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.     

Fusiform dilatations of the esophagus secondary to protracted distention and emetogenic injury

We report the case of a 74-year-old woman who presented with a 2-year history of dysphagia, weight loss, nausea, and vomiting. She was diagnosed as having secondary achalasia due to external compression probably by a tumor of the lower part of the esophagus. At autopsy, however, no tumor was found at that site, whereas a pancreatic microcystic serous adenoma and multiple gastric leiomyomata--one of which occupied the pyloric sphincter area leading to gastric outlet obstruction--were noted. The esophagus displayed two fusiform dilatations located at the lower and midportions, the latter being associated with rupture and necrosis of the muscularis and adventitial wall layers. The lower dilatation showed only attenuation of the muscularis, without necrosis. The epithelium was intact in both dilatations. This was an unusual series of pathogenetic events, leading from gastric outlet obstruction to secondary achalasia and protracted vomiting, followed by spontaneous partial esophageal wall rupture (a variant of intramural hematoma) or atrophy of the muscularis, morphologically evident as fusiform dilatations.     

Aortic dissection decades following internal carotid artery dissection--report of two cases

BACKGROUND: In patients with cirrhosis, portosystemic shunts allow intestinal bacteria and endotoxin to enter the systemic circulation. Endotoxemia may induce increased synthesis of nitric oxide, thereby contributing to arterial vasodilation. OBJECTIVE: To test the hypothesis that the antibiotic norfloxacin blocks the effects of nitric oxide. DESIGN: Placebo-controlled, double-blind, crossover study. SETTING: Alfred Hospital, Melbourne, Australia. PATIENTS: 9 patients with alcohol-related cirrhosis and 10 healthy controls. INTERVENTION: Norfloxacin, 400 mg twice daily, for 4 weeks. MEASUREMENTS: Peripheral blood flow was measured by using forearm venous occlusion plethysmography. RESULTS: Basal forearm blood flow was higher in patients with cirrhosis than in controls (3.69 +/- 0.27 mL/100 mL per minute and 2.47 +/- 0.40 mL/100 mL per minute; P = 0.014) but returned toward normal after norfloxacin was given (2.64 +/- 0.31 mL/100 mL of tissue per minute in patients with cirrhosis). Responses to NG-monomethyl-L-arginine were greater in patients with cirrhosis but returned to normal after norfloxacin was given. CONCLUSION: Bacterial endotoxemia in patients with cirrhosis induces increased synthesis of nitric oxide that can be corrected with norfloxacin.     

Pseudo-tandem stenosis of the internal carotid artery

Two cases of pseudo-tandem stenosis of the internal carotid artery are presented. Proximal stenosis was produced by a large, focal atherosclerotic plaque. The severe intracranial "stenosis" was thought to be an angiographic artifact. Repeat cerebral angiography after carotid endarterectomy revealed normal intracranial arteries. The recognition of this entity is important because a decision to operate is based largely upon angiographic findings.     

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.     

Penetrating trauma of the internal carotid artery

OBJECTIVE: To assess management of penetrating internal carotid artery (ICA) injuries. DESIGN: Retrospective review of institutional protocol. SETTING: Level 1 trauma center in a major urban area. PATIENTS: Sixty-one patients with penetrating ICA injuries. INTERVENTIONS: In the period 1975 to 1987 (group 1; n = 36), management was based on individual surgeons' preferences. Between 1988 and 1995 (group 2; n = 25), an algorithm was employed: (1) hemodynamically stable patients with suspected ICA injuries underwent a diagnostic angiography; (2) surgically accessible injuries were reconstructed regardless of neurologic status with 2 exceptions: (a) neurologically intact patients with ICA occlusion were treated by anticoagulation and mild pharmacological hypertension and (b) minimal nonocclusive injuries were managed nonoperatively and followed up by serial angiography or duplex ultrasonography; and (3) heparinization, shunting, and completion angiography were employed. MAIN OUTCOME MEASURES: Neurologic status at admission and discharge were compared by the Fisher exact test. RESULTS: In group 1, 24 patients (67%) presented neurologically intact, and 12 (33%) with a deficit. Sixteen injuries were managed nonoperatively, 14 were repaired, and 6 were ligated. At discharge 6 (17%) were improved, 24 (66%) were unchanged, 6 (17%) were worse. Four patients (11%) died of cerebrovascular causes. In group 2, 19 patients (76%) presented neurologically intact, and 6 (24%) with a deficit. Eleven injuries were managed nonoperatively, 12 were repaired, and 2 were ligated. A death occurred in a patient who arrested, was admitted to the hospital in a coma, and died before ICA repair. CONCLUSIONS: Neurologic outcome after ICA injury is enhanced by an algorithm predicated on the liberal use of angiography, a predefined surgical approach, and selective observation.     

Spontaneous dissection of the internal carotid artery

The arteriographic diagnosis of spontaneous, nontraumatic dissection of the internal carotid artery was made in 19 patients and confirmed at operation in ten. The tapered narrowing beginning in or about the carotid bulb and ending at the bony canal was a consistent finding. Four patients had associated aneurysm formation. All but one patient developed an acute hemispheric neurologic deficit as the initial symptom. The deficit was transient in ten and prolonged in eight. The dissection occurred in the outer layers of the media. None of the surgical specimens showed atherosclerosis. Surgical methods of management included segmental resection and grafting, thrombectomy and intimectomy, dilation, and simple ligation. Considerable improvement of luminal diameter occurred in six of seven patients whose arteries were left undisturbed.     

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.     

Congenital absence of the internal carotid artery

The aim of this study was to adapt the single-breath technique with positive expiratory pressure to measure exhaled nitric oxide (eNO) in infants. We hypothesized that exhaled eNO was greater in wheezy than in healthy infants. We studied 30 infants (16 wheezy and 14 healthy). The forced expiratory volume in 0.5 s (FEV0.5) was determined with the raised volume rapid thoracic compression technique, and eNO was measured during constant expiratory flow with a rapid-response chemiluminescence analyzer. After passive inflation to a preset pressure of 20 cm H2O, thoracic compression with an inflatable jacket caused forced expiration to occur through a face-mask with an expiratory flow resistor attached. During the forced expiration, the jacket pressure was increased to maintain a constant driving mouth pressure and hence a constant expiratory flow (50 ml/s). The mean level of eNO in the wheezy infants (31.8 ppb) was significantly higher than the level in healthy infants (18.8 ppb) (p = 0.03). A family history of atopy in parents was associated with increased eNO levels (p < 0.001) independent of age, sex, weight, length, wheezing, and FEV0.5. We conclude that the single-breath technique with positive expiratory pressure is a feasible method for measuring eNO in infants. Levels of eNO were significantly higher in wheezy infants and in those with a family history of atopy.     

Effect of anesthetic technique on cardiac morbidity following carotid artery surgery

Clarithromycin and rifabutin are among the most promising drugs for the therapy of infections caused by Mycobacterium avium or other atypical mycobacteria. Since synergism of combined drugs is important in order to achieve strong antimycobacterial activity, the combined inhibitory effects of antibacterial agents should also be investigated when agents are evaluated for possible use in antimycobacterial drug therapy. In the present study we examined the antimycobacterial activity of clarithromycin, rifabutin, and their combination against 51 clinical isolates of the M. avium complex from patients with acquired immune deficiency syndrome (AIDS) with disseminated mycobacteriosis. A concentration-dependent inhibition was seen for each drug. The antibacterial effect was significantly more pronounced for the combined drugs than for the agents tested separately. Synergism, against up to 88% of the strains tested, was seen for the tested drugs combined at different concentrations. All 51 M. avium strains were susceptible to the combination of 4 mg/l clarithromycin and 2 mg/l rifabutin.     

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.     

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.     

Fusiform P1 segment artery aneurysm in a pediatric patient: technical case report

We report a case of cavernous sinus thrombosis in an 8-year-old boy, following a neglected and untreated nasal furuncle. This rare entity is manifested by hyperthermia, with headache, vomiting and involvement of the III-IV & VI cranial nerves. It is usually a complication of a facial infection. The diagnosis is established by CT-Scan or MRI. Without appropriate and early treatment, the prognosis is poor, with a fatal outcome or severe sequelae.     

Dilated lesion at internal carotid artery posterior communicating artery junction

The diagnosis and surgical indication of an incidental aneurysm at the IC-PC junction is sometimes vague. In this report, 28 lesions in 26 cases with aneurysmal dilatation at the IC-PC junction, which were surgically treated, were analyzed. These lesions are classified according to the operative findings. Only 6 of the lesions were confirmed to be true aneurysms. However, 19 lesions were the dilated changes of the posterior communicating arteries (Pcom) themselves, without aneurysmal formation. Two lesions were accompanied with blood blister like aneurysm at the wall. Another one was dilated Pcom with peripheral Pcom occlusion. The correlation between operative findings and angiographic findings are studied, and the importance of the diagnostic angiographic findings of the Pcom is strongly emphasized for their diagnostic value.