Endovascular treatment of internal iliac artery aneurysms

BACKGROUND: Homeless people with mental illness have relatively high rates of human immunodeficiency virus, comorbid antisocial personality disorder, and may be homeless more frequently and for greater lengths of time. All of these factors may increase the risk of tuberculosis. METHODS: Our study was done to ascertain if homeless men with psychotic disorders are at an increased risk for tuberculosis infection. One hundred fifty homeless men were interviewed and given purified protein derivatives (PPDs) at a downtown shelter in New Orleans, Louisiana, during a 3-month period. RESULTS: The findings show a strong relationship between psychotic disorders and positive PPDs, with a relative risk of 4.48. CONCLUSIONS: Homelessness and mental illness present barriers to seeking and completing treatment for medical illnesses such as tuberculosis. Use of services may be low even when available; therefore, homeless men with psychotic disorders may be serving as a reservoir for tuberculosis.     

Surgical treatment of internal carotid and posterior communicating artery aneurysms

Saccular aneurysms of the subarachnoid segment of the internal carotid artery (ICA) are very common. Although some of the aneurysms arising from the subarachnoid ICA have earned the reputation of easy to treat surgically, aneurysms in this region may be complex and quite difficult to repair. Even a simple aneurysm associated with the posterior communicating artery may harbor surprises for the unwary or inexperienced surgeon. This article details the pertinent anatomy of the subarachnoid internal carotid artery and associated saccular aneurysms, provides a guide to their diagnosis and surgical treatment, and briefly reviews some of the published surgical results. Pitfalls and technique tips are highlighted.     

Blood blisterlike aneurysms of the internal carotid artery

1. The effects of ryanodine, procaine, and N-(6-aminohexyl)-5-chloro-1-naphthalenesulfonamide (W-7) on noradrenaline (NA)- and caffeine-induced contractions of human vas deferens were investigated. 2. In the presence of nifedipine (1 microM), NA ( 100 microM) evoked biphasic contractions. Caffeine (20 mM) evoked repeatable tonic contractions. 3. Ryanodine (30 microM) inhibited the initial but not the secondary component of NA contractions. Procaine (1 and 10 mM) inhibited both components. Contractions induced by caffeine were unaffected by ryanodine or procaine. 4. The calmodulin antagonist W-7 (100 microM) reduced, in a reversible manner, both components of NA-induced response. Caffeine-induced contractions were also reduced in most preparations (8 of 11). In all preparations, contractions induced by caffeine were markedly inhibited after the washout of W-7. Higher doses of W-7 (300 microM) induced an increase in basal tension. 5. These results indicate that NA contracts the longitudinal muscle of human vas deferens by a ryanodine-sensitive calcium-induced calcium release (CICR) mechanism and, in addition, a ryanodine-insensitive pathway: both are sensitive to procaine. In contrast, contraction induced by caffeine is mediated by a pathway that is atypically insensitive to either ryanodine or procaine. The sensitivity of NA- and caffeine-induced contraction to W-7 suggests a role for calcium and its interaction with calmodulin in the response to both agents. The paradoxical action of W-7 is discussed.     

Endovascular treatment of acute thrombotic occlusion of the cervical internal carotid artery associated with embolic occlusion of the middle cerebral artery: case report

A 68-year-old man with acute, total thrombotic occlusion of the right cervical internal carotid artery, associated with embolic occlusion of the ipsilateral middle cerebral artery, was treated by the endovascular approach, i.e., intra-arterial fibrinolysis and balloon angioplasty. Endovascular treatment for a totally occluded internal carotid artery is indicated in the very early stage where there is no thrombus or a short thrombus that can be evacuated. Fibrinolysis of the associated embolus in the middle cerebral artery, if any, can be done in the same session, enabling an early restoration of the blood flow.     

Endovascular stent graft repair of aortic aneurysms

Vascular surgeons are increasingly encountering older patients with large aneurysms associated with severe comorbid conditions. This situation can increase operative morbidity and elevate the mortality rate of aortic surgery over 60%. With some frequency many patients will represent a prohibitive risk for conventional graft replacement. The endoluminal treatment of 110 patients has proved to be feasible and may represent an alternative solution. One hundred six of the patients had an abdominal aortic aneurysm and in four patients, the thoracic aorta was involved. All of them underwent endoluminal repair for the aortic pathology using the combination of stents and grafts in aorto-aortic or aorto-iliac position, with straight, tapered, or bifurcated stent-graft devices. The results are as follows: Initial success was 84% in aorto-aortic abdominal devices and 100% in aorto-aortic thoracic devices. In aorto-iliac devices, initial success was 75%. Late success rates were 62% of the initial group and 80% of the initially successful group.     

The microsurgical treatment of large and giant aneurysms of the internal carotid artery located parasphenoidally

Internal carotid aneurysms in the ophthalmic area presents a challenge in cerebrovascular neurosurgery. The study was undertaken to provide evidence for the application of intravascular aspiration during direct surgical interventions and to outline their variants used at the N. N. Burdenko Institute of Neurosurgery. The study included 4 (3 females and 1 male) patients with large and giant internal carotid aneurysms of parasphenoidal site who were treated at the Institute. Clipping of the aneurysmal neck was made by employing intravascular blood aspiration from the aneurysm. The technique proved to be effective in proximal monitoring the carotid artery at surgery. It substantially reduced aneurysmal blood flow and wall tension, thus favouring aneurysmal dissection to make clipping.     

Clinical analysis of internal carotid artery aneurysms with reference to classification and clipping techniques

OBJECTIVE: To determine the differential effects of parental major depression (MDD) on psychopathology of childhood, adolescent, and early-adult onset in offspring. METHOD: One hundred eighty-two offspring from 91 families in which one or more parents or neither parent had MDD were followed for more than 10 years and blindly reassessed by means of a structured diagnostic instrument. RESULTS: Parental MDD is associated with increased risk in offspring of childhood-onset MDD (eightfold), anxiety disorder (threefold), conduct disorder (fivefold), and early-adult-onset MDD (fivefold) but not adolescent-onset MDD, where there is a marked increase in risk, particularly in girls, regardless of parental diagnosis. These findings were not explained by parental comorbidity, but the association with MDD was explained by parental age at onset of MDD--there was a 13-fold increase in childhood-onset MDD and a 7-fold increase in adult-onset MDD in offspring of parents with MDD of early (before age 30 years) onset. CONCLUSION: Childhood- and early-adult-onset MDD may be etiologically homogeneous and familial subtypes. The reason for the high incidence of adolescent-onset MDD, particularly in girls, regardless of parental diagnosis, needs to be determined. The childhood offspring of depressed parents are a potential target for evaluation, especially when the parent had an early-onset depression.     

Dissecting hematoma of the internal carotid artery following chiropractic cervical manipulation

A patient with a dissecting hematoma of the internal carotid artery following chiropractic neck manipulation is described. This injury, apparently previously unreported in the literature, is thought to be caused by trauma to the artery by rotatory movement of the neck and pressure against the artery by the transverse process of C-2.     

Surgical results and the related topographic anatomy in paraclinoid internal carotid artery aneurysms

Paraclinoid internal carotid artery aneurysms arising between the roof of the cavernous sinus and the origin of the posterior communicating artery are of considerable interest with regard to their anatomical variations and technical surgical challenges. Twenty-seven patients with 30 paraclinoid aneurysms were treated surgically through pterional intradural approach. Neck clipping was performed in 22 (73%) of the 30 aneurysms, coating in seven, and trapping in one. The surgical outcome was excellent in 24 patients (24/27, 89%), with two patients showing ipsilateral partial visual field defect (2/27, 7%). There was one death (4%) due to infarction after unintended carotid artery trapping. The characteristic topographic anatomical features which we considered to pose technical difficulties and to be responsible for the complications or failure in neck clipping were aneurysmal dome extending into the anterior clinoid process, atheroma at the neck, multiple paraclinoid aneurysms, ophthalmic artery originating at the neck, and marked supero-medial shift of the C2 segment of the carotid artery. pre-operative depiction of the topographical anatomy around the paraclinoid aneurysm is essential but not always possible on the basis of conventional angiography. Magnetic resonance or three-dimensional computerized tomographic angiography, and their axial source imaging, were useful in delineating the topography with unusual aneurysmal growth, overlap of aneurysm with the parent artery, and uncommon variations of the surrounding structures.     

Interlocking-clipping technique for giant aneurysms of the internal carotid artery: technical case report

OBJECTIVE AND IMPORTANCE: Direct clipping of giant intracranial aneurysms is sometimes difficult. A unique technique using multiple fenestrated clips for closing a giant aneurysm is described. CLINICAL PRESENTATION: A 65-year-old woman presented with a 10-month history of headache and gait disturbance. Cerebral angiography disclosed an unruptured giant aneurysm of the right internal carotid artery. INTERVENTION: Surgical exposure confirmed the presence of a giant aneurysm with the splaying and incorporation of the parent artery and a number of perforating arteries originating from the dome. Four angled and three straight fenestrated clips were applied in tandem to the aneurysm to reconstruct the parent artery and preserve the perforating vessels. Through their blades and heads, the closely arranged clips were successfully interlocked. CONCLUSION: This "interlocking-clipping" technique is a modification of the tandem clipping technique. The aim of this approach is to enhance closing pressure and allow a more stable "seating" of the clips in giant cerebral aneurysms.     

Combined treatment of patients with affected extracranial segment of the internal carotid artery

The results of examination of 84 patients with extracranial a. carotis externa affection were analysed. In 36 patients the combined treatment was conducted, including surgical intervention and postoperative therapy course.     

Results of surgical management of internal carotid artery aneurysm by the cervical approach

From 1981 to 1995 a total of 14 patients with a mean age of 52 years (range: 23-71) underwent surgery for 15 aneurysms of the extracranial internal carotid artery. Fusiform aneurysms of the carotid bifurcation were not included in this study. Aneurysm led to brain ischemia in 10 cases and rupture in one case. In the remaining four cases, aneurysm was asymptomatic including three that were detected following hemispheric stroke related to a contralateral aneurysm. The etiology was spontaneous dissection in four cases, blunt trauma in three cases, fibromuscular disease in five cases, and atheroma in three cases. The upper limit of the aneurysm was located at C1-C2 in six cases, at C1 in three cases, and above C1 (at the base of the skull) in six cases. The cervical approach was used to successfully perform 12 revascularizations and three ligations (including one after extra-intracranial bypass). There were no postoperative deaths. One transient ischemic attack (TIA) occurred after ligation. Peripheral facial paralysis (PFP) occurred in four of the nine cases in which an extended cervical approach was used. No patients were lost to follow-up. Mean duration of follow-up was 4 years (range: 2 months-10 years). Two patients died at 2 and 4 years of causes unrelated to the procedure. All carotid reconstructions are currently patent and no neurologic manifestations have occurred. PFP persisted in one case. The results of this series confirm that surgical therapy of aneurysms of the extracranial internal carotid artery achieves satisfactory short- and medium-term results and that the extended cervical approach allows treatment of lesions near the base of the skull.     

The late results of the surgical treatment of gigantic carotid-ophthalmic aneurysms of the internal carotid artery (2 cases)]

It is described a new born child with many hemangiomas on the liver. It is made a karyogram to exclude. The possibility of chromosome disease. We fixed male karyotype 46 XY--syndrome Morris. We found out that it is a rare combination of testicular feminization with disseminated hemangiomatosis. After the medical treatment with high doses of cortisone the hemangiomas decreased their sizes.     

A posttraumatic visual defect with late exacerbation associated with an aneurysm of the cervical internal carotid artery

A posttraumatic visual deficit which worsened eleven weeks later, with sudden visual loss, is reported. The neuro-ophthalmologic examination was suggestive of central retina artery occlusion. The intra-arterial angiography revealed a traumatic pseudo-aneurysm of the ipsilateral high extracranial portion of the internal carotid artery. Based upon the clinical examination, the hypothesis of embolization has been considered the most probable mechanism, which is a rarely described etiopathogenesis. The clinical, pathogenic and diagnostic aspects of this situation are discussed. Finally, the authors describe the treatment, which consisted of the occlusion of the internal carotid artery with detachable latex balloons.     

Endovascular treatment of carotid artery occlusion in progressive stroke syndromes: technical note

OBJECTIVE AND IMPORTANCE: We describe two patients, with progressing neurological deficits, who showed improvement after revascularization of their carotid arteries using stents. CLINICAL PRESENTATION: One patient presented clinically with the symptoms of a middle cerebral artery territory stroke. Angiography demonstrated total occlusion of the right internal carotid artery (ICA), with evidence of clot from the origin of the ICA to the middle cerebral artery trifurcation. The second patient presented with bilateral ICA occlusions and evidence of a progressing left hemispheric deficit; she was receiving therapeutic levels of heparin at the time of deterioration of her condition. INTERVENTION: Thrombolysis and stenting successfully recanalized the occluded vessels, and the deficits of the first patient were reversed. With the second patient, a dissected carotid loop was encountered. Straightening of the loop with a wire and stenting of the carotid artery using two stents allowed revascularization of the left hemisphere and resolution of most of the deficits of this patient. CONCLUSION: This report demonstrates the technical feasibility of placing stents in high-risk patients with carotid artery occlusions from either dissection or atherosclerosis. Both patients sustained much smaller infarctions than would have been expected if the carotid artery territory had been infarcted. We report on the technical feasibility of reopening acutely closed ICAs by using endovascular methods.     

Endovascular stent graft repair for aneurysms on the descending thoracic aorta

BACKGROUND: The traditional treatment of aneurysms of the descending thoracic aorta includes posterolateral thoracotomy and aortic replacement with a prosthetic graft. In this study, we report our experiences and results in endovascular stent graft placement as an alternative to surgical repair. METHODS: Between January 1989 and July 1997, a total of 68 patients (24 women) underwent replacement of the thoracic aorta. Mean age at operation was 51 years. Fifty-eight patients underwent conventional surgical treatment. All of these patients were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Ten patients (1 chronic dissection, 9 atherosclerotic aneurysm) received in the past 8 months the first commercially manufactured endovascular stent graft. The mean diameter of the aneurysms in this group was 7 cm (range, 6 to 8 cm). Two stent patients were operated on using only spinal cord analgesia. All stent grafts were custom designed for each of the 10 patients. RESULTS: The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Mean length of intervention was 320 minutes in the conventional group versus 150 minutes in the endovascular group. Spinal cord injury occurred in 5 patients (12%) in the surgical group, whereas none of the stented patients developed any neurologic sequelae. Mean intensive care unit stay was 13 days, followed by a mean of 10 days on a ward in the first group compared to 4 days in the intensive care unit and 6 days on the ward in the stent group. One stent was required in 2 patients, two stents were required in 3 patients, and four stents were deployed in 5 patients of our series. Five patients required transposition of the left subclavian artery to achieve a sufficient neck for the proximal placement of the stent. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent graft in 8 patients (80%). Two patients required restenting as a result of leakage (20%). Stent graft placing was performed through the femoral artery in 8 patients, whereas access was only achieved through the abdominal aorta in 2 patients. CONCLUSIONS: These preliminary results demonstrate that endovascular stent graft replacement might be a promising, cheaper, and safe alternative method in selected patients with descending thoracic aneurysms.     

Ophthalmologic manifestations of internal carotid artery dissection

PURPOSE: To report the ophthalmologic symptoms and signs associated with extracranial internal carotid artery dissection. METHODS: One hundred forty-six consecutive patients with extracranial internal carotid artery dissection were evaluted; 29 were studied retrospectively from 1972 to 1984 and 117 prospectively from 1985 to 1997. RESULTS: Sixty-two percent of patients (91/146) with extracranial internal carotid artery dissection had ophthalmologic symptoms or signs that were the presenting symptoms or signs of dissection in 52% (76/146). Forty-four percent (65/146) had painful Horner syndrome, which remained isolated in half the cases (32/65). Twenty-eight percent (41/146) had transient monocular visual loss, which was painful in 31 cases, associated with Horner syndrome in 13 cases, and described as "scintillations" or "flashing lights"-often related to postural changes or exposure to bright lights-suggesting acute choroidal hypoperfusion in 23 cases. Four patients had ischemic optic neuropathy; one had diplopia. Among the 76 patients with ophthalmologic symptoms or signs as the presenting features of carotid dissection, a nonreversible ocular or hemispheric stroke later occurred in 27, within a mean of 6.2 days (range, 1 hour to 31 days). Eighteen patients had a stroke within the first week after the onset of neuro-ophthalmic symptoms and signs, and 24 had a stroke within the first 2 weeks. CONCLUSION: Ophthalmologic symptoms or signs are frequently associated with and are often the presenting features in internal carotid artery dissection. Painful Horner syndrome or transient monocular visual loss should prompt investigations to diagnose carotid artery dissection and begin early treatment to prevent a devastating ocular or hemispheric stroke.     

Endovascular treatment of isolated aneurysms of the hypogastric artery: technical considerations apropos of 2 cases

Isolated aneurysm of the internal iliac artery is uncommon, with an incidence approaching 0.4%; its diagnosis is difficult; its natural course is progressive expansion and rupture. Two cases of hypogastric aneurysms, promptly treated with embolization, are reported. In selected patients the endovascular technique can represent a good alternative to the traditional surgical treatment that is associated with higher complication and mortality rate.