Oral manifestations and differential diagnosis of isolated hypoglossal nerve palsy: report of two cases

Isolated hypoglossal nerve palsy is rare, but occasionally it appears as the initial or solitary sign of an intracranial or extracranial space-occupying lesion, a head and neck injury, or a vascular abnormality of the internal carotid artery. Therefore it should be considered in differential diagnosis. We report two cases of isolated unilateral hypoglossal nerve palsy. In Case 1 the cause of the palsy appeared to be hypoglossal nerve neurilemmoma within the hypoglossal canal, whereas in Case 2 the cause could not be identified. Neither patient complained of any disability other than slight dysarthria. The tongue deviated toward the healthy side at rest and toward the affected side on protrusion. Hemiatrophy of the tongue with fatty displacement was demonstrated by means of T1-weighted magnetic resonance imaging. Dentists who might at times see patients with isolated hypoglossal nerve palsy should be aware of the significance of its oral manifestation, and they should be able to perform differential diagnosis of patients with the condition who appear for treatment.     

Refusion of anterior cerebral artery after aneurysm clipping--a case report

Herein, we are describing an unusual case suffering from a left anterior cerebral artery aneurysm (A1). Both the anterior cerebral arteries were supplied by the left internal carotid artery as was found in digital substraction angiography (DSA) preoperatively. The postoperative angiograms revealed that left anterior cerebral artery was supplied from the left internal carotid artery and the right anterior cerebral artery by the right internal carotid artery respectively. This finding of cerebral angiograms is interesting and rarely mentioned in the literature. Its hemodynamic change and pathogenesis were unclear and different to that of the coronary circulation, ischemic change of gut and skeletal muscle. The causes may include: 1) vasospasm at the anterior communicating artery after manipulation at surgery; 2) desiccation or shrivelling the adjacent artery by intraoperative electrocoagulation; 3) occlusion the anterior communicating artery by the wing of clip. 4) the deprivation of the blood flow from the left internal carotid artery after totally or partially narrowing left A1 by an aneurysm clip. The redistribution of blood volume in the previously hypoplastic right anterior cerebral artery and decreased caliber of the left anterior cerebral artery (A1) are likely playing a role in this case.     

A case of persistent hypoglossal artery

A personal case of persistent hypoglossal artery is presented and the literature on the subject from 1967 to the present reviewed. The 16 cases collected, following on the 26 already reported in the well-known monograph of T.A. Lie on congenital anomalies of the carotid arteries, complete the statistical picture of this malformation. After discussing the embryonic origin and describing the radiological anatomy of the anomaly, the authors briefly present their case and discuss, in the light of the cases collected, the possible role of persistent hypoglossal artery in the pathogenesis of vascular diseases of the head.     

MR demonstration of a giant cavernous carotid aneurysm with occlusion of the contralateral intracranial carotid artery: an unusual complication of cavernous sinus thrombosis

We present an unusual combination of vascular complications of cavernous sinus thrombosis in a 7-year-old girl. MRI and MR angiography showed occlusion of the intracranial portion of the left internal carotid artery and a contralateral giant cavernous carotid aneurysm. This combination of vascular findings may influence the management in such cases.     

Mydriatic pupil as the presenting sign of common carotid artery dissection

BACKGROUND: Ipsilateral mydriasis is known to accompany signs of cerebral ischemia in unilaterally compromised carotid blood flow. Mydriasis as the presenting sign of common carotid artery (CCA) dissection has not been reported thus far. CASE DESCRIPTION: We report the case of a patient who presented with a mydriatic pupil after intraoperative injury of the ipsilateral CCA. Mydriasis preceded complete third-nerve palsy and symptoms of cerebral ischemia for 12 hours. Cerebral angiography revealed occlusion of the CCA with slow collateral flow to the internal carotid artery and fetal origin of the posterior cerebral artery, suggesting a hemodynamic mechanism causing ischemia of the oculomotor nerve. Signs of cerebral ischemia and third-nerve palsy resolved completely after reconstructive surgery of the occluded vessel. CONCLUSIONS: A mydriatic pupil may be the unusual first sign of compromised carotid blood flow and impending cerebral ischemia.     

Angioplasty of the occluded internal carotid artery

PURPOSE: To review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful. METHODS: We reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed. RESULTS: All four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent. CONCLUSION: In acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.     

Spontaneous dissection of extra-intracranial intern carotid

Dissection of internal carotid artery is an unusual cause of stroke. It generally affects the extracranial portion of the vessel, rarely the intra-cranial portion and exceptionally both sections simultaneously. We present two cases of spontaneous dissection with extra and intra-cranial involvement. Two females, 46 and 36 years old, presented as stroke of the right internal carotid (ICA) associated with headaches and ipsilateral Horner's syndrome. An echo-Doppler was done on the first patient, which turned to be normal, and carotid angiography was done to both patients. The first patient showed a filiform stenosis of the right ICA that ran from the origin to the carotid siphon. The second patient showed a longitudinal stenosis of the right ICA 2 cm from the origin, which ended in an obstruction of the terminal branches. The control angiographs at five and six months respectively, showed partial re-channelling or complete re-channelling. The first case was treated with anti-aggregants and the second with anticoagulants. There were no new episodes in either cases. Dissection of the ICA usually only affects the extracranial portion of the artery, stopping in the petrous portion. We do not know why dissection also affected the intra-cranial section of the artery in these two cases.     

Scapular avulsion fracture of a high school wrestler

A method of management of a dual stenoses affecting the proximal common carotid artery and the internal carotid artery, the tandem lesion, is described in two cases. The combination of a surgical endarterectomy of the internal carotid artery narrowing and percutaneous balloon dilatation of the more proximal common carotid artery narrowing, via the arteriotomy site, with clamping of the internal carotid artery was successfully employed to avoid an extrathoracic bypass procedure.     

Avid uptake of technetium-99m-HMPAO by an intracranial plasmacytoma during carotid balloon test occlusion

A 56-yr-old woman was evaluated for removal of a tumor at the base of the skull. A test to determine the risk of carotid artery sacrifice was performed prior to surgery using carotid balloon occlusion of the left internal carotid artery and 99mTc-HMPAO perfusion scintigraphy during the occlusion. An unusual intense focus of increased uptake was seen at the site of the primary tumor in the left cavernous sinus. The tumor, found to be plasmacytoma at surgery, demonstrated only mild washout from 30 min to 2 hr after administration of 99mTc-HMPAO, with a tumor-to-cerebellum ratio of 1.6 and 1.5, respectively, and a tumor-to-contralateral cranial ratio of 2.5 and 2.4, respectively. Intracranial plasmacytoma shows good response to radiation therapy, and the differentiation of this tumor from other neoplasms is pertinent to the mode of treatment and surgical approach. Technetium-99m-HMPAO SPECT imaging may be a useful tool in distinguishing these tumors from other neoplasms at the base of the skull.     

Noninvasive assessment of collateral blood flow of the cerebral hemisphere by Doppler ultrasound

Directional flow in the frontal artery, a terminal branch of the ophthalmic artery, was assessed nonivasively by Doppler ultrasound druing brief digital compression of the ipsilateral common carotid artery in 62 patients. Directional frontal artery flow during carotid compression was compared with mean distal internal carotid back pressure measured at subsequent carotid endarterectomy. Mean carotid back pressure in 28 patients with normal frontal artery flow direction during carotid compression, 68 +/- 14 millimeters of mercury, was significantly higher than that observed in 24 patients in whom frontal artery flow was completely obliterated and ten in whom frontal artery flow was reversed. Distal internal carotid back pressure exceeded 48 millimeters of mercury in all patients with normal frontal artery flow direction during carotid compression. Conversely, carotid back pressure was below 41 millimeters of mercury in all but one patient in whom frontal artery flow was obliterated or bliterated or reversed during carotid compression. The results of this study indicate that Doppler ultrasound assessment of frontal artery flow direction during simultaneous carotid compression provides a rapid, sale noninvasive estimate of the adequacy of collateral hemispheric circulation.     

Concurrent aneurysm rupture and thrombosis of high grade internal carotid artery stenosis: report of two cases

BACKGROUND: The simultaneous presentation of aneurysmal subarachnoid hemorrhage and thrombosis of a high-grade internal carotid artery stenosis is rare, and their management raises several treatment dilemmas. METHODS: Two such patients with ruptured aneurysms are presented: one with high-grade internal carotid artery stenosis that progressed to occlusion and one with acute internal carotid artery occlusion. RESULTS: Both patients were treated with craniotomy for clipping of the ruptured aneurysm followed by carotid thromboendarterectomy. CONCLUSIONS: We advocate urgent surgical treatment of both lesions, dealing with the most symptomatic lesion first. These two cases demonstrate the importance of reestablishing blood flow in patients with an acutely thrombosed carotid artery.     

Lamotrigine toxicity secondary to sertraline

Branches of the extracranial internal carotid artery are very rare. A case is reported wherein an aberrant artery originated from the bulb of the internal carotid artery (ICA) approximately 2 cm from the bifurcation. The ICA was occluded distal to the branch's origin. Arteriography in this case gave the appearance of a carotid "string sign". Vascular surgeons and radiologists should be aware of this anomaly when interpreting carotid arteriograms.     

Effect of ligation on internal carotid artery blood pressure in horses

The effect of a single ligature on back pressure in the internal carotid artery was studied in nine horses. In six anesthetized horses, one internal carotid artery was catheterized 2 cm from its origin and blood pressure was recorded continuously. Then the artery was ligated, pressure was recorded again, and the horses were euthanatized. In another three anesthetized horses, indwelling catheters were placed in both internal carotid arteries and a loose ligature was placed proximal to one catheter. After horses recovered from anesthesia, the ligature was tied and blood pressure was recorded in both arteries on that day and 3 days later, then these horses were euthanatized. The anatomy of the cerebral arteries was examined in all nine horses. Blood pressure in the internal carotid arteries did not change after ligation. Subjectively, collateral channels considered most likely to maintain blood pressure in the ligated internal carotid artery were the caudal intercarotid artery and the cerebral arterial circle. We concluded that ligation of the internal carotid artery would not prevent severe hemorrhage from the internal carotid artery in horses with guttural pouch mycosis until the ligated artery thrombosed to the level of the lesion.     

Surgical correction of the kinked carotid artery

The hemodynamic significance of the kinked internal carotid artery and cerebrovascular insufficiency are demonstrated. Several procedures have been devised to correct a carotid kink, but these involve resection or excision of the internal, external or common carotid artery. We currently prefer a reimplantation technique whereby preservation of the external carotid is maintained, resection of the internal carotid artery is avoided and, when necessary, endarterectomy may be safely employed.     

Radiation exposure of the population by roentgen diagnosis. II. The collective effective dosage of the population in former East Germany caused by 1987/1988 roentgen diagnosis

OBJECTIVES: To examine the relations between the development of neurologic events and the following variables: degree of stenosis of the contralateral carotid artery, prior neurologic symptoms and stump pressure of the ipsilateral internal carotid artery in patients undergoing carotid endarterectomy under regional anesthesia. PATIENTS AND METHODS: We undertook a prospective study of 92 patients undergoing carotid endarterectomy with a blockade of the superficial and deep cervical plexus. Neurological integrity was assessed and internal carotid artery stump pressure was monitored. Contralateral carotid artery stenosis and neurologic disease present before surgery were studied. RESULTS: Neurologic events developed when the carotid artery was clamped in 9.7% of patients. Mean stump pressure was significantly lower in symptomatic patients (43 +/- 11 mmHg) than in asymptomatic patients (74.6 +/- 24 mmHg) (p < 0.001). Neurologic symptoms developed during clamping of the carotid in 27.2% of the patients with stump pressure less than or equal to 50 mmHg, but in only 4.2% of those with stump pressure surpassing 50 mmHg. Stump pressure was significantly lower in patients with contralateral carotid stenosis. The incidence of neurologic events during clamping was unrelated to contralateral carotid condition, however. Likewise, neurologic symptoms before surgery was also unrelated. In six of the nine patients with neurologic events, internal carotid stump pressure was less than or equal to 50 mmHg, indicating that the sensitivity of this parameter to the development of neurologic events in our series was 66%. CONCLUSIONS: Although internal carotid artery stump pressure identifies a subset of patients likely to have a higher incidence of neurologic events during carotid artery clamping, it can not be considered the only criterion for placement of an intraluminal shunt to prevent such events. The state of the contralateral carotid artery and preexisting neurologic symptoms are not objective screening criteria for identifying patients at high risk of neurologic events during carotid clamping.     

Duplication of the extracranial internal carotid artery

We describe a case of duplication of the left internal carotid artery from a point 1 cm distal to the origin to the proximal petrous segment where the vessel reunites. Duplication and fenestration of the internal carotid artery are discussed. A review of embryologic development is presented. Identification of these entities is important, especially in patients who require surgical intervention involving the internal carotid artery.     

Transient osteoporosis of the hip: a densitometric study

A 62-year-old man was admitted to our hospital with abrupt onset of monoballism in the left arm. Brain MRI showed a hemorrhagic lesion in the right subthalamic nucleus. MRA demonstrated occlusion of the right internal carotid artery occlusion. Cerebral angiogram indicated a leptomeningeal anastomosis to the right middle cerebral artery from the right posterior cerebral artery. SPECT with 99mTc-HMPAO demonstrated the reduction of cerebral blood flow in the right frontotemporal region. Right superficial temporal artery-middle cerebral artery anastomosis was performed 7 months after onset. Monoballism disappeared after surgery and the patient had a good clinical course during the postoperative period. Monoballism associated with internal carotid artery occlusion is rare, and we were able to show the subthalamic nucleus lesion with MRI soon after onset. We considered that the reason for this hemorrhage in the subthalamic nucleus was the hemodynamic stress to the posterior cerebral artery area caused by the ipsilateral occlusion of the internal carotid artery.     

Ischaemic stroke from cerebral embolism in cephalic fibromuscular dysplasia

Fibromuscular dysplasia (FMD) of the internal carotid arteries and its relationship with focal cerebral ischaemia is unproven. This vasculopathy is often detected incidentally during a cerebral angiogram for non-ischaemic cerebral events. FMD affects the proximal one-third of the internal carotid artery in almost all cases and is bilateral in 60% to 85%, with middle-aged women affected in 85% of the cases. Ischaemic stroke has been postulated to result from severe stenosis or thrombotic occlusion at the FMD site. Cerebral embolism from FMD has rarely been reported. We report 3 young patients with acute ischaemic stroke who had FMD on cerebral angiography. They presented with a focal hemispheric stroke where the probable pathophysiology is embolism to the distal internal carotid artery from thrombus formed at the proximal FMD site. The patients were all males, with unilateral proximal internal carotid artery FMD lesions and occlusion of the internal carotid artery distally on the same side. All were extensively investigated and no other causes for stroke were found.     

Low incorporation of soleus tendon: a potential diagnostic pitfall on MR imaging

Head pain is one of the main presenting symptoms of internal carotid artery (ICA) dissection, usually in association with ischemic and/or local signs such as Horner's syndrome, lower cranial nerve palsies, or tinnitus. In rare cases, head pain remains isolated and mimics other conditions. We report a patient who suffered isolated prolonged orbital pain as the only sign of intrapetrous ICA dissection. Early recognition of such unusual facial pain may be crucial in decreasing the risk of secondary cerebral or retinal ischemia.     

Endoluminal repair of internal carotid artery aneurysm: a feasible but hazardous procedure

PURPOSE: The aim of this study was to report the repair of an aneurysm of the internal carotid artery using the endoluminal method. METHODS: A 70-year-old male patient noted a swelling in the right side of his neck 22 years after endarterectomy of the right internal carotid artery. Duplex ultrasound confirmed the clinical diagnosis of aneurysm of the internal carotid artery. Further investigation included contrast-enhanced computed tomographic (CT) scanning and carotid angiography performed via a retrograde femoral approach. The aneurysm contained thrombus and was 3 cm in diameter and in length. It extended superiorly from a point 0.5 cm above the carotid bifurcation to a point estimated to be 2 cm from the base of the skull. Repair of the aneurysm was undertaken using the endoluminal method. A self-expanding endograft 8 mm in diameter and 4 cm in length was introduced through a 12F sheath in the common carotid artery. An on-table completion angiogram of the right-sided extracranial carotid arteries and the intracranial internal carotid artery and branches was obtained. RESULTS: The completion angiogram and postoperative CT scan confirmed exclusion of the aneurysm sac from the circulation. The patient awoke from anesthesia with complete paralysis of the left arm. Recovery of movement commenced 1 hour later. A brain CT scan demonstrated the event to be an embolic stroke. Strength had returned by 7 days. Function of the arm was good 1 month after operation, but coordination for fine movements was lacking. At the 6-month follow-up, good arm function was maintained. A duplex ultrasound scan demonstrated not only continued exclusion of the aneurysm sac but occlusion of the endograft, also. CONCLUSIONS: Endoluminal repair of aneurysms of the internal carotid artery is feasible but carries the risk of major morbidity as a result of peripheral embolization and early occlusion of the endograft.