1/59. Diagnostic and therapeutic management of bilateral carotid artery occlusion caused by near-suicidal hanging.In cases of attempted suicide by hanging, a combination of mechanisms causing local destruction of the pharynx, larynx, vessels, and spine, as well as neurologic complications, has to be considered. We present a case of hanging in which a deeply unconscious patient without any palpaple pulsation of the carotid arteries was referred to our otolaryngology department. Computed tomography and angiography showed parapharyngeal air, complete obstruction of both common carotid arteries, and a compensatory circulation through the vertebral arteries. Three hours after the trauma, surgical exploration with resection of the enrolled intima of both carotid arteries and repair of the pharynx was performed. The patient awoke with an infarct of the right hemisphere with incomplete left hemiparesis the next day, but symptoms slowly declined during the following months, and the patient learned swallowing again perfectly. We conclude from our experience that in near-hanged patients a prompt onset of adequate diagnostic and therapeutic measures is mandatory, as good neurologic and functional results may occur even in cases with coma and severe destruction of the carotid arteries and pharyngeal and laryngeal structures. Surgical repair of blunt carotid lesions is recommended and may be crucial for a good outcome.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
2/59. Severe stenosis of the internal carotid artery presenting as loss of consciousness due to the presence of a primitive hypoglossal artery: a case report.BACKGROUND: Symptoms of ischemic attacks in the internal carotid system usually involve focal cerebral dysfunction, i.e., hemiparesis or aphasia. However, an ischemic attack in the vertebrobasilar artery system usually presents with combined symptoms. The variety of manifestations included in the vertebrobasilar profile makes the potential pattern of symptoms considerably more variable and complex than that in the carotid system. Manifestations can include syncope and also vertigo. METHOD AND RESULTS: A 42-year-old woman experienced frequent attacks of faintness with vertigo. angiography demonstrated severe stenosis of the left internal carotid artery with a persistent primitive hypoglossal artery just distal to the stenosis. The right internal carotid artery was normal and cross circulation through the anterior communicating artery was not well developed. Both vertebral arteries were hypoplastic. The patient underwent carotid endarterectomy and, thereafter the episodes of syncope completely disappeared. CONCLUSION: It was supposed that global ischemia including the brain stem occurred because of stenosis of the left internal carotid artery attributable to the presence of a primitive hypoglossal artery.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
3/59. Thyrocervical to vertebral artery transposition and ipsilateral carotid endarterectomy.BACKGROUND: We report a new method for treating patients with symptomatic high-grade stenosis of the proximal vertebral artery associated with high-grade stenosis of the ipsilateral carotid artery. methods: Our patient had high-grade stenosis of the proximal right vertebral artery as well as high-grade stenosis of the ipsilateral carotid artery and suffered continued posterior circulation ischemic neurological deficits despite anticoagulation. RESULTS: The patient was successfully treated with a carotid endarterectomy and thyrocervical-to-vertebral artery transposition in a single operation. CONCLUSION: This procedure has the advantage in this setting of avoiding additional cross clamping on the diseased carotid artery that would normally be required for the vertebral-to-carotid artery transposition with carotid endarterectomy. Also, thrombosis at one anastamosis site would not endanger the other site as well.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
4/59. Treatment of carotid tandem stenosis by combined carotid endarterectomy and balloon angioplasty: technical case report.OBJECTIVE AND IMPORTANCE: Cervical internal carotid artery disease associated with high-grade carotid siphon stenosis poses a therapeutic challenge. This report describes the combination therapy of carotid end-arterectomy and intraoperative transluminal balloon angioplasty of the carotid siphon. CLINICAL PRESENTATION: A 67-year-old man sustained repeated left hemispheric and retinal transient ischemic attacks. Results of a diagnostic examination, including angiography, disclosed a 70% ulcerative stenosis of the left extracranial internal carotid artery as well as a 90% stenosis of the left intracavernous carotid artery. The decision was made for combined open and endovascular therapy. INTERVENTION: After standard endarterectomy, an introducer for the dilation catheter was placed into the common carotid artery before final closure of the arteriotomy and recirculation. Under intraoperative fluoroscopy, a 3-mm dilation balloon was navigated into the carotid siphon stenosis and inflated several times. A 30% residual stenosis in the carotid siphon was obtained as a final result. The intervention was completed without complications. No further neurological symptoms were observed during the follow-up period of 30 months. CONCLUSION: Carotid endarterectomy, combined with intraoperative transluminal angioplasty of carotid siphon stenosis, is a feasible procedure for selected patients with carotid tandem stenosis.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
5/59. Practice variability in management of transient ischemic attacks.To define practice patterns in the management of transient ischemic attacks (TIAs), we surveyed practicing neurologists attending an educational conference in san francisco, evaluating management decisions in 2 TIA case vignettes. In a vignette describing a hemispheric TIA 1 day prior with ipsilateral bruit, 53% chose admission, 47% elected an outpatient work-up, 28% treated with intravenous heparin and 70% chose aspirin, reflecting the disagreement about medical management of carotid stenosis in the literature. There was more agreement in the second case, a posterior circulation TIA 1 day prior with atrial fibrillation, in which 84% chose hospital admission, 74% chose intravenous heparin and 90% treated with some form of anticoagulation. There are areas of important practice variability in the management of TIAs. Further research is justified to guide patient care decisions in TIA patients.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
6/59. Persistent primitive hypoglossal artery associated with cerebral aneurysm and cervical internal carotid artery stenosis--case report.A 71-year-old female had vertigo attacks once or twice a day secondary to vertebrobasilar insufficiency. Left carotid angiography revealed persistent primitive hypoglossal artery (PPHA) associated with a large internal carotid artery (ICA) aneurysm and severe stenosis of the ICA. The bilateral vertebral arteries were hypoplastic. The basilar artery was opacified via the PPHA but not via vertebral arteries. Clipping of the aneurysm was performed first because the risk of rupture of the aneurysm was not negligible. One month after clipping, carotid endarterectomy using a T-shaped shunt system was successfully performed. The postoperative course was uneventful and the vertebrobasilar ischemic attacks did not recur. Left carotid angiography demonstrated complete obliteration of the aneurysm and disappearance of the carotid artery stenosis. Low ICA flow (70 ml/min) and low stump pressure of the PPHA (25 mmHg) strongly suggested low perfusion of the posterior circulation. Carotid endarterectomy may be essential for augmentation of the posterior circulation in patients with PPHA associated with ICA stenosis.- - - - - - - - - - ranking = 2keywords = circulation (Clic here for more details about this article) |
7/59. Intracranial deployment of coronary stents for symptomatic atherosclerotic disease.Intracranial percutaneous transluminal balloon angioplasty (PTA) has been used as a technique of last resort in the treatment of intracranial atherosclerotic disease when medical and surgical alternatives have failed or cannot be applied. The major risks associated with PTA include intracranial vessel rupture and abrupt vessel dissection causing occlusion. angioplasty techniques in the extracranial circulation have been improved by the development of safe stent technology in combination with potent antiplatelet agents. We report three successful cases of symptomatic intracranial atherosclerotic disease in middle-aged adults treated by endovascular PTA followed by deployment of coronary stents.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
8/59. Vertebral and carotid artery dissection following chiropractic cervical manipulation.A 50-year-old woman presented a sudden left occipital headache and a posterior circulation stroke after cervical manipulation for neck pain. Magnetic resonance imaging documented a left intracranial vertebral artery occlusive dissection associated with an ipsilateral internal carotid artery dissection with vessel stenosis in its prepetrous tract. This is the first reported case showing an associate vertebral and carotid artery dissection following cervical manipulation. Carotid dissection was asymptomatic and, therefore, its incidence may be underestimated. We emphasize that cervical manipulation should be performed only in patients without predisposing factors for artery dissection and after an appropriate diagnosis of neck pain.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
9/59. A case of posterior cerebral artery aneurysm associated with idiopathic bilateral internal carotid artery occlusion: case report.BACKGROUND: Aneurysms of the posterior circulation are challenging lesions to neurosurgeons, despite improvements in microsurgical techniques and advances in skull base approaches. We present a rare case of a posterior cerebral artery (PCA)-posterior communicating artery (PcomA) junction aneurysm associated with bilateral internal carotid artery (ICA) occlusion successfully treated with an endovascular procedure. CASE DESCRIPTION: A 57-year-old female presented with sudden onset of severe headache and loss of consciousness. CT scan showed diffuse subarachnoid hemorrhage and acute hydrocephalus. The patient developed severe neurogenic pulmonary edema and shock. Although her neurogenic pulmonary edema did not resolve, she recovered from shock. However, her general condition was so critical and her vital signs so unstable, that direct surgery under general anesthesia was considered too risky. A cerebral angiogram showed complete occlusion of both internal carotid arteries without any Moyamoya vessels. A saccular aneurysm located at the right PCA-PcomA junction was seen. To obliterate the aneurysm and prevent rerupture, the patient underwent coil embolization via an endovascular approach under sedation with local anesthesia. The balloon remodeling technique was useful to prevent occlusion of parent arteries. Finally, four interlocking detachable coils (IDC) with a total length of 44 cm were used to completely obliterate the aneurysm using the balloon remodeling technique. The patient made a full recovery after treatment and the aneurysm remained obliterated 2 years after coil embolization. CONCLUSIONS: We emphasize the advantages of the endovascular approach for the patient in critical condition. We believe that this is the first report of a PCA-Pcom junction aneurysm associated with bilateral ICA occlusion without moyamoya disease.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
10/59. Continued lodging of retinal emboli in a patient with internal carotid artery and ophthalmic artery occlusions.Internal carotid artery or ophthalmic artery occlusions are devastating ophthalmological events which lead to severe impairment of vision. A case of multiple branch retinal artery occlusions in a 63-year-old male with internal carotid artery and ophthalmic artery occlusions on brain angiography is presented. Emboli lodging in branches of the retinal arteries were bright, glistening, yellow or orange in appearance. Such a distinctive ophthalmoscopic appearance led to the diagnosis of cholesterol emboli. fluorescein and indocyanine green angiography disclosed delayed filling of the retinal vessels and choroid, and showed multiple hypofluorescence distal to the vessels in which the emboli were lodged. At the time of initial examination, the number of emboli lodged in retinal arteries was estimated at more than 20. As time passed, a few of the previous emboli disappeared and new emboli appeared in other sites on fundus examination. We think that the lodging of new emboli in other sites is due to the continued break-up of atheromatous tissue through the collateral circulation associated with the occlusion of the internal carotid and ophthalmic arteries.- - - - - - - - - - ranking = 1keywords = circulation (Clic here for more details about this article) |
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