success rate of PTA was 50% (2 of 4), and the overall treatment success rate was 100% (4 of 4). Three patients had favorable outcomes (modified Rankin Scale [mRS] score 0-2), but unfortunately, 1 patient had severe disability (mRS score >3) on discharge. The PTA-successful patients had no perioperative complications. On the other hand, 1 of the 2 patients who underwent eCAS experienced embolic complications, including distal embolization. CONCLUSIONS: In this investigation, both eCAS and SAP could be performed safety. However, performing SAP first without antiplatelet drugs to avoid hemorrhagic complications and cerebral hyperperfusion syndrome appears to have considerable validity.

An internal carotid artery pseudoaneurysm with neck hematoma: A rare cause of a life-threatening neck mass mimicking an abscess.

A neck mass has a broad and complex differential diagnosis, generally divided into neoplastic, congenital and inflammatory categories. An internal carotid artery hemorrhage with pseudoaneurysm formation is a very rare entity that may resemble other common conditions in the differential diagnosis. Large, expanding or symptomatic pseudoaneurysm is critical to efficiently diagnose and manage, due to risk of life-threatening hemorrhage. We present a case of an adult male patient with clinical and laboratory signs of severe neck cellulitis and a large gradually increasing neck mass, primarily suggestive of an abscess. Neck CT and MRI imaging revealed the presence of a disruption of the internal carotid artery resulting in a large hematoma and formation of pseudoaneurysm. A multidisciplinary team of interventional radiologists and ENT surgeons successfully treated the patient by endovascular placement of stents and subsequent surgical drainage. Awareness of such a rare, life-threatening condition and efficient multidisciplinary teamwork are essential for patient management.

Angiography of Cervical Carotid Plaque Rupture Due to Percutaneus Transluminal Balloon Arterioplasty.

We describe the rare imaging of a plaque rupture at cervical internal carotid artery stenosis after balloon arterioplasty. The patient was an 82-year-old male who complained of left hemiparesis. Diffusion-weighted magnetic resonance imaging revealed multiple high-signal intensity in the right cerebral hemisphere. Magnetic resonance angiography showed severe stenosis at the cervical internal carotid artery. We considered the high risk of hyperperfusion syndrome after revascularization. We planned staged angioplasty. Angiography after arterioplasty revealed a meshlike appearance, like a net, in the arterial wall, which indicated the critical sign of ischemic complications.

Use of Simple Neck Extension to Improve Guiding Catheter Accessibility in Tortuous Cervical Internal Carotid Artery for Endovascular Embolization of Intracranial Aneurysm: A Technical Note.

BACKGROUND: In endovascular embolization of intracranial aneurysms, a tortuous cervical internal carotid artery can limit guiding catheter access to a sufficiently high position. Although intermediate distal access catheters can go beyond the tortuous segment of internal carotid arteries, they may increase the risk of procedure-related complications, require significantly complex technical procedures, and limit the use of adjunctive techniques. Using simple neck extension alone, we successfully improved guiding catheter access in 2 patients. METHODS: Through a provocative test, we confirmed suitability of manual neck extension in 2 patients with severe posterior curvature of a tortuous internal carotid artery. Intraoperatively, we manually extended the neck and stretched the curvatures. We guided a 6F guiding catheter superiorly and performed coil embolization with an occlusion balloon catheter in 1 case and with the balloon-assisted neck remodeling technique in 1 case. RESULTS: Coil embolization was completed without any adverse events in both cases. CONCLUSIONS: The simple neck extension technique successfully improved accessibility of the guiding catheter. As the need for safe and highly skilled intervention increases, our technique may be useful because it can reduce procedure-related complications and allow balloon-assisted techniques.

Effect of carotid artery aberrancy on the distance between the vessel and nasopharyngeal subsites.

BACKGROUND: Life-threatening hemorrhaging due to nasopharyngeal internal carotid artery (ICA) aberrancy may occur during routine nasopharyngeal surgery. To understand better the potential adverse effect of nasopharyngeal ICA aberrancy on routine nasopharyngeal surgery, we classified aberrant nasopharyngeal ICAs and analyzed the differences in mean distances from the ICA to nasopharyngeal subsites between aberrant and nonaberrant vessels. METHODS: The courses of nasopharyngeal ICAs were examined and classified for an aberrant pathway. Various distances were measured on magnetic resonance brain scans. The mean values of the measured variables were compared using an unpaired two-sample t test. RESULTS: The mean distances to the torus tubarius, the opening of Rosenmuller's fossa, and the posterior nasopharyngeal wall were 19.6 mm, 15.8 mm, and 16.7 mm, respectively, in the aberrant case group, and 23.1 mm (p < 0.001), 19.8 mm (p < 0.001), and 20.7 mm (p < 0.001) in the nonaberrant control group. CONCLUSION: The mean distances between the ICA and nasopharyngeal subsites were significantly shortened (by 15-21%) in the presence of aberrant nasopharyngeal segments, which may increase the risk of severe complications in common and uncomplicated nasopharyngeal surgery, such as adenoidectomy, eustachian tuboplasty, and nasopharyngeal biopsies. However, the mean distances were not shortened by the severity (kinking and coiling) of the aberrant nasopharyngeal carotid arteries.