1/528. 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. ( info) |
| Although the use of carotid artery stents is increasing, the management of recurrent stenosis after their placement is undefined. The authors report on a patient who underwent two left carotid endarterectomies followed by left carotid angioplasty and stent placement for recurrent stenosis. A third symptomatic recurrence was subsequently managed by placement of a saphenous vein interposition graft from the common carotid artery to the distal cervical internal carotid artery. The patient remained without hemispheric or retinal ischemia at his 5-month follow-up visit. Interposition grafting should be considered as a treatment option for carotid restenosis after initial endarterectomy and stent placement. ( info) |
3/528. Recurrent stenosis of common carotid-intracranial internal carotid interposition saphenous vein bypass graft caused by intimal hyperplasia and treated with endovascular stent placement. Case report and review of the literature. Intimal hyperplasia is a well-known cause of delayed stenosis in vein bypass grafts in all types of vascular surgery. Options for treatment of stenosis in peripheral and coronary artery bypass grafts include revision surgery and the application of endovascular techniques such as balloon angioplasty and stent placement. The authors present a case of stenosis caused by intimal hyperplasia in a high-flow common carotid artery-intracranial internal carotid artery (IICA) saphenous vein interposition bypass graft that had been constructed to treat a traumatic pseudoaneurysm of the intracavernous ICA. The stenosis recurred after revision surgery and was successfully treated by endovascular stent placement in the vein graft. The literature on stent placement for vein graft stenoses is reviewed, and the authors add a report of its application to external carotid-internal carotid bypass grafts. Further study is required to define the role of endovascular techniques in the management of stenotic cerebrovascular disease. ( info) |
4/528. Improved imaging of carotid artery bifurcation using helical computed tomographic angiography. Although duplex scan and magnetic resonance angiography (MRA) provide reliable and noninvasive tests for detecting extracranial carotid artery disease, they sometimes fail to differentiate between high-grade stenosis and total carotid occlusion. Helical computed tomographic angiography (CTA) is a safe, noninvasive technique that allows the rapid acquisition of data that can be reconstructed into two- and three-dimensional images. Axial images can be magnified and provide a cross-sectional view of the carotid vessel and the atherosclerotic plaque. Maximal intensity projection technique allows data to be reconstructed into images that closely resemble conventional arteriograms. Helical CTA has previously been shown to have a diagnostic accuracy approaching 90%. We present two case reports demonstrating the utility of helical CTA in carotid artery imaging when duplex scan and MRA results are ambiguous. These cases illustrate improved carotid imaging with helical CTA. Duplex scan results are unreliable in the presence of thick calcified plaques, and severe stenoses can be misread as occlusion by duplex and MRA due to low blood flow. Thus, helical CT angiography should be considered as a confirmatory test, before arteriography, when duplex scan or MRA results are equivocal. ( info) |
5/528. 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. ( info) |
6/528. 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. ( info) |
7/528. Orthostatic hypotension improved after bilateral carotid endarterectomy--case report. A 60-year-old male with recurrent syncopal attacks presented with orthostatic hypotension on the head-up tilt test. Angiography also showed severe stenosis of the bilateral extracranial carotid arteries. He underwent two-staged bilateral carotid endarterectomy. After the operations, the orthostatic hypotension resolved and the syncopal attacks have disappeared completely. Orthostatic hypotension in this patient was due to vasodepressor-type carotid sinus syndrome caused by compression of the carotid baroreceptors by atherosclerotic plaques. ( info) |
8/528. mastication steal: an unusual precipitant of cerebrovascular insufficiency. An 83-year-old man had episodic dizziness, visual disturbance, and facial and extremity weakness associated with eating. Occlusion of the ipsilateral common carotid artery and stenosis or occlusion of the major collateral sources were demonstrated. We believe this anatomic configuration, combined with increases in demand for external carotid artery blood flow necessitated by the act of chewing, resulted in a vascular steal syndrome. An extended carotid endarterectomy was performed, and there were no additional episodes. ( info) |
9/528. Painful oculomotor nerve palsy - A presenting sign of internal carotid artery stenosis. We report a 72-year-old patient presenting acute painful partial left IIIrd nerve palsy with pupillary involvement. Due to the patient's age and mild hyperlipidemia a microangiopathic ischemic origin was assumed after a compressive or inflammatory cause had been excluded by magnetic resonance imaging, blood and cerebrospinal fluid analyses. Carotid ultrasound examination disclosed a high-grade stenosis of the ipsilateral internal carotid artery (ICA). In the absence of diabetes mellitus, other significant vascular risk factors and leukoencephalopathy indicative of advanced arteriosclerotic disease, we suggest a pathogenetic role of the ICA stenosis in ischemic IIIrd nerve palsy. The frequency of a IIIrd nerve palsy as the presenting symptom in patients with ICA stenosis as well as the frequency of an ICA stenosis being the cause in patients with isolated IIIrd nerve palsy is not well documented in the literature. Both seem to be rare but may be underestimated. We advocate cervicocerebral ultrasound examination in patients presenting IIIrd nerve palsy with no obvious or a presumed ischemic cause. ( info) |
10/528. Restenosis following carotid endarterectomy--clinical profiles and pathological findings. Restenosis following carotid endarterectomy is not a rare condition. Among 122 endarterectomies we experienced, five restenoses (4.1%) were encountered and treated by the second surgery. The present report clarifies the clinical profiles and pathological findings of restenosis following carotid endarterectomy. Mean age of restenosis group (59 years old) was not significantly different from the group without restenosis (62 years old). Average duration between the first endarterectomy and the second surgery was 17 months (8-30 months). Initial symptoms were transient ischemic attack in three sides, minor stroke in one side, and asymptomatic in one. Degree of stenosis was tight (> or = 90%) in two and moderate (70-89%) in three. It is interesting to note that no ulcer was noted in the first endarterectomy specimen. At surgery for restenosis, two cases had symptoms and another two cases were asymptomatic, though all had neck bruits. Four of five lesions were treated by short venous graft from common carotid artery to distal internal carotid artery and another lesion was treated by second endarterectomy and Dacron patch graft. pathology was studied in four and all showed myointimal hyperplasia. Three of four restenosis tissues showed mutant form p53 by immunohistochemistry. The present study indicates that restenosis following carotid endarterectomy is not a rare status. Short venous bypass across the stenotic portion is the treatment of choice. Monoclonal growth of smooth muscle with mutant form p53 might be related to the restenosis. ( info) |