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BACKGROUND AND PURPOSE: CTA has shown limited accuracy and reliability in distinguishing tandem occlusions and pseudo-occlusions on initial acute stroke imaging. The utility of early and delayed contrast-enhanced MRA in this setting is unknown. We aimed to assess the accuracy and reliability of early and delayed contrast-enhanced MRA for carotid bulb patency in patients with acute ischemic stroke. MATERIALS AND METHODS: We retrospectively reviewed patients who had ICA occlusion and underwent thrombectomy with preprocedural early and delayed contrast-enhanced MRA in a single comprehensive stroke center. During 2 sessions, 10 raters independently assessed 32 cases with early contrast-enhanced MRA (with an additional delayed contrast-enhanced MRA sequence during the second reading session). Their judgments were compared with DSA as a reference standard. Accuracy and interrater agreement were measured. Five raters undertook a third reading session to assess intrarater agreement. RESULTS: Accuracy for the assessment of carotid bulb patency with early contrast-enhanced MRA was limited (69%; 95% CI, 59%–79%), with moderate interrater agreement (κ = 0.42; 95% CI, 0.27–0.55). The second reading with an additional delayed contrast-enhanced MRA sequence improved both accuracy (82%; 95% CI, 73%–91%; P < .001) (raters corrected 43%–77% of incorrect diagnoses with early contrast-enhanced MRA alone; mean = 59%) and interrater agreement (κ = 0.56; 95% CI, 0.41–0.73; P = .07). Intrarater agreement was almost perfect, substantial, and moderate for 3, 1, and 1 raters. CONCLUSIONS: Early contrast-enhanced MRA has limited accuracy and repeatability for the evaluation of carotid bulb patency in acute ischemic stroke. The additional delayed contrast-enhanced MRA sequence may improve accuracy and reliability.

OBJECTIVES To determine how measurements of the internal carotid artery (ICA) cross-sectional area will differ systematically when obtained by grayscale, color Doppler, and power Doppler imaging. METHODS A total of 451 patients had greater than 40% diameter stenosis in at least a single ICA. Anteroposterior and transverse luminal diameters were measured in 609 arteries on grayscale, color, and power Doppler transverse images of the carotid bulb and proximal and distal ICAs. Cross-sectional areas were calculated and compared by a repeated-measures analysis of variance model to assess for significant differences. RESULTS Mean ICA cross-sectional areas ± SDs as measured by grayscale, power Doppler, and color Doppler imaging were 122 ± 81, 122 ± 79, and 125 ± 79 mm2 , respectively. The mean ICA area estimated by color Doppler imaging was significantly greater than that estimated by power Doppler imaging (P

The objectives of this study are to (1) examine the “10-year cardiovascular risk” in the common carotid artery (CCA) versus carotid bulb using an integrated calculator called “AtheroEdge Composite Risk Score 2.0” (AECRS2.0) and (2) evaluate the performance of AECRS2.0 against “conventional cardiovascular risk calculators.” These objectives are met by measuring (1) image-based phenotypes and AECRS2.0 score computation and (2) performance evaluation of AECRS2.0 against 12 conventional cardiovascular risk calculators. The Asian–Indian cohort (n = 379) with type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), or hypertension were retrospectively analyzed by acquiring the 1516 carotid ultrasound scans (mean age: 55 ± 10.1 years, 67% males, ∼92% with T2DM, ∼83% with CKD [stage 1-5], and 87.5% with hypertension [stage 1-2]). The carotid bulb showed a higher 10-year cardiovascular risk compared to the CCA by 18% ( P < .0001). Patients with T2DM and/or CKD also followed a similar trend. The carotid bulb demonstrated a superior risk assessment compared to CCA in patients with T2DM and/or CKD by showing: (1) ∼13% better than CCA (0.93 vs 0.82, P = .0001) and (2) ∼29% better compared with 12 types of risk conventional calculators (0.93 vs 0.72, P = .06).

Aberrant vertebral artery (VA) origins are uncommon, and those arising from the carotid bulb are exceedingly rare. We report a 79-year-old man with a right thalamic stroke and subsequent amaurosis fugax that was found to have severe right carotid bulb and internal carotid artery stenoses, as well as an aberrant VA arising from the bulb. He underwent carotid endarterectomy including eversion endarterectomy of the VA and had no recurrence of amaurosis fugax or posterior circulation symptoms at the 1-year follow-up. We also present a comprehensive review of the literature, focusing on symptomatic cases and those arising from the carotid bulb.

Carotid web (CW) is an atypical form of intimal fibromuscular dysplasia that occurs at the level of the carotid bulb. It is associated with ischemic strokes. The first report of this association was in 1967 and it is currently known to represent a significant percentage of cryptogenic stroke. We report the case of a young female patient with a history of transient ischemic attack who presented a cerebral infarction of the territory of the left middle cerebral artery. The diagnosis of CW was suggested by the findings of the ultrasound carotid duplex and was confirmed by digital subtraction angiography. Likewise, brain magnetic resonance angiography showed an incipient alteration in the morphology of the wall of the left internal carotid artery in its intracranial segment. Aspirin treatment was started and there was no recurrence up to two years of follow-up. CW represents a diagnostic challenge; it should be suspected in young adults with ischemic stroke. In them, studies of the supra-aortic vessels should be performed. Ultrasound carotid duplex can be a useful diagnostic tool.

Objective: To evaluate the safety and outcomes of surgical revascularization for patients with symptomatic kinking of the internal carotid artery (ICA). Methods: Twenty-five consecutive patients presented with symptomatic kinking of the ICA and a history of transient ischemic attack (TIA) or stroke were prospectively enrolled in this study. All patients were treated with ICA transection and end-to-side reimplantation at the level of the carotid bulb. Patients were followed up for a median of 32 months. Results: There were no deaths or strokes within the 30 days of the treatment. No postprocedural thrombosis or narrowing of the ipsilateral ICA was observed. One (4%) patient had temporary recurrent nerve palsy, which was completely recovered at 4-week follow-up. One (4%) patient had a myocardial ischemic event. At the end of the 32-month follow-up, 1 (4%) patient developed ipsilateral minor stroke. No recurrent stenosis was detected by Doppler ultrasound. Conclusion: Surgical treatment for isolated, symptomatic kinking of the ICA and a history of TIA or stroke is safe, and the outcomes are acceptable.

Patients with Klippel-Feil syndrome (KFS) have an increased incidence of vascular anomalies as well as vertebral artery (VA) anomalies. In this article, we presented imaging findings of a 15-year-old female patient with KFS with a rare association of extraforaminal cranially ascending right VA that originated from the ipsilateral carotid bulb. Trifurcation of the carotid bulb with VA is a very unusual variation and to the best of our knowledge, right-sided one has not been reported in the literature.

A 52-year-old woman without cardiovascular risk factors presented with an acute middle cerebral artery infarction. An ipsilateral thin, smooth, membrane-like intraluminal filling defect along the posterior wall of the internal carotid bulb compatible with carotid web (CW) was observed on Doppler ultrasound, CT, and magnetic resonance angiography (figure). No other abnormalities were found on extensive diagnostic workup. CW is thought to represent an intimal variant of fibromuscular dysplasia.1,2 Although data are scarce, CW may be associated with increased stroke risk in young patients with cryptogenic anterior circulation infarction and with a high risk of stroke recurrence.2

Carotid artery ultrasound is a non-invasive and reproducible technique used for early atherosclerotic assessment. Intimal flap has been described in the presence of dissection or mobile plaque rupture, however presence of carotid thin fluttering bands (TFBs) have not been described yet. To investigate frequency, characteristics and impact of TFBs in carotid lumen of patients who underwent carotid ultrasound scan (CUS). 3341 patients were admitted from January 2009 to January 2014. Patients with history of cerebral ischemia (CI) were excluded. In the cases in which TFBs were observed, a 3-months clinical and CUS follow-up (FU) was performed. TFBs were found in 71 patients (2.1%). The mean age was 63.41 ± 11.20 years (range 42-89). All patients showed a mean increase in intima-media thickness. We identified two subgroups: in 22 patients the TFB was related to a carotid plaque while in 49 no carotid plaque was found. TFB mostly originated in the carotid bulb (88.7%) and was similarly located in carotid arteries (49.3% left-side and 50.7% right-side). CUS and clinical FU were available for all patients (mean duration 25.34 months, median 19). CI occurred in none of the patients. TFB disappeared in 13 patients (18.3%) with no sign or symptoms of CI. In 3 of 49 patients without carotid plaque (6.1%), progressive thickening beneath TFB was observed. TFB is a rare finding. Longer FU is needed to evaluate its prognosis. To date, the pathophysiology is unknown, however it could be related to vascular remodeling.

Background: Carotid web is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. Carotid webs have been associated with recurrent strokes and traditionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic carotid webs. Methods: Retrospective review of patients admitted to three comprehensive stroke centers identified to have a carotid web with otherwise negative stroke workup that underwent stenting. A carotid web was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT/MR angiography and confirmed with conventional angiography. Results: Twenty patients with symptomatic (80% Stroke/20% TIA) carotid webs were stented. Median age was 48[41-61] years, 7(35%) were male, and 15(75%) Black. Median NIHSS was 11[2-16] while ASPECTS 8[7-8]. Eight (40%) received intravenous thrombolysis and 10 (50%) thrombectomy. All patients were stented on dual antiplatelets (aspirin and clopidogrel[17] or ticagrelor[3]) at a median 9[4-30]days after the last vascular event. Closed-cell stents were used in 75% of cases (XACT [14] and Wallstent [1]) while open-cell stents in 25% (Acculink[5]). No cases required angioplasty for residual stenosis had to be performed. DIstal embolic protection was used in 19 cases (SpiderFX[18] and Emboshield_NAV6[1]) while proximal protection in 1 (MoMa). No periprocedural events occurred with the exception of two cases of hypotension/bradycardia (one requiring 24-hour vasopressors). No parenchymal hematomas were observed but one patient developed vaginal hemorrhage requiring discontinuation of one antiplatelet at 2 months. Modified Rankin Scale 0-2 (independence) at 90 days was recorded in 95% of patients. Clinical follow-up post stent occurred for a median of 4 [2-12] months and no follow-up cerebrovascular events were noted. Follow-up vascular imaging was performed in 95% patients at a median of 3[2-12]months and were all unremarkable. Conclusions: Stenting for symptomatic carotid web appears to be a valid, safe, and effective alternative to surgical piecemeal resection. Further studies are warranted.

Carotid webs are an uncommon cause of recurrent ischaemic strokes. They are considered a form of fibromuscular dysplasia, possibly developmental in origin, with non-inflammatory and non-atherosclerotic features and a characteristic appearance on CT angiography. They have been described as a thin intraluminal filling defect along the posterior wall of the carotid bulb in oblique sagittal reformats and a septum on axial CT angiography. Here we summarize two cases of ischaemic strokes secondary to carotid webs with characteristic images. Detection and awareness of carotid webs and their imaging features among radiologists and physicians are important as it is associated with a high risk of recurrent cerebrovascular events.

Introduction: Carotid Web (CW) is a rare form of focal fibromuscular dysplasia that results in an abnormal shelf-like projection of intimal fibrous tissue into the carotid bulb. It is theorized that CW leads to ischemic stroke secondary to blood flow stasis and subsequent embolization. There is uncertainty in diagnosis, prognosis, and optimal management of this uncommon entity. To address this knowledge gap, we performed a systematic literature review (SLR) of CW. Methods: Our literature search for CW and related terms yielded 1017 results. After a preliminary assessment of all 1017 retrieved manuscripts; 72 manuscripts were reviewed in detail. A total of 31 manuscripts met entry criteria and were included in our SLR. We present the demographics, cardiovascular (CV) risk factors, neuroimaging findings, stroke recurrence or stroke free-duration, and treatment modality of CW patients. Results: Our SLR resulted in 104 patients with CW, (median age at presentation: 45.7 [IQR 45-57], 52.3% female). The majority (68.3%) of CW patients did not have CV risk factors, however, 22.2% of patients were smokers. 47.8% of patients suffered recurrent stroke. The majority of patients were ultimately treated with antiplatelet therapy (94.4%) and 21.2% underwent carotid revascularization (4.8% carotid stenting, 16.3% carotid endarterectomy). None of the patients who underwent revascularization had a reported stroke recurrence. See Table. Conclusions: CW is a rare disease leading to ischemic stroke in younger patients without typical CV risk factors. CW patients in our SLR were at extremely high risk for recurrent stroke (47.8%). Aggressive secondary stroke prevention measures are indicated in this patient population, however, the optimal treatment strategies remain unclear. Carotid revascularization may be the definitive treatment for certain patients with CW, but further studies are needed as incomplete reporting and potential publication bias limit our findings.

Fibromuscular dysplasia (FMD) is known as rare cause ischemic stroke and usually involves the internal carotid or vertebral arteries in middle age women. A poorly known type of FMD located at the carotid bulb is called atypical fibromuscular dysplasia. We present the case of 3 young black patients suffering from recurrent ischemic strokes in the same middle cerebral artery territory. Computed tomographic angiography and arteriography showed a moderate diaphragmatic stenosis of the carotid bulb. After surgical removal of the dysplasia, postoperative course was uneventful without any recurrence. Pathologic examination confirmed atypical FMD. Carotid-bulb atypical FMD is a rare cause of stroke and concerns mostly young black patients. Surgical approach should be recommended to avoid recurrent stroke.

Tonsillectomy, though a popular surgery, has now downsized to limited indications. Although rare, this surgery may cause trauma to the great vessels leading to life-threatening hemorrhage. The congenitally tortuous internal carotid artery (ICA) is an unusual but important anomaly, especially when it is situated in the tonsillar fossae. About 1%–16% of patients have a surgically vulnerable ICA manifested clinically. Here, we present the first reported case of carotid bulb in the right tonsillar fossa. A 7-year-old female child underwent tonsillectomy for obstructive sleep apnea syndrome. Intraoperatively, she was found to have a carotid bulb in both tonsillar fossae, right more prominent than left one. Computed tomography angiogram confirmed the presence of a prominent carotid bulb in the right tonsillar fossa at the C2level. This case report highlights the importance of a heightened awareness of the anatomic variations of carotid artery, in particular, the carotid bulb. This is of critical significance for a safe tonsillectomy as well as any procedure performed in the oropharyngeal region.

ventricular assist devices: A novel observation John T. Reul, George J. Reul, MD, and O.H. Frazier, MD From the Center for Cardiac Support, Texas Heart Institute at St. Luke’s Hospital, Houston, Texas; Division of Cardiovascular Surgery, Texas Heart Institute at St. Luke’s Hospital, Houston, Texas; and the Peripheral Vascular Laboratory, Texas Heart Institute at St. Luke’s Hospital, Houston, Texas

Purpose: To compare postoperative morphological and rheological conditions after eversion carotid endarterectomy versus conventional carotid endarterectomy using computational fluid dynamics. Basic methods: Hemodynamic metrics (velocity, wall shear stress, time-averaged wall shear stress and temporal gradient wall shear stress) in the carotid arteries were simulated in one patient after conventional carotid endarterectomy and one patient after eversion carotid endarterectomy by computational fluid dynamics analysis based on patient specific data. Principal findings: Systolic peak of the eversion carotid endarterectomy model showed a gradually decreased pressure along the stream path, the conventional carotid endarterectomy model revealed high pressure (about 180 Pa) at the carotid bulb. Regions of low wall shear stress in the conventional carotid endarterectomy model were much larger than that in the eversion carotid endarterectomy model and with lower time-averaged wall shear stress values (conventional carotid endarterectomy: 0.03–5.46 Pa vs. eversion carotid endarterectomy: 0.12–5.22 Pa). Conclusions: Computational fluid dynamics after conventional carotid endarterectomy and eversion carotid endarterectomy disclosed differences in hemodynamic patterns. Larger studies are necessary to assess whether these differences are consistent and might explain different rates of restenosis in both techniques.

Introduction Carotid angioplasty and stenting (CAS) is a treatment option for carotid stenosis in high surgical risk patients. As it implies instrumentation of the carotid bulb, baroreceptors dysfunction may be provoked with consequent hemodynamic instability. Report An 83-year-old woman treated by CAS presented with episodes of flushing, dyspnea and palpitations accompanied by transitory desaturation, hypertension, agitation and anxiety. Symptoms started 12 h after the procedure. Each episode lasted 10 min. Five episodes in 3 days were observed. Discussion A dysfunction of the carotid baroreceptors and chemoreceptors was hypothesized.

This study was performed to determine whether early duplex findings predicted restenosis after carotid endarterectomy.One hundred ninety-two symptomatic patients who underwent carotid endarterectomy were studied with color duplex imaging at 1 day and 1 week after surgery to identify minor residual disease (causing50% stenosis), arterial kinking, and suture stricture, and to measure the external and luminal diameters of the carotid bulb and distal internal carotid artery. Patients were then observed prospectively with duplex surveillance for a median of 24 months to identify50% restenosis.Twenty-five stenoses50% of the operated carotid artery (13%) were identified, four at 1 day (residual) and 21 at a median follow-up of 6 months (restenosis). On multiple logistic regression analysis,50% restenosis was found to be associated with minor day-1 residual stenosis (p = 0.01) and with small luminal diameter of the distal internal carotid artery (p = 0.03) as measured 1 week after carotid endarterectomy. Life table analysis showed restenosis at 24 months to be more common for patients with below-median than patients with above-median carotid bulb external diameter (18% vs 5%, respectively; p = 0.01).Duplex scanning within a week of carotid endarterectomy identifies50% residual stenosis, in addition to minor residual 25% to 50% stenosis and small carotid dimensions, which are good predictors of50% restenosis at 6 months.

Background: Restenosis of the carotid artery is a major complication of carotid endarterectomy (CEA). The purpose of this study was to examine the role of CEA techniques on carotid dimensions variation, postoperative versus preoperative multi-segmental diameters and its impact on the development of restenosis at 12 months follow up. Methods: 175 consecutive patients eligible for carotid surgery were included in the study. 75 underwent CEA by patch reconstruction (PR), 53 by eversion (EV) and 47 by primary closure (PC). Before the procedures and at discharge, carotid diameters were measured at four reference points (common carotid, CC; carotid bulb, CB; proximal internal carotid artery, PICA; distal internal carotid artery, DICA) by ultrasonography. The rate of minor (< 50%) and major (≥ 50%) restenosis was evaluated at 12 months follow up. Results: PR produced an increase in all carotid diameters while PC and EV produced a decrease in carotid diameters, having PC affected all diameters while EV affected CB and PICA diameter. However, postoperative diameters had comparable dimension independently of the surgical technique used. The rate of overall and major restenosis did not differ significantly between the three types of surgery. Logistic regression analysis showed that female gender was associated with major restenosis (OR 6.9, 95% CI 1, 23 – 38, 49) irrespective of surgical technique. Conclusion: This study shows that carotid diameters and restenosis rate after CEA are comparable whatever is the surgical technique adopted, and that women are at high risk of major restenosis.

We report the case of a patient with congenital absence of the external carotid artery in whom we performed a carotid endarterectomy. The radiographic features and operative findings are presented. Four similar cases previously reported in the literature are reviewed. A comment on the pathophysiology of atherosclerosis at the carotid bulb in the absence of a bifurcation and a brief discussion on the possible embryologic explanation of this anomaly are discussed. (J Vasc Surg 2002;35:573-5.)

In the setting of an acute stroke caused by arterial dissection, navigating a microcatheter and microguidewire past the dissected artery to gain access to the distal thromboembolic lesion may exacerbate the underlying pathology. We review a case report whereby successful recanalization of an acute carotid terminus occlusion due to intimal-media dissection in the cervical carotid artery emphasizing the importance of aggressive proximal guide catheter aspiration in conjunction with flow arrest from the carotid bulb proximal to the dissection. We discuss the strengths and limitations of this approach and underscore the importance of a pathology-based approach to acute stroke therapy.

We thank Dr Sarikaya and colleagues for their response to our image and case report on carotid dissection and profound bradycardia, and we welcome diversity of interpretation of the underlying mechanism of the observations.1 The profound progressive bradycardia observed was reminiscent of reflex bradycardia seen most often in vasovagal syncope and carotid sinus sensitivity. The patient’s history of vasovagal syncope in combination with local injury to the carotid bulb region …

In addition to intima-media thickness (IMT), IMT inhomogeneity may carry information about atherosclerosis progression. In 147 vascular diseased patients (mean 66 y, 48% male), we determined the carotid bulb stenosis degree based on local Doppler blood flow velocities. Common carotid artery (CCA) morphologic characteristics, i.e . IMT, IMT-inhomogeneity (intraregistration variation) and IMT uni- and bilateral intrasubject variation (ΔIMT), were measured using multiple M-mode. Associations of morphologic characteristics, stenosis degree and Framingham score were evaluated with Pearson correlation ( r ) and multiple regression analysis. The IMT distributions for subjects without and with stenosis were not similar. The stenosis degree score correlated significantly to unilateral ( r = 0.68) and bilateral ΔIMT ( r = 0.62), IMT ( r = 0.41) and IMT-inhomogeneity ( r = 0.45). The averaged IMT and IMT-inhomogeneity increased slightly for singular stenosis and abruptly for multiple stenoses. Mean uni- and bilateral ΔIMT per stenosis degree increased linearly with this degree, reaching a correlation close to 1 ( r = 0.98 and r = 0.97). Interestingly, the majority of the subjects with a moderate to severe bulb stenosis exhibited a carotid IMT lower than the considered critical threshold of 0.9 mm. In conclusion, although CCA is not prone to plaques, its morphologic characteristics are positively correlated with stenosis degree score and other risk scores. ΔIMT can be more reliable derived from inter-registration rather than from intra-registration variation. In the CCA, ΔIMT substantiates vascular alteration better than IMT. (E-mail: A.Hoeks@BF.Unimaas.nl )

Response We thank Dr Bladin et al for their interest in our work, “Carotid Stenosis Index Revisited With Direct CT Angiography Measurement of Carotid Arteries to Quantify Carotid Stenosis”1 and our related works.2–4 We agree that the optimal method to quantify carotid stenosis remains somewhat controversial. All methods of carotid stenosis quantification are relatively flawed, despite the imaging modality or the statistical technique. Nonetheless, the attempts to improve this quantification have all played an important role in our understanding of carotid disease and measurement methodology. Bladen et al correctly state our message that carotid stenosis should be directly measured and individualized. We agree that we could have measured the widest portion of the carotid bulb, instead of at the level of tightest luminal stenosis. Yet, the carotid stenosis index (CSI)5 does not involve measurement of the carotid bulb at all. Instead the CSI method relied on a presumed …

Stroke is the third-leading cause of death in the United States. It occurs in almost 700,000 people per year and cost an estimated US dollars 57.9 billion in 2006. Atherosclerotic disease is the cause of one third of these strokes, with more than one half of these stenoses being extracranial in location. Carotid stenoses are usually unifocal and 90% occur within 2 cm of the carotid bulb. Currently, carotid endarterectomy accounts for 117,000 surgical revascularizations per year, whereas carotid angioplasty and stenting are performed less than 10,000 times annually. Stenoses amenable to revascularization are the topic of this article.

Peripheral Interventions: Imaging in Diagnosis (Abstract nos. PP-132 w PP-142) The American Journal of Cardiology MARCH 26e29, 2015 11 IN AND C PP-132 Eversion and Conventional Carotid Endarterectomy Techniques in Terms of a Comparison of Hypertension. Haydar Yasa, Muhammed Akyuz, Barcin Ozcem, Mehmet Bademci, Nihan Karakas, Banu Akdag Lafci, Tayfun Goktogan, Ali Gurbuz. Bati Anadolu Central Hospital; Ege University; Katip Celebi University Ataturk Training And Research Hospital; Near East University Faculty Of Medicine. Background: The role of carotid endarterectomy for the treatment of carotid bifurcation atherosclerosis is now well established. The operative procedures for carotid stenosis, the eversion techniques require an oblique circumferential incision of the internal carotid artery (ICA) at the carotid bulb and transection of the carotid sinus nerve fibers. In this study, the incidence of postoperative hypertension (HTN) after eversion carotid endarterectomy (E-CEA) was compared with conventional carotid endarterectomy (C-CEA) in the shortand mid-term follow-up periods. Methods: Baseline blood pressures were recorded in all patients 1-2 weeks before the CEA. Systolic blood pressure values and diastolic blood pressure values were 1⁄4.078). The number of patients that had continued administeration of antihypertensive agents were, 4 (5.2%) and 3(3.4%) in the E-CEA group and C-CEA group, respectively. Normalization of arterial blood pressure was achieved in the other patients. No significant postoperative neurological, surgical, or cardiac complications developed in any patient in either group. Conclusion: As a result, the researchers suggest that there is no difference between the two groups after E-CEA control of hypertension at the early and middle periods.

Background and Purpose — Conventionally, carotid ultrasonography has been performed with a 7.5-MHz linear probe to evaluate the extracranial internal carotid artery (ICA). However, usually only the carotid bulb or proximal portion of the ICA can be evaluated. We attempted to evaluate the distal extracranial ICA with a 3.5-MHz convex probe. Methods — The subjects were 17 consecutive patients with ICAs free of occlusive disease and 3 other patients with distal extracranial ICA stenosis. Using a 7.5-MHz linear probe and a 3.5-MHz convex probe, we performed long-axis B-mode imaging of the ICAs to evaluate the distance between the distal limit of visualized ICA and the bifurcation of the common carotid artery. Results — The distal limit of the ICA, visualized with a 7.5- or a 3.5-MHz probe, was 31±11 or 57±8 mm distal to the common carotid artery bifurcation, respectively. In the 3 patients with distal extracranial ICA stenosis, the lesion could be successfully diagnosed with only the 3.5-MHz probe. Conclusions — This form of carotid imaging is feasible and may be potentially useful in the evaluation of carotid disease.

We report a patient in whom we were able to make an accurate diagnosis of left carotid bulb and left internal carotid artery stenosis by carefully and slowly withdrawing the probe from the esophagus into the pharynx.

The flow dynamics and pressure relationships in an ulcerated atherosclerotic carotid bulb obtained at post-mortem were studied and correlated with angiographic findings in a similar live patient. Using the lost wax technique, we created replicas of an ulcerated atherosclerotic carotid bulb from a fresh cadaver, and placed those replicas in a circuit of pulsating non-Newtonian fluid. Flow profiles were adjusted to replicate human physiologic flows, and flow rates of 400,600, and 800 milliliters per minute were evaluated. In the replicas, the slipstreams were opacified with iso-baric dyes, and images were recorded both on 35 mm film and on SuperVHS high speed video. Data were collected from needles placed radially in the common carotid artery, in the region of the maximal atherosclerotic narrowing, and in the internal carotid artery. Though pressure relationships could not be obtained in the live human for ethical reasons, angiography in a similar stenosis was evaluated for slipstream dynamics. The post-mortem replica had a 55% diameter stenosis (88% area stenosis) of the carotid bulb with a shallow 3 mm ulcer. Flow in the common carotid artery showed undisturbed slipstreams, but as these slipstreams entered the narrow bulb, they crowded together, accelerating dramatically, with a jet continuing distally beyond the maximal narrowing for at least 2 vessel diameters, where flow again became normal. As fluid entered the narrowed bulb, radial pressures decreased and within the ulcer a vortex circulation was found. Similar findings were observed on the angiographic images of the live patient. This combination of events, the slowly swirling fluid in the ulcer, which would allow platelet aggregates to form, and the intermittent low pressure of the Bernoulli effect which could pull the aggregates into the adjacent rapidly flowing blood may help explain how ulcerated carotid plaques lead to embolic stroke.

Whereas International Headache society (IHS) criteria of carotidynia were defined in 1988, its validity as a distinct nosological entity has recently been questioned, leading this entity to be removed from the second IHS classification in 2004. We report the case of a 30-year-old woman who developed a pain located at the left carotid bulb, associated with typical findings on ultrasonography and MRI. We discuss new criteria and denomination of this clinical entity.

Purpose: To determine the prevalence of carotid disease in patients presenting for a routine ECHO for non-vascular reasons and to correlate the findings with the patient's Framingham Risk Score (FRS). Methods: Males ≥40 years and females ≥50 years were eligible for participation. All gave signed informed consent to participate and completed a questionnaire regarding history of previous vascular disease, current Statin use, current smoking, diabetes, treatment for hypertension and family history of premature coronary disease. A recent lipid profile was obtained from their family doctor and if not available blood work was taken for fasting lipids. A limited carotid study was performed during the ECHO, 6 images were taken to include the Common Carotid Artery (CCA), carotid bulb and internal carotid artery bilaterally. Any carotid plaque or CCA IMT ≥1.20mm is indicative of increased cardiovascular risk according to the Canadian lipid guidelines. Results: 431 consecutive patients underwent a routine ECHO. 315 patients were excluded, mostly due to either current Statin use, or known vascular disease, (215), or age criteria (23 males 2.0mmol/l which is the Canadian guideline threshold for Statin therapy. 38 patients were classified as high FRS and 36 of these had an LDL cholesterol >2.0mmol/l, yet none were treated indicating that their FRS had likely never been previously calculated. [1]: pending:yes

Background: Transient ischemic attacks and stroke are commonly caused by vulnerable plaques in the carotid bulb. Noninvasive ultrasound imaging techniques, revealing spatial inhomogeneities in strain distribution, could possibly improve the timely diagnosis of plaque at risk of rupturing. Methods: In 20 subjects with cerebrovascular ischemia, radiofrequency ultrasound data, covering 20 by 24mm, of the carotid bulb and distal common carotid artery (CCA) were twice and bilaterally recorded during 6 cardiac cycles to assess 2D wall strain rate distribution at radial and lateral increments of 0.45mm and 1.8mm, respectively at peak distension rate. Results: Reproducible strain rates were obtained for distal CCA and carotid bulbs free of plaques (unilateral intrasubject variation of 1.1±0.6%/s and 1.2±0.7 %/s, respectively). Strain rate was generally higher in the distal CCA (7.5±3.9%/s) than in carotid bulb (3.4±2.5%/s). Strain inhomogeneity was significantly associated to plaque area (p

Carotidynia is a syndrome of pain in the neck and face accompanied by local tenderness of the carotid artery. The symptoms are often misdiagnosed due to similarities with more common syndromes involving the cervical region. Spontaneous remission is common; more severe cases generally respond to anti-inflammatory medication or prophylactic drugs used for migraine. A case of severe carotidynia, unassociated with migraine is reported. Failure to respond to medical therapy led to surgical denervation of the carotid bulb. The immediate relief of symptoms following surgery confirms earlier observations regarding the mechanism of the symptoms. In severe cases of carotidynia, surgical denervation of the carotid artery may be indicated if medical therapy has failed.

The combination of pulsed echo with pulsed Doppler provides a system that is capable of imaging peripheral arteries and veins and evaluating velocity patterns across suspected areas of narrowing. The method has been most widely applied to the evaluation of carotid artery disease for the detection and grading of lesions in the carotid bulb. Recent experience has suggested that the technique may also be applied to the vessels of the limb, the abdominal aorta, visceral arteries, and the deep veins. The use of this method is indicated for screening purposes and long-term follow-up of patients who have or have not had surgery.

In patients with carcinoma of the head and neck region, various muscle flaps have been utilized to cover large surgical defects to help buttress a suture line, for cosmetic purposes, or to protect the carotid bulb and carotid arteries. The technic and our experience with more than fifty cases are outlined.

To the Editor: —Dr. Comroe's reasonable and thoughtful criticisms deserve comment. First, he would require sham operations for a control series. This, in effect, has been done. Professor Nakayama accepted 50 unrelieved patients who had been operated upon by other surgeons but with no change in their asthmatic statuses. The carotid bulb area had been previously exposed, but apparently the carotid body was overlooked. Dr. Nakayama reoperated, located the carotid body, and removed it. Relief in this group paralleled that obtained in other cases where removal was documented histologically. After our initial success with glomectomy in certain desperate asthmatic patients, we have had an increasing number of patients referred to us specifically for cartoid body removal. In balancing a negligible risk against the probable benefits of glomectomy, we could do nothing but proceed with excision of one carotid body in all those patients in whom we considered it to be