Dissecting aneurysm of the extracranial vertebral artery causing TIA: a case report

Spontaneous dissecting aneurysm of the extracranial vertebral artery is not frequent. We report a case of dissecting aneurysm of the left extracranial vertebral artery causing TIA. A 44-year-old man was admitted to our hospital with severe occipitalgia of sudden onset on Dec. 21, 1995. On admission, he presented with left hemiparesis and left hemidysesthesia. CT scan and SPECT showed no abnormal findings. His neurological deficits completely improved on the following day. Initial cerebral angiography performed on Dec. 27, 1995 showed pearl and string sign at V3 segment and irregular stenosis at V2 segment suggesting a dissecting aneurysm. We treated conservatively. Repeated angiography performed four weeks after the onset showed resolution of the stenosic lesion and disappearance of the aneurysm. We discussed diagnosis and etiology and treatment of dissecting aneurysm of the extracranial vertebral artery.     

Extracranial carotid aneurysms

Extracranial carotid artery aneurysms occur very seldom. Here will be reported on 15 aneurysms (11 arteriosclerotic, 3 false and 1 dissecting aneurysm). Therapy of choice during the second half of this period was aneurysm exstirpation and PTFE interposition, twice with reinsertion of the external carotid artery. No patient died perioperatively, one permanent and one transient ischemic neurologic deficit occurred. Three lesions of the cranial nerves recovered completely. As to avoid cerebral embolisation each extracranial carotid artery aneurysm should be operated on if possible. This can be managed with tolerable risk and represents an effective embolic prophylaxis.     

Spontaneous occlusion of supraclinoid aneurysms after the creation of extra-intracranial bypasses using long grafts: report of two cases

OBJECTIVE: We describe two cases of giant supraclinoid aneurysms, treated by means of saphenous vein grafting between the external carotid artery and the middle cerebral artery, which unexpectedly spontaneously occluded. CLINICAL PRESENTATION: Two patients presented with subarachnoid hemorrhage and headache, respectively. In the first case, angiography showed an aneurysm of the right internal carotid artery (ICA), which had been treated by clipping. Repeat angiography showed a giant aneurysm of the right ICA, the formation of which was probably caused by sliding of the clip that had been applied during the previous operation. The patient was operated on again, but it was impossible to exclude the aneurysm because no clear neck could be identified. In the second case, magnetic resonance imaging and cerebral angiography showed a large, partially thrombosed aneurysm of the supraclinoid segment of the left ICA. TECHNIQUE: In view of the patients' ages and the statuses of compensatory circulation, each patient underwent cerebral revascularization with a long saphenous vein graft placed between one branch of the middle cerebral artery and the external carotid artery, in anticipation of subsequent endovascular treatment of the aneurysm and/or closure of the ICA in the neck. Postoperative angiography demonstrated spontaneous occlusion of the aneurysms. CONCLUSION: Thrombosis of an aneurysm may occur spontaneously or after explorative surgery. However, it should be remembered that spontaneous occlusion of an aneurysm may be induced or favored by hemodynamic vascular alterations that take place inside the aneurysm after a high-flow extra-intracranial bypass has been created.     

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.     

Surgical repair of a dissecting aortic aneurysm with entry at proximal descending aorta through left thoracotomy--a case report

A 45-year-old man underwent a distal arch and descending aortic replacement through a left thoracotomy. His chronic type A dissecting aortic aneurysm had the entry at the proximal descending aorta. After 9 years of his first dissection, he suffered from a second dissection. In computerized tomogram (CT), the ascending and descending aorta enlarged to 6.0 cm and 7.0 cm in diameter, respectively and descending aorta showed a three channeled dissection. The open proximal anastomosis technique was used under the deep hypothermic circulatory arrest (HCA) followed by selective cerebral perfusion (SCP). Surgical repair included the obliteration of the proximal false lumen at the level between the left carotid and subclavian artery. A thrombosed retrograde dissection in the ascending aorta was revealed in postoperative evaluation, and decreased in size at follow up CT.     

Olfactory epithelium of the rat. Lectin-mediated histochemical studies

BACKGROUND: Twenty-nine patients with large bulbous and giant aneurysms of the paraclinoid segment of the internal carotid artery (ICA) were operated on, using Dolenc's combined epi- and subdural approach, between 1985 and 1994. Ages ranged from 25 to 79 (83% female; 17% male). METHODS: Proximal control was established in all patients through either an extracranial or petrous carotid exposure. The aneurysm was approached through a wide exposure by removing the anterior clinoid extradural. All but one aneurysm was clipped directly. A saphenous vein graft from the petrous-to-supraclinoid bypass was performed in this remaining case. RESULTS: Surgical morbidity was assessed at 20%. One patient developed a postoperative subdural hematoma and remained severely disabled. Two patients developed permanent third nerve palsy. One patient experienced severe disabling cognitive deficit. One patient died from complications related to a stroke. One patient developed transient diabetes insipidus. Visual outcome, which was assessed separately, was unimproved in 50% of the cases during a follow-up period that averaged 7 years. CONCLUSIONS: With the development of cranial base procedures such as Dolenc's combined epi- and subdural approach, large and giant aneurysms of the paraclinoid segment can be directly clipped with acceptable morbidity, allowing the ICA to remain patent.     

Primary stenting of the extracranial internal carotid artery in a patient with multiple cervical dissections: technical case report

OBJECTIVE AND IMPORTANCE: Spontaneous dissection of the extracranial internal carotid artery (ICA) and vertebral artery (VA) is a well-documented cause of stroke in young, previously healthy patients. The majority of patients with spontaneous dissection are successfully treated with antiplatelet or anticoagulation therapy, but a significant proportion of patients progress to suffer devastating morbidity and mortality. Surgical intervention has primarily consisted of proximal ligation, extracranial-intracranial bypass, or endarterectomy. Generally, these procedures are technically demanding and yield disappointing clinical results. CLINICAL PRESENTATION/INTERVENTION: A 36-year-old man without a significant medical history initially presented with a several-day history of episodic right upper extremity weakness and numbness and visual obscurations. Cerebral angiography revealed bilateral ICA long segment narrowing (95%), distal left VA high-grade (95%) stenosis compatible with dissections, and right VA proximal occlusion. While therapeutically anticoagulated on heparin, the patient continued to experience crescendo episodes of right upper extremity paresis and paresthesias as well as aphasia. The patient underwent primary stenting of the left ICA, using a series of six overlapping stents (three Gianturco-Roubin coronary stents and three Palmaz-Schatz coronary stents). The patient remained symptom-free without neurological complications, and subsequent angiography performed at the 9-month follow-up examination confirmed continued patency of the stented left ICA as well as recanalization of the right ICA and VA. CONCLUSION: Neurovascular stents offer a minimally invasive and potentially efficacious treatment for the prevention of cerebral ischemia in patients with spontaneous extracranial dissection who remain symptomatic despite therapeutic anticoagulation.     

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.     

Agenesis of internal carotid artery associated with aneurysm of anterior communicating artery (author's transl)

A case of agenesis of the left internal carotid artery with an aneurysm of the anterior communicating artery was reported in detail. The patient was a 48-year-old man who had an episode of subarachnoid hemorrhage about 10 years ago. This time left heminumbness and motor weakness of the left lower extremity occured and he was brought our hospital. Right common carotid angiography, left retrograde brachial serial angiography and aortography demonstrated an agenesis of the left internal carotid artery, an aneurysm of the anterior communicating artery, tortuous megadolic hobasilar artery and anomalies on the circle of Willis such as absence of supra optic portion of the right anterior cerebral artery, and large left posterior communicating artery. We confirmed latter findings by operation. After successful neck clipping of the aneurysm, his clinical findings were remarkably improved.     

Circulatory arrest with profound hypothermia during the surgical treatment of large internal carotid artery aneurysm--case report

A 43-year-old male presented with a cerebral aneurysm manifesting as right facial paresthesia, without neurological deficit. Angiography revealed a large aneurysm (22 mm) of the left internal carotid artery. Intravascular treatment using placement of a detachable coil was attempted, but the coil did not stay in the aneurysmal cavity and the procedure was abandoned. The patient did not tolerate the transient balloon occlusion test of the left internal carotid artery. Therefore, the aneurysm was clipped through an open craniotomy with profound hypothermia (20 degrees C) with cardiac arrest (24 minutes). The aneurysmal dome was collapsed, allowing easy dissection of the posterior communicating artery. The closed chest method was used during the extracorporeal cardiopulmonary bypass. Postoperative angiography revealed complete neck clipping with preservation of carotid blood flow. The patient recovered well and resumed his employment. Circulatory arrest with hypothermia provides several benefits for the surgical treatment of large and giant aneurysms.     

Combined intraoperative retrograde stent implantation and thrombendarterectomy of the carotid artery

HISTORY AND CLINICAL FINDINGS: A 63-year-old man developed recurrent transitory ischaemic episodes of vertigo and weakness in the legs 6 weeks before admission. 3 weeks later he had a left amaurosis fugax. A stenotic murmur was heard over the left carotid artery. INVESTIGATION: Intraarterial digital subtraction angiography of the arteries to the head revealed occlusion of the right internal carotid artery (RICA) and marked narrowing at the origin of the left common carotid artery (LCCA), which could not be passed by catheter. TREATMENT AND COURSE: As a catheter could not be passed into the LCCA, a stent was at operation placed retrogradely into it. Intraoperative angiography showed subtotal stenosis of the left ICA, which was treated by thrombendarterectomy and dacron patch-plasty. The postoperative course was without complication and the patient was free of symptoms. Follow-up angiography was unremarkable. CONCLUSION: If a stenosis of the carotid artery cannot be passed by catheter, intraoperative retrograde placement of a stent is an alternative to percutaneous antegrade transluminal angioplasty or surgical bypass.     

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.     

Collateralization of an occluded internal carotid artery via a vas vasorum

BACKGROUND: Reopening of an occluded internal carotid artery (ICA) is often seen in dissections but only rarely occurs in atherothrombotic occlusion of the internal carotid artery. CASE DESCRIPTION: A 60-year-old man suffered a minor stroke with dysphasia in March 1995. Color-coded duplex ultrasonography of his neck arteries revealed a left ICA occlusion. He was placed on a regimen of aspirin and followed up clinically and with ultrasonography. At follow-up 18 months later, the patient was asymptomatic. On duplex ultrasonography his left occluded ICA was found to be reopened, with a residual, proximal, high-grade stenosis. However, intra-arterial digital subtraction angiography demonstrated a persistent ICA occlusion and a vas vasorum originating from the carotid bulb and draining into the ICA distal to the occlusion. CONCLUSIONS: The rare collateralization of an occluded ICA by vasa vasorum seems to take several months. It can be a pitfall in the ultrasound diagnosis of carotid artery occlusive disease.     

Progressive intracranial aneurysmal disease in a child with progressive hemifacial atrophy (Parry-Romberg disease): case report

Intracranial aneurysms are uncommon in children, and their presence often leads to suspicion of a systemic connective tissue disorder. We describe the case of a young male patient with progressive hemifacial atrophy (Parry-Romberg disease) and multiple intracranial aneurysms, a previously undescribed association, and propose that a neural crest defect may be the underlying abnormality in this patient. At age 5 years, the patient was treated for a giant aneurysm of the left cavernous carotid artery with carotid ligation in the neck and a superficial temporal artery-middle cerebral artery bypass. At age 12 years, the patient was similarly treated for a giant aneurysm of the right cavernous carotid artery, which had progressed from a previously noted minute dilatation at age 5 years, with carotid ligation and a superficial temporal artery-middle cerebral artery bypass. At age 21 years, the patient was endovascularly treated for a de novo saccular aneurysm of the left posterior cerebral artery at the P1-P2 junction and a fusiform aneurysm of the distal left posterior cerebral artery. Various studies have suggested that the facial dermis, the subcutaneous tissues, and the skeleton, as well as the tunica media of the cervicocephalic arteries, all arise from neural crest cells, and a disorder of neural crest migration might explain the constellation of findings in this patient.     

Post-traumatic hemiplegia in a patient with fibromuscular dysplasia of the carotid artery

A 44-year-old patient, without remarkable medical history, was admitted with a head trauma with initial loss of consciousness and a thoracic trauma. The initial treatment included the insertion of a chest drain for evacuation of a pneumothorax and intrapleural analgesia with bupivacaine. The day after admission, the patient experienced a generalized epileptic crisis, without prodomes. Later, a left proportional hemiplegia with aphasia was recognized. The CT scan obtained immediately after the crisis, as well as the carotid Doppler ultrasonography and echocardiography were normal. The bilateral carotid angiography showed an image of fibromuscular dysplasia of the extracranial segment of the right internal carotid artery. The migration of a carotid thrombus initiated by the trauma was hypothetized. A treatment with a platelet aggregation inhibiting drug was started and associated 20 days later with low molecular weight heparin. The patient recovered a normal motility within 10 days; only the aphasia remained. Trauma of the carotid artery is not a frequent cause of cerebrovascular accident. The occurrence of the latter is favoured by a pre-existing lesion of this artery. This case demonstrates that in a trauma patient not all central nervous system manifestations are initiated by a head trauma.     

Staged intracranial and extracranial revascularization

Twenty patients with a combination of intracranial and extracranial cerebrovascular lesions were identified in a series comprised of 118 candidates for superficial temporal artery to middle cerebral artery (STA-MCA) bypass. Ten patients had internal carotid (ICA) occlusion and contralateral ICA stenosis, seven patients had combinations of ipsilateral lesions, usually ICA occlusion and external carotid (ECA) stenosis, and three patients had multiple lesions. Eighteen patients had a STA-MCA bypass performed; 11 of these had contralateral reconstruction for ICA stenosis, and seven had ECA stenosis corrected. Two additional patients became asymptomatic after ECA endarterectomy only and their proposed STA-MCA bypass has been postponed. There were two deaths, one early and one late. Eleven patients are asymptomatic, five are improved, one is unchanged, and one is neurologically worse.     

Varying impact of common carotid artery digital compression and internal carotid artery balloon test occlusion on cerebral hemodynamics

BACKGROUND: The purpose of this study was to compare the cerebral hemodynamic changes brought about by common carotid artery (CCA) digital compression and angiographic internal carotid artery (ICA) balloon occlusion. METHODS: Bilateral transcranial Doppler ultrasonographic monitoring of the middle cerebral artery blood velocity (VMCA) was performed in 12 subjects with neck neoplasms or traumatic carotid-cavernous fistulas. The MCA pulsatility index (PIMCA) and hemodynamic tension (Uhem MCA) were calculated. RESULTS: Common carotid artery compression provoked the largest drop in ipsilateral VMCA, PIMCA, and Uhem MCA. Common carotid artery compression caused a steal of blood from the intra- to the extracranial circulation, with the discrepancy in hemodynamic findings between CCA and ICA test occlusions being dependent on the quantity of reversed ipsilateral ICA blood flow. CONCLUSION: If the carotid artery is to be sacrificed, permanent ICA closure is the procedure of choice with respect to the occurrence of cerebral ischemic lesions in patients with neck neoplasms and ICA flow reversal during CCA compression.     

Agenesis of the internal carotid artery associated with an aneurysm of the anterior communicating artery

We report a case of agenesis of the internal carotid artery which was revealed by a subarachnoid hemorrhage. Angiography showed a ruptured aneurysm of the anterior communicating artery and unilateral absence of the left internal carotid artery. Both the left anterior and middle cerebral arteries were perfused from the right carotid artery via the anterior communicating artery. Absence of the left carotid canal was proved on bone CT. Such an association is discussed. An hemodynamic stress on a congenital defect of the cerebral arterial wall could be the origin of the aneurysm development.     

Endoscopic removal of a dental instrument from the stomach: case report

The records of 628 patients admitted to the Joint Study of Extracranial Arterial Occlusion with transient symptoms of carotid system ischemic disease were examined to determine the accuracy of predicting disease of the extracranial internal carotid artery on the basis of clinical information alone. A patient with a history of episodes of amaurosis fugax is more likely to have a lesion of the internal carotid artery on the same side than if he were having only transient cerebral ischemic attacks. In patients with transient symptoms and a carotid bruit on the appropriate side, the incidence of an angiographically normal carotid artery was 15%. In those patients with transient symptoms and no palpable pulsation in the cervical region on the appropirate side, the incidence of an angiographically normal carotid artery was zero.     

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.