Search

Background Patients with isolated cervical carotid artery occlusion not eligible to recanalization therapies but with compromised intracranial hemodynamics may be at risk of further clinical events. Apart from lying flat until spontaneous recanalization or adjustment of the collateral circulation hopefully occurs, no specific treatment is currently implemented. Improving collateral flow is an attractive option in this setting. Lower body positive pressure (LBPP) is known to result in rapid venous blood shift from the lower to the upper body part, in turn improving cardiac preload and output, and is routinely used in acute hemorrhagic shock. We report here cerebral blood flow velocities measured during LBPP in this patient population. Methods This is a retrospective analysis of the clinical, physiological, and transcranial Doppler monitoring data collected during and 15 min after LBPP in 21 consecutive patients (10 females, median age: 54 years) with recently symptomatic isolated carotid occlusion/tight stenosis (unilateral in 18) mostly due to atherosclerosis or dissection. LBPP was applied for 90 min at a median 5 days after symptom onset. Results At baseline, middle-cerebral artery velocities were markedly lower on the symptomatic, as compared to asymptomatic, side. LBPP significantly improved blood flow velocities in both the symptomatic and asymptomatic middle-cerebral artery as well as the basilar artery, which persisted 15 min after discontinuing the procedure. LBPP also resulted in mild but significant increases in mean arterial blood pressure. Conclusions LBPP improved intracranial hemodynamics downstream recently symptomatic carotid occlusion/tight stenosis as well as in the contralateral and posterior circulations, which persisted after LBPP deflation. Randomized trials should determine if this easy-to-use, noninvasive, nonpharmacologic approach has long-lasting benefits on the intracranial circulation and improves functional outcome.

Background and purpose Extracranial-to-intracranial (EC-IC) surgical bypass improves cerebral blood flow (CBF) and cerebrovascular vasoreactivity (CVR) for patients with carotid occlusion. Bypass graft patency and contribution of the graft to the postoperative increase in CVR are challenging to assess. To assess the effectiveness of 4D flow magnetic resonance imaging (MRI) to evaluate bypass graft patency and flow augmentation through the superficial temporal artery (STA) before and after EC-IC bypass. Methods Three consecutive patients undergoing EC-IC bypass for carotid occlusion were evaluated pre- and postoperatively using CVR testing with pre- and poststimulus 4D flow-MRI for assessment of the bypass graft and intracranial vasculature. Results Preoperatively, 2 patients (patients 1 and 3) did not augment flow through either native STA. The third, who had evidence of extensive native EC-IC collateralization on digital subtraction angiography (DSA), did augment flow through the STA preoperatively (CVR = 1). Postoperatively, all patients demonstrated CVR > 1 on the side of bypass. The patient who had CVR > 1 preoperatively demonstrated the greatest increase in resting postoperative graft flow (from 40 to 130 mL/minute), but the smallest CVR, with a poststimulus graft flow of 160 mL/minute (CVR = 1.2). The 2 patients who did not demonstrate augmentation of graft flow preoperatively augmented postoperatively from 10 to 20 mL/minute (CVR = 2.0) and 10-80 mL/minute (CVR = 8.0), respectively. Intracranial flow was simultaneously interrogated. Two patients demonstrated mild reductions in resting flow velocities in all interrogated vessels immediately following bypass. The patient who underwent CVR testing on postoperative day 48 demonstrated a stable or increased flow rate in most intracranial vessels. Conclusion Four-dimensional flow MRI allows for noninvasive, simultaneous interrogation of the intra- and extracranial arterial vasculature during CVR testing, and reveals unique paradigms in cerebrovascular physiology. Observing these flow patterns may aid in improved patient selection and more detailed postoperative evaluation for patients undergoing EC-IC bypass.

Positional occlusion of the internal carotid artery is an unusual phenomenon. Reports are scarce in the literature and generally related to compression by external agents when the head is rotated. Cases with no extrinsic etiology are even more uncommon and require high suspicion to avoid misdiagnosis. We present a case of a patient with intermittent internal carotid occlusion depending on the position of the head with no external agent identified. Due to the dynamic characteristics of this presentation, diagnostic tests yielded contradictory results. Carotid ultrasound during neck rotation revealed the positional occlusion. Ultrasound is a versatile technique to explore the carotid arteries in different angles of the neck, useful if positional pathology is suspected. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s40477-020-00490-7) contains supplementary material, which is available to authorized users.

Summary: Background: The correct diagnosis of internal carotid artery (ICA) occlusion is crucial as it limits unnecessary intervention, whereas correct identification of patients with severe ICA stenosis is paramount in decision making and selecting patients who would benefit from intervention. We aimed to evaluate the accuracy of ultrasonography (US) in the diagnosis of ICA occlusion. Methods: We conducted a systematic review in compliance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) of diagnostic test accuracy studies. We interrogated electronic bibliographic sources using a combination of free text and thesaurus terms to identify studies assessing the diagnostic accuracy of US in ICA occlusion. We used a mixed-effects logistic regression bivariate model to estimate summary sensitivity and specificity. We developed hierarchical summary receiver operating characteristic (HSROC) curves. Results: We identified 23 studies reporting a total of 5,675 arteries of which 722 were proven to be occluded by the reference standard. The reference standard was digital subtraction or cerebral angiography in all but two studies, which used surgery to ascertain a carotid occlusion. The pooled estimates for sensitivity and specificity were 0.97 (95% confidence interval (CI) 0.94 to 0.99) and 0.99 (95% CI 0.98 to 1.00), respectively. The diagnostic odds ratio was 3,846.15 (95% CI 1,375.74 to 10,752.65). The positive and negative likelihood ratio were 114.71 (95% CI 58.84 to 223.63) and 0.03 (95% CI 0.01 to 0.06), respectively. Conclusions: US is a reliable and accurate method in diagnosing ICA occlusion. US can be used as a screening tool with cross-sectional imaging being reserved for ambiguous cases.

Background and Purpose: Despite the findings reported in the COSS (Carotid Occlusion Surgery Study), patients with atherosclerotic cerebrovascular disease continue to be referred for superficial temporal artery to middle cerebral artery bypass surgery. Here, we determined how today’s patients differ from the population reported in COSS. Methods: We retrospectively analyzed all patients that were referred to our Department for superficial temporal artery to middle cerebral artery bypass surgery of atherosclerotic cerebrovascular disease following the publication of COSS. Results: Between 2012 and 2019, 179 patients were referred for 186 bypass surgeries. Ninety-one (51%) patients suffered atherosclerotic, unilateral internal carotid occlusion and 88 (49%) atherosclerotic multivessel disease. All patients had received intensive medical management. A single transitory ischemic attack or ischemic stroke within the last 120 days according to the inclusion criteria of COSS occurred in only 36 out of 179 (20%) patients, whereas 27 out of 179 (15%) suffered >1 transitory ischemic attack within 120 days, 109 out of 179 (61%) had recurrent minor ischemic stroke, and 7 out of 179 (4%) were hemodynamically unstable and required blood pressure maintenance. The distribution of symptoms did not differ between atherosclerotic unilateral internal carotid artery occlusion and atherosclerotic multivessel disease ( P =0.376) but hemodynamic impairment was significantly greater in atherosclerotic multivessel disease ( P Conclusions: Patients referred for flow augmentation surgery today appear to suffer more severe symptoms and vessel occlusion patterns than patients reported in COSS. A new, carefully designed randomized controlled trial appears warranted, considering the still poor prognosis of severe atherosclerotic cerebrovascular disease.

Covid-19 infection has been declared a pandemic by the World Health Organization. We present a unique case of a middle-aged gentleman, who recovered from asymptomatic Covid-19 infection and presented again with delayed stroke. He had vision loss secondary to internal carotid artery occlusion in the absence of neurological symptoms. To the best of our knowledge, this is the first case that describes cerebrovascular stroke due to delayed large vessel occlusion secondary to Covid-19 infection presenting as monocular vision loss.

The presence of contralateral carotid occlusion (CCO) has been controversial throughout the history of carotid intervention. Some studies cite a higher stroke risk in the setting of CCO, whereas other studies document no difference in stroke risk. We investigated the risk of stroke after intervention in the setting of CCO in a large, national, validated dataset.Data were obtained from the 2011-2014 American College of Surgeons National Surgical Quality Initiative Project files using targeted carotid endarterectomy (CEA), carotid angioplasty, and carotid artery stenting (CAS) data. Patient and procedural characteristics, and 30-day postoperative outcomes were compared using Pearson χDuring the study period, 11,948 CEA and 422 CAS procedures were available for study, with significantly fewer CEA (4.73% of all CEA) than CAS (9.95%; P .0001) occurring in the setting of CCO. CAS was associated with more severe degree of stenosis than CEA (P = .045). Multivariable logistic regression showed that stroke after procedures was higher in patients with CCO than without CCO (odds ratio, 1.73; 95% confidence interval, 1.08-2.76; P = .02), but specific procedure (CEA vs CAS) was not associated with stroke while controlling for confounders. However, when evaluating our secondary composite outcome, CCO was not associated with the outcome while controlling for confounders.There is currently a bias that CCO confers a higher risk on patients undergoing carotid procedures and this notion is manifest in the proportion of CEA and CAS procedures done in the setting of CCO. Our study observes that CCO provides only a minor influence on periprocedural stroke risk and that other factors are more closely tied to outcomes of CEA and CAS.

Objective To describe the first cases of carotid occlusions identified by the Portuguese neurologist Egas Moniz while performing the cerebral angiography he invented. Methods We reviewed the publications of Egas Moniz on the subject of cerebral angiography and ischemic stroke. Results We identified the first description of carotid occlusion a situation unknown until then. Also, some of the carotid occlusions he described were suggestive of dissection an unknown situation. Nevertheless, he admitted the role of trauma in such cases by lesioning the intimal layer and he also described the characteristic post-bulbar ”bezel-like“ image of dissection. Conclusions In 1936 Egas Moniz described, for the first time, one case of carotid occlusion a situation unknown until then. He also described some of the characteristic aspects of carotid dissections. Carotid occlusions were only thoroughly described in English literature more than a decade later with the well-known work of Miller Fisher, in 1951.

BackgroundThe optimal treatment and prognosis for stroke patients with tandem cervical carotid occlusion are unclear. We analyzed outcomes and treatment strategies of tandem occlusion patients in the ESCAPE-NA1 trial.MethodsESCAPE-NA1 was a multicenter international randomized trial of nerinetide versus placebo in 1105 patients with acute ischemic stroke who underwent endovascular treatment. We defined tandem occlusions as complete occlusion of the cervical internal carotid artery (ICA) on catheter angiography, in addition to a proximal ipsilateral intracranial large vessel occlusion. Baseline characteristics and outcome parameters were compared between patients with tandem occlusions versus those without, and between patients with tandem occlusion who underwent ICA stenting versus those who did not. The influence of tandem occlusions on functional outcome was analyzed using multivariable regression modeling.ResultsAmong 115/1105 patients (10.4%) with tandem occlusions, 62 (53.9%) received stenting for the cervical ICA occlusion. Of these, 46 (74.2%) were stented after and 16 (25.8%) before the intracranial thrombectomy. A modified Rankin Score (mRS) of 0–2 at 90 days was achieved in 82/115 patients (71.3%) with tandem occlusions compared with 579/981 (59.5%) patients without tandem occlusions. Tandem occlusion did not impact functional outcome in the adjusted analysis (OR 1.5, 95% CI 0.95 to 2.4). Among the subgroup of patients with tandem occlusion, cervical carotid stenting was not associated with different outcomes compared with no stenting (mRS 0–2: 75.8% vs 66.0%, adjusted OR 2.0, 95% CI 0.8 to 5.1).ConclusionsTandem cervical carotid occlusion in patients with acute large vessel stroke did not lower the odds of good functional outcome in our study. Functional outcomes were similar irrespective of the management of the cervical ICA occlusion (stenting vs not stenting).

Background: The degree of cortical venous opacification could reflect the degree of ischemia in tandem occlusions strokes. We assessed the association between asymmetric cortical vein opacification and outcome among patients with acute ischemic stroke and tandem occlusion. Methods: ESCAPE NA1 was a multicenter randomized-controlled trial comparing medical treatments nerinetide vs. placebo in patients with acute ischemic stroke and large vessel occlusion who underwent EVT. Tandem carotid occlusion was defined as complete occlusion of the ICA on catheter angiography. We assessed cortical venous opacification on baseline CTA using the COVES score (Jansen, et al. Radiology 2019, ranging from 0-6 with lower numbers indicating poor cortical venous filling, and dichotomized to 0 vs. 1-6). The influence of cortical venous opacification on functional outcome was analyzed using regression modelling with adjustment for age, baseline NIHSS and ASPECTS, thrombolysis and treatment allocation. Results: We assessed 115 patients with tandem occlusion. Median COVES score was 2 (IQR 1-3) with 9 patients (8%) scoring 0 (complete absence of cortical venous filling). Patients with COVES 0 were less likely to have good leptomeningeal collaterals (good collaterals: COVES 0: 0/9 (0%) vs. COVES 1-6: 19/102 (18%), p = 0.007). Patients with COVES 0 were less likely to achieve good outcome (mRS 0-2, COVES 0: 3/9 patients (33%) vs. COVES 1-6: 79/106 (74%), p=0.016). Cortical venous filling was significantly associated with good functional outcome on univariable analysis (OR 5.9, 95%CI 1.4 - 25.0), and after adjustment for baseline variables (OR 8.6, 95%CI 1.4 - 51.0). Cervical carotid angioplasty and/or stenting did not modify functional outcome after adjustment for COVES score. Conclusion: Impaired venous drainage is a marker of poor pial collaterals and is associated with poorer outcome in tandem occlusion patients.

Background: The optimal treatment for stroke patients with tandem cervical carotid occlusion is debated. We analyzed the treatment strategies and outcomes of tandem occlusion patients in the ESCAPE NA1 trial. Methods: ESCAPE NA1 was a multicenter international randomized trial of nerinetide vs. placebo in patients with acute ischemic stroke who underwent EVT. We defined tandem occlusions as complete occlusion of the cervical ICA on catheter angiography. The influence of tandem occlusions on outcome was analyzed using regression modeling with adjustment for age, sex, baseline NIHSS and ASPECTS, occlusion location, thrombolysis and treatment allocation. Results: 115 of 1105 patients (10.4%) had tandem occlusions. 73/115 tandem patients (66.0%) received treatment for the cervical occlusion: 21.9% were stented before thrombectomy, 68.5% were stented after thrombectomy, and 8.2% had angioplasty alone. Successful reperfusion was significantly higher in patients who had thrombectomy first followed by carotid treatment (eTICI 2b-3: 40/40 (100.0%)) or carotid angioplasty before and cervical stent after intracranial thrombectomy (9/10 (90.0%)) compared to carotid intervention before intracranial thrombectomy: (19/23 (82.1%), p=0.016). 90-day mRS 0-2 was achieved in 82/115 patients (71.3%) with tandem occlusions (treated occlusions: 74.0%, untreated: 66.7%) compared to 579/981 (59.5%) patients without tandem occlusions. In adjusted analysis, tandem occlusion was not predictive of outcome. In the subgroup of tandem patients, cervical stent-treatment was nominally associated with better outcomes (OR 2.2, 95% CI 0.5 - 9.2). Conclusion: Cervical carotid stenting may improve outcomes for EVT patients with tandem occlusions, but these results are limited by the sample size and non-randomized selection of patients for stenting.

Introduction: Contralateral carotid occlusion (CCO) is an established high-risk feature for carotid endarterectomy (CEA) and is a reason to recommend carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA. We investigated the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry. Hypothesis: CCO confers an elevated risk of in-hospital adverse events among patients undergoing CEA, but not CAS. Methods: All patients undergoing CEA or CAS from 2005-2019 in the NCDR CARE and PVI registries were included. The primary exposure was the presence of a CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Analyses were stratified by treatment with CEA or CAS. Multivariable logistic regression models were used to identify factors associated with adverse outcomes. Results: Among 58,423 patients, 4,624 (7.9%) patients had a CCO. Of those, 68.9% (N=3,185) underwent CAS and 31.1% (N=1,439) underwent CEA. The average age of patients with CCO was 69.5±9.7, 32.6% were female, 92.8% were Caucasian, 51.7% had a prior TIA or stroke, and 45.4% had symptomatic disease. Over the study period, there was a 4.3% decline in procedures performed on patients with CCO (p Conclusions: In this contemporary nationwide registry analysis, CCO remains an important predictor of increased risk in patients undergoing CEA, but not CAS. These data support the continued use of CCO to guide carotid revascularization strategy.

The presence of a contralateral carotid occlusion (CCO) is an established high-risk feature for patients undergoing carotid endarterectomy (CEA) and is traditionally an indication for carotid artery stenting (CAS). Recent observational data have called into question whether CCO remains a high-risk feature for CEA.The purpose of this study was to determine the clinical impact of CCO among patients undergoing CEA and CAS in a contemporary nationwide registry.All patients undergoing CEA or CAS from 2007 to 2019 in the NCDR CARE (National Cardiovascular Data Registry Carotid Artery Revascularization and Endarterectomy) and PVI (Peripheral Vascular Intervention) registries were included. The primary exposure was the presence of CCO. The outcome was a composite of in-hospital death, stroke, and myocardial infarction. Multivariable logistic regression and inverse-probability of treatment weighting were used to compare outcomes.Among 58,423 patients who underwent carotid revascularization, 4,624 (7.9%) had a CCO. Of those, 68.9% (n = 3,185) underwent CAS and 31.1% (n = 1,439) underwent CEA. The average age of patients with CCO was 69.5 ± 9.7 years, 32.6% were women, 92.8% were Caucasian, 51.7% had a prior transient ischemic attack or stroke, and 45.4% presented with symptomatic disease. Over the study period, there was a 41.7% decrease in the prevalence of CCO among patients who underwent carotid revascularization (p0.001), but CAS remained the primary revascularization strategy. Unadjusted composite outcome rates were lower in patients with CCO after CAS (2.1%) than CEA (3.6%). Following adjustment, CCO was associated with a 71% increase in the odds of an adverse outcome after CEA (95% confidence interval: 1.27 to 2.30; p 0.001) compared with no increase after CAS (adjusted odds ratio: 0.94; 95% confidence interval: 0.72 to 1.22; p = 0.64).CCO remains an important predictor of increased risk among patients undergoing CEA, but not CAS.

We report the case of a 62-year-old male patient, admitted for aortic valve replacement. Bilateral common carotid artery occlusion and bilateral internal carotid artery occlusion have been reported, as well as right vertebral artery occlusion. Aortic valve replacement was performed in the standard fashion using the cardiopulmonary bypass. No neurological deficit was apparent on emergence from anesthesia. Keywords: bilateral carotid occlusion, the vertebral artery occlusion, cardiac surgery

Chronic carotid occlusion is a poorly explored subject, deserving clarity regarding its definition, risks, and management. In this chapter we explore the etiologies of chronic carotid occlusion and the multitude of terminologies that have been used to describe it. We review its potential clinical manifestations, including the risk of stroke, which has varied widely in the existing body of literature. We describe diagnostic techniques to distinguish chronic carotid occlusion from acute occlusion or high-grade stenosis. Finally, we discuss management and review prior and ongoing studies which attempt to lower risk by a medical, surgical, or endovascular approach.

Acute and subacute carotid occlusion represents a challenging clinical scenario. Treatment paradigms are shifting towards being more aggressive with revascularization. In patients with a symptomatic occlusion and a favorable infarct burden, revascularization should be considered. Multiple imaging modalities, including DUS, CTA, MRI, perfusion imaging, and traditional catheter angiography should be used to draw a comprehensive picture of the patient’s intracranial perfusion and reserve at the time of presentation. Questions regarding the superiority of open versus endovascular treatment, angioplasty and stenting versus angioplasty alone, and proximal-to-distal versus distal-to-proximal treatment order have yet to be answered.

Background: The efficacy of single-session stereotactic radiosurgery (sSRS) for the treatment of intracranial meningioma is widely recognized. However, sSRS is not always feasible in cases of large tumors and those lying close to critically radiation-sensitive structures. When surgery is not recommended, multi-session stereotactic radiosurgery (mSRS) can be applied. Even so, the efficacy and best treatment schedule of mSRS are not yet established. The aim of this study is to validate the role of mSRS in the treatment of skull base meningiomas. Methods: A retrospective analysis of patients with skull base meningiomas treated with mSRS (two to five fractions) at the University of Messina, Italy, from 2008 to 2018, was conducted. Results: 156 patients met the inclusion criteria. The median follow-up period was 36.2 &plusmn, 29.3 months. Progression-free survival at 2-, 5-, and 10- years was 95%, 90%, and 80.8%, respectively. There were no new visual or motor deficits, nor cranial nerves impairments, excluding trigeminal neuralgia, which was reported by 5.7% of patients. One patient reported carotid occlusion and one developed brain edema. Conclusion: Multisession radiosurgery is an effective approach for skull base meningiomas. The long-term control is comparable to that obtained with conventionally-fractionated radiotherapy, while the toxicity rate is very limited.

Post carotid endarterectomy seizures as a result of hyperperfusion syndrome are well known. Nonconvulsive status epilepticus following carotid endarterectomy manifesting as decreased mental response and akinetic mutism mimicking post carotid endarterectomy stroke occurred in a patient with severe ipsilateral carotid stenosis and contralateral internal carotid occlusion. Prompt confirmation of diagnosis by EEG and timely institution of anti-seizure medications resulted in satisfactory outcome.

Background Large vessel disease stroke subtype carries the highest risk of early recurrent stroke. In this study we aim to look at the association between impaired perfusion and early stroke recurrence in patients with intracranial atherosclerotic disease or total cervical carotid occlusion. Methods This is a retrospective study from a comprehensive stroke center where we included consecutive patients 18 years or older with intracranial atherosclerotic disease or total cervical carotid occlusion admitted with a diagnosis of ischemic stroke within 24 h from symptom onset with National Institute Health Stroke Scale max > 6 s mismatch volume (penumbra volume–infarct volume) of 15 ml or more. The outcome was recurrent cerebrovascular events at 90 days defined as worsening or new neurological symptoms in the absence of a nonvascular cause attributable to the decline, or new infarct or infarct extension in the territory of the affected artery. We used Cox proportional hazards models to determine the association between impaired perfusion and recurrent cerebrovascular events. Results Sixty-two patients met our inclusion criteria; mean age 66.4 ± 13.1 years, 64.5% male (40/62) and 50.0% (31/62) with intracranial atherosclerotic disease. When compared to patients with favorable perfusion pattern, patients with unfavorable perfusion pattern were more likely to have recurrent cerebrovascular events (55.6% (10/18) versus 9.1% (4/44), p Conclusion Perfusion mismatch predicts recurrent cerebrovascular events in patients with ischemic stroke due to intracranial atherosclerotic disease or total cervical carotid occlusion. Studies are needed to determine the utility of revascularization strategies in this patient population.

Purpose To evaluate the diagnostic accuracy and reliability of computed tomographic (CT) angiography to distinguish true cervical internal carotid artery (ICA) occlusion from pseudo-occlusion (defined as an isolated intracranial thrombus that impedes ascending blood flow) in the context of acute stroke. Materials and Methods This was a retrospective study of patients who underwent thrombectomy with preprocedural CT angiography that helps to demonstrate a lack of attenuation in the cervical ICA on the symptomatic side (24 men and 13 women; mean age, 63 years; age range, 30-86 years). Seven readers, including five neuroradiologists and two interventional neuroradiology fellows, independently reviewed the CT angiography images to assess whether there was true cervical ICA occlusion. Their results were compared with digital subtraction angiography (DSA) as the reference standard. Sensitivity and specificity for detecting true occlusion as well as accuracy and diagnostic odds ratio were calculated, with inter- and intraobserver κ statistics. Results Cervical ICA pseudo-occlusion occurred in 12 of 37 patients (32.4%) with nonattenuation of the cervical ICA on the symptomatic side. Interobserver agreement coefficients did not reach the substantial value of 0.61 for either pairs or groups of readers. The cohort's average sensitivity and specificity was 68% (95% confidence interval [CI]: 59%, 76%) and 75% (95% CI: 71%, 80%), respectively, with a diagnostic odds ratio of 8 (95% CI: 3, 18) and only fair interobserver agreement (κ = 0.32; 95% CI: 0.16, 0.47). Conclusion In the context of acute ischemic stroke with ipsilateral ICA nonattenuation at single-phase CT angiography, even specialized radiologists may not reliably distinguish true cervical occlusion from pseudo-occlusion.

This study sought to analyze the incidence of contralateral microembolic infarctions (MIs) on diffusion-weighted imaging (DWI) following protected carotid artery stenting (CAS) and compared the difference of risk factors between ipsilateral and contralateral lesions. From April 2010 to March 2017, 147 CASs in 140 patients were performed. All the patients underwent DWI within 1 week before and 24 hrs after the procedures. CAS was successfully completed in 145 (98.6%) of the 147 procedures. Forty-nine (33.8%) patients with new MIs revealed on postprocedural DWI were enrolled. They were divided into ipsilateral and contralateral groups based on the side of the CAS and MIs. The ipsilateral group indicates patients with MIs exclusively on the side of CAS. The contralateral group includes patients with MIs on the opposite side of the CAS or both sides. Patients with MIs at vertebrobasilar territory were excluded. Patient characteristics, morphology of the carotid artery and aortic arch, and procedural data were retrospectively assessed and compared between the two groups. Twenty-two (15.2%) and 14 (9.7%) patients were assigned to the ipsilateral and contralateral groups, respectively. Advanced age, left-sided stenosis, severe aortic arch calcification (AAC) on chest X-ray and contralateral carotid occlusion significantly increased the occurrence of contralateral MIs. On multivariable logistic regression analysis, severe AAC was statistically more frequent in the contralateral group. In the present study, the incidences of contralateral MIs after CAS is relatively not low. Advanced aortic atherosclerosis is statistically predictive for contralateral MIs. AAC on chest X-ray is a useful finding for estimating aortic atherosclerosis in candidates for CAS.

Background: Craniotomy and surgical clipping is the standard modality of treatment in patients of cerebral aneurysms. However, the surgical clipping of aneurysm may pose serious difficulties in the case of a bilateral carotid artery occlusion. The endovascular treatment has shown promising results in this disease. Methods: A retrospective study of all patients of posterior circulation aneurysms in the background of carotid occlusive disease at our department was performed. The aim of this study was to describe the clinical, radiological characteristics, and the treatment of this rare entity. Results: Four patients were treated from January 2009 to October 2015. The mean age of our patients was 34 years with ages that ranged from 17 to 45 without any gender predominance. The mean period between onset of symptoms and diagnosis was 6 weeks. Angiographic localization of the disease was observed in all patients. All patients were treated by endovascular techniques. The postoperative course has been satisfactory with a complete neurological recovery in all patients. Conclusions: Rupture of posterior circulation aneurysms in the setting of bilateral internal carotid artery occlusion is extremely rare. Treatment is exclusively endovascular intervention. The functional outcome of ruptured posterior circulation aneurysms in setting of bilateral carotid occlusive disease is particularly favorable with good neurological recovery.

Acute carotid occlusion is a rare but important complication that can occur after a carotid endoacrterectomy (CEA) procedure. Standard intervention after a re-occlusion is usually surgical. We reported a case of a 78-year old patient with acute internal carotid occlusion after a CEA and sociated intracranial embolization to the posterior communicating artery. Surgical approach was therefore excluded because of the above-mentioned cerebral perfusion deficit. Endovascular treatment allowed to restore the proper ICA vessel caliber and the cerebral blood flow through a thromboaspiration catheter. Moreover, the procedure was performed using devices usually intended for other body district. Endovascular treatment could represent an alternative treatment in post-CEA acute occlusions, especially in patient with associated intracranial perfusion deficit, allowing the operator to resolve both issues and reduce the overall ischemic time.

Carotid duplex ultrasound (CDU) is a commonly performed vascular exam for the detection of carotid disease. In most cases, the exam is performed to detect hemodynamically significant changes that could cause a cerebrovascular accident. Ultrasound is accurate in the detection of >70% stenosis. CDU exams are often used to detect a potentially harmful atherosclerotic process before it embolizes. In some cases, the atherosclerotic formation will be so great that it will occlude the extracranial vessels. The true incidence of carotid occlusion is not well known as it may be asymptomatic. CDU can show where the occlusion is located and if the bifurcation is patent which can reveal treatment options for the patient. Carotid occlusions can be medically managed or may require surgery to restore flow to the cerebrovasculature.

This study aimed to report the clinical features and early and long-term outcomes of patients treated with carotid endarterectomy (CEA) combined with a routine shunt for carotid stenosis with the occlusion of the contralateral carotid artery (CCO), and to compare them with patients without contralateral occlusion (NO-CCO). A retrospective analysis included 301 patients who had carotid artery stenosis treated with CEA using a routine shunt. Of these patients, 35 patients and 266 patients were categorized into a CCO group and NO-CCO group, respectively. Demographics and short-term and long-term outcomes were documented and compared. The demographic characteristics were not significantly different between the two groups. The periprocedural mortality, stroke rate, and rate of periprocedural myocardial infarction were not significantly different between both groups. The mean follow-up period for long-term outcomes was 34.45 ± 22.99 months, and the Kaplan-Meier analysis showed no statistical difference between both groups regarding stroke, myocardial infarction, and mortality. CEA combined with the routine shunt is an effective and durable procedure for carotid artery stenosis patients with CCO.

Summary: Background: To assess the vascular and clinical course of acute symptomatic extracranial internal carotid artery (ICA) occlusion. Patients and methods: Patients with an acute ischemic event in the anterior circulation and corresponding extracranial ICA occlusion at CT angiography and/or color-coded duplex sonography underwent recurrent duplex follow-up for detection of spontaneous recanalization. Stroke recurrence and functional outcome 4.5 months after the ischemic index event assessed by modified Rankin scale served as secondary outcome parameters. Results: 133 patients (91 men, mean age 62.3 years, SD 10.8) demonstrated symptomatic occlusion of the extracranial ICA with open intracranial ICA and open middle cerebral artery and were followed-up for spontaneous recanalization. Twenty-eight recanalized spontaneously, 25 to high-grade focal stenosis within 12 days, revealing an early cumulative recanalization rate of 23 %. Detection of recanalization was independently associated with de novo dual anti-platelet therapy (adjusted odds ratio [OR], 3.24; 95 % confidence interval [CI], 1.34 to 7.80). Ischemic recurrence occurred in 16 patients, of which 10 deemed to be embolic and 5 hemodynamic. Spontaneous ICA recanalization and an exhausted cerebrovascular reserve in the hemisphere distal to the occluded ICA were both independently associated with the occurrence of a recurrent ischemic event at Cox regression. An increasing NIHSS score at admission, a decreasing middle cerebral artery flow velocity and an ischemic recurrence independently predicted poor outcome (modified Rankin scale 3 to 6) in multivariate analysis. Conclusions: Acute symptomatic extracranial ICA occlusion is an unstable condition with frequent spontaneous recanalization to severe stenosis and early embolic stroke recurrence, demanding appropriate prevention especially in those patients with only mild deficit.

We aimed to investigate the effect of chronic cerebral hypoperfusion on cerebral hemodynamics and perivascular nerve density in a rat model. Bilateral common carotid artery (CCA) ligation (n = 24) or sham‐operation (n = 24) was performed with a 1‐week interval. A subgroup (ligated n = 6; sham‐operated n = 3) underwent magnetic resonance imaging (MRI) before the procedures and 2 and 4 weeks after the second procedure. After termination, carotids were harvested for assessment of complete ligation and nerve density in cerebral arteries that were stained for the general neural marker PGP 9.5 and sympathetic marker TH by computerized image analysis. Five rats were excluded because of incomplete ligation. MRI‐based tortuosity of the posterior communicating artery (Pcom), first part of the posterior cerebral artery (P1) and basilar artery was observed in the ligated group, as well as an increased volume (p = 0.05) and relative signal intensity in the basilar artery (p = 0.04; sham‐group unchanged). Immunohistochemical analysis revealed that compared to sham‐operated rats, ligated rats had increased diameters of all intracircular segments and the extracircular part of the internal carotid artery (p

Objective: To evaluate the cerebral hemodynamic variations in patients with unilateral carotid artery stenosis and contralateral carotid occlusion (CCO) in hours following carotid artery stenting (CAS) by transcranial Doppler (TCD) or transcranial color-code Doppler (TCCD).Methods: Sixty-five consecutive patients who underwent unilateral CAS were enrolled. Among them, 14 patients had ipsilateral severe stenosis and CCO (CCO group) while the other 51 patients had only unilateral severe carotid stenosis without CCO (UCS group). All patients underwent TCD or TCCD monitoring before, at 1 and 3 h after CAS. We monitored bilateral middle cerebral artery (MCA) peak systolic velocity (PSV), pulsatility index (PI), and blood pressure (BP), and compared that data between two groups.Results: In UCS group, ipsilateral MCA PSV increased relative to baseline at 1 h (96 ± 30 vs. 85 ± 26 cm/s, 15%, P < 0.001) and 3 h (97 ± 29 vs. 85 ± 26 cm/s, 17%, P < 0.001) following CAS. Significant PI increases were observed at 1 and 3 h following CAS on the ipsilateral side. In CCO group, ipsilateral MCA PSV increased relative to baseline at 1 h (111 ± 30 vs. 83 ± 26 cm/s, 35%, P < 0.001) and 3 h (107 ± 28 vs. 83 ± 26 cm/s, 32%, P

Background Emergent large vessel occlusive (ELVO) stroke secondary to underlying carotid occlusive disease is frequently encountered in endovascular ischemic stroke therapy and trials. Up to 29% of all cerebral vascular accidents are attributed to severe carotid occlusive disease, and recent interventional trials have demonstrated this occurrence in 18.6–32.2% of ELVO stroke. We present a novel technique using the stent retriever guide wire to expedite angioplasty and/or stent placement for associated carotid occlusive disease during mechanical thrombectomy of ELVO stroke. This technique utilizes the “waiting time” during stent retriever integration within the thrombus as an opportunity to initiate revascularization of the cervical carotid, using the deployed stent retriever guidewire as an ad hoc rapid exchange wire while the stentriever serves as a potential surrogate distal embolic protection device. We present 23 cases using this novel endovascular approach, which we have called the single-cross technique, as the cervical lesion is only traversed once during therapy. Methods A case series of 23 consecutive patients who underwent a novel endovascular technique for treating tandem ICA origin and intracranial occlusive lesions is presented. Endpoints measured were time to re-perfusion, rates of intracranial hemorrhage and clinical outcomes (mRS at 30 and 90 days). Results Average procedure time for revascularizing both the carotid and intracranial lesions was 52 min. A symptomatic ICH rate of 9% was observed. Seventy-four percent of patients had an mRS of 0–2 at follow-up. Conclusions The single-cross technique appears to be a safe and effective option for treating tandem occlusive lesions in the setting of ELVO.

To assess technical results and close functional outcomes of acute ischemic stroke (AIS) in patients treated with endovascular thrombecomy (ET) in regional vascular centers (RVC) of St-Petersburg.Retrospective analysis of 183 patients with AIS, including 143 patients with AIS due to a large intracranial vessel occlusion in anterior (AC) and 25 patients in posterior cerebral (PC) circulation, 15 with isolated extracranial carotid occlusion treated in 6 RVC in 2017 was performed. All patients underwent ET.Effective reperfusion (mTICI 2b-3) was achieved in 71.5% (71.3% AC, 72% PC). On discharge, 35,7% patients had good (mRs 0-2) functional outcome (37.1% AC, 28% PC). The incidence of symptomatic intracranial hemorrhage (according to ECASS II criteria) was 10.7% (9.1% AC, 20% PC), the mortality was 29.2% (22.4% AC, 68% PC).). The results of our study show the possibility of effective and safe application of ET in patients with AIS in the anterior and posterior cerebral circulation in regional vascular centers of St.-Petersburg.Цель исследования. Оценить технические результаты и ближайшие функциональные исходы у пациентов, подвергшихся внутрисосудистой тромбоэмболэктомии (ВСТЭ) при остром ишемическом инсульте (ИИ), в условиях региональных сосудистых центров Санкт-Петербурга. Материал и методы. Проведен ретроспективный анализ результатов лечения 183 больных в остром периоде ИИ в 6 региональных сосудистых центрах в 2017 г. У 143 пациентов имел место инсульт, вызванный окклюзией магистральной интракраниальной артерии в каротидной системе (1-я группа), у 25 - окклюзия в вертебрально-базилярной системе (2-я группа), у 15 - изолированное поражение внечерепного отдела внутренней сонной артерии. Всем пациентам выполнялась ВСТЭ. Результаты и заключение. Частота эффективной реперфузии (градация по mTICI 2b-3) составила 71,5% (71,3 и 72% в 1-й и 2-й группах соответственно). Хороший функциональный исход (0-2 балла по mRs) на момент выписки был достигнут у 35,7% пациентов (у 37,1 и 28%). Частота симптомных внутричерепных кровоизлияний (по критериям ECASS II) составила 10,7% (9,1 и 20%), летальность - 29,2% (22,4 и 68%). Таким образом, результаты исследования свидетельствуют о возможности эффективного и безопасного использования ВСТЭ у пациентов с ИИ в передних и задних отделах артериального круга большого мозга в условиях региональных сосудистых центрах мегаполиса.

Purpose To introduce a case of bilateral retinal artery occlusions with carotid occlusions to achieve a fuller understanding of hemodynamic flow changes and the origin of emboli. Observations A 58-year-old male presented with binocular vision loss. Fundus examination revealed bilateral retinal whitening with multiple emboli. Cherry red spot was surrounded and shaped by white edematous ischemic retina. FAG showed retinal refilling but not to the macula and choroidal background. Carotid arteriography and color Doppler images demonstrated bilateral carotid occlusions. CT angiography showed compensatory flows perfused from vertebral arteries for the brain. Orbital color Doppler images revealed bilateral reversed ophthalmic flows indicating another compensatory flow arising from external carotid/ophthalmic collaterals to both eyes. Conclusions and Importance Reversed ophthalmic flow indicates the presence of external carotid/ophthalmic collaterals as the source of ocular blood supply and the origin of emboli. In this case, all the embolic, hemodynamic, and serotonin mechanisms may be responsible for the pathogenesis. RAO with multiple emboli is an important sign warning critical flow changes of carotid occlusions.

Persistence of proatlantal artery (PA) is a rare condition. More than 40 cases were described in the literature. Aneurysm may involve the PA itself in approximately 2% of cases, most arising from the internal carotid artery (ICA) side of PA. This case was particular because the PA showed a saccular aneurysm on the posterior wall, probably due to atherosclerosis disease and other alterations: plaque ulcerative of ICA, occlusion of left ICA, and aberrant right VA.

This study aims to investigate the relationship between cerebrovascular reserve (CVR) capacity, as measured by single-photon emission computed tomography (SPECT) and collateral blood flow, according to a transcranial colour-coded duplex(TCCD), in patients with symptomatic total carotid occlusion (TCO). Additionally, the study aims to determine whether vascular risk factors have an effect on collateral blood flow, as well as on the CVR.Thirty-four patients with chronic TCO, diagnosed by carotid duplex scanning and confirmed by other vascular imaging modalities, who had ischaemic symptoms either as stroke or transient ischaemic attack, were subjected to clinical assessment, SPECT under dipyridamole stress, and grading of cerebral collateral blood flow using TCCD. Demographics and vascular risk factors were correlated with SPECT and TCCD findings.CVR showed a significant positive correlation with the intensity of collaterals with P value0.001 and a Spearman correlation coefficient of 0.686. Hypertension was the only predictor of poor collaterals (p value =0.049; OR =11.5 with 95% CI 1.01-131.16).Smoking was predictive of poor CVR as measured by qualitative SPECT (p value =0.02; OR =13.2 with 95% CI 1.4-120.6).Cerebral collaterals have an important role in the maintenance of CVR in patients with TCO. Preventive measures should be directed towards hypertension and smoking to preserve cerebral collateral patency and consequently improve CVR in patients with TCO.

Introduction/purpose Management of tandem carotid occlusions is not yet well-defined. Though several authors have proposed acute carotid stenting followed and intracranial mechanical thrombectomy, the subsequent need for immediate antiplatelet therapy comes with an associated risk of potentially devastating hemorrhage. We sought to demonstrate that carotid stenting can be safely delayed in tandem carotid occlusions with good clinical outcomes. Materials and methods Between July 2015 and July 2016, we report our first ten consecutive patients with tandem carotid occlusions to our university comprehensive stroke center. Demographics, technical variations, recanalization rates and times, and clinical follow-up are reported. The abstract will be updated with additional consecutive cases of tandem occlusion through June 2018. Results A total cohort of our first ten consecutive patients (avg NIHSS=17) included seven carotid occlusions and three 95%–99% carotid bulb stenosis. Tandem intracranial occlusions included three at M2, four at M1, and three ‘T’ lesions at the ICA terminus. All patients were initially wire re-canalized, followed by prolonged PTA and mechanical thrombectomy. Nine patients received IV tPA (avg DTN 31 min) and five were drip-n-ship. The average tPA to groin puncture time was 104 min, and the average groin puncture to recanalization time was 50 min. TICI 2b/3 recanalization was obtained in nine of ten patients with only one patient 2a/2b. Nine patients had delayed carotid stenting between days 7–14 post-stroke. One patient had silently re-occluded the carotid bulb on the day of planned stenting, one patient had a small reperfusion hemorrhage prior to antiplatelet therapy (90 d MRS=0), and one patient had a small ICH after stent placement (90 d MRS=3). All patients had a 90 d MRS=/ Conclusion It appears that tandem carotid occlusions can be treated with emergent prolonged PTA of the extra-cranial carotid occlusion followed by intra-cranial mechanical thrombectomy. Delayed carotid stenting appears to be safe and may lead to good clinical outcomes. Further studies are needed to confirm the findings in this small cohort. Disclosures C. Green: None. B. Wiseman: None. A. Ferrell: None. P. Brown: None. P. Kvamme: None.

The surgical treatment of hypervascular or invasive temporal bone tumors has a number of endovascular considerations. Surgical treatment may involve a planned preoperative tumor embolization or an inadvertent carotid injury. Some tumors may not be a good target for embolization, and preoperative carotid occlusion might be considered. It is advantageous to understand the patient’s ability to tolerate carotid sacrifice prior to surgery, and this can be assessed through a carotid balloon test occlusion. This chapter describes the indications and technique for performing a carotid balloon test occlusion, as well as the relevant vascular anatomy and collateral circulation necessary for a patient to tolerate occlusion.

Background and purpose Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown. Methods Consecutive patients presenting at a single center with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) were retrospectively reviewed. Those treated with intravenous thrombolysis or intra-arterial thrombolysis/thrombectomy were excluded. Patients were divided into two groups based on whether they experienced recurrent in-hospital stroke. Results The selected study population (n = 33) represented a small (20.4%) proportion of all newly symptomatic carotid occlusions, who nevertheless had an elevated risk of recurrent stroke during admission (24.2%). Of the variables examined (age, gender, admission National Institutes of Health Stroke Scale score, vascular risk factors, atrial fibrillation, prior stroke/transient ischaemic attack and anticoagulation within 48 h of presentation), only anticoagulation was significantly associated with a lower risk of in-hospital recurrent stroke. Anticoagulated patients showed a decreased incidence of stroke recurrence within the first week (6.7% vs. 38.9%, P = 0.032) and fewer strokes or deaths at 1 month (13.3% vs. 47.1%, P = 0.040). Hemorrhagic transformation was not observed in any patient. On follow-up imaging, ICA recanalization was significantly more frequent in anticoagulated patients (46.2% vs. 9.1%, P = 0.047). Conclusion Patients with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) represent a small but high risk subgroup of patients with carotid occlusion. Early anticoagulation was associated with fewer recurrent strokes and increased ICA recanalization. Larger scale prospective studies may be justified.

We report an 8-year-old female who developed left abducens nerve palsy and progressively enlarging left internal carotid aneurysm in the setting of sphenoid sinusitis. Despite conservative management with antibiotics and antiplatelet agent, she developed enlargement of the aneurysm with embolic stroke. For that reason, she underwent occlusion of her left internal carotid artery with coiling, after confirmation of good collateral circulation. The patient tolerated the procedure well, with improvement of her symptoms. To our knowledge, this is the first report documenting good neurological outcome after elective internal carotid occlusion. Due to lack of guidelines, management of aneurysms secondary to infection should be individualized, based on collateral circulation and risk of intervention.

Introduction: Intra-arterial thrombectomy (IAT) is an effective treatment for large artery occlusive stroke. However, there is a pressing need for data on the (cost-) effectiveness of different models of IAT service provision. To inform a model to estimate the impact of different service configurations for delivery of IAT, we determined current characteristics of interventional neuroradiology services in England. Method: A survey instrument was emailed to all 24 IAT services in England to request data on provision of IAT, patient selection criteria, diagnostic imaging resources required and opinions on future IAT service provision. Results: 18 centres provided responses to the survey (75% response) with a median of 3 (IQR = 1) interventional neuroradiologists (INRs). 10 (56%) centres had formal IAT protocols and 6 protocols for inter-hospital transfers. 1 centre claimed it had 24/7 IAT provision. A majority (n = 16; 89%) required only computed tomography (CT) or CT angiography (CTA) but most required expert radiology review of CTA. There was variable use of different imaging scoring systems, including variation across centres in terms of factors influencing patient selection for IAT (e.g. NIHSS). There was minor variation between units in terms of anaesthesia technique, undertaking/approach used in IAT when complete carotid occlusion was present. Most centres (n = 16, 89%) did not administer heparin or anti-platelets during IAT. Model preferences for future IAT provision were delivery by INRs in a network where necessary, drip and ship inter-hospital transfers, and anaesthetic support via crash type systems. Discussion: There is incomplete consensus on the organisation of future service provision for IAT in England.

Limb-shaking associated with steno-occlusion of the internal carotid artery (ICA) was first reported by Miller Fisher1 in 1962, and is characterized by brief, jerky, coarse, involuntary movements involving an arm or leg. Limb-shaking TIA is an under-recognized manifestation of an intracranial and extracranial carotid occlusion or severe stenosis. Although hemodynamic compromise has been suggested to be associated with shaking movements, the pathogenic nature of this symptom remains unclear. Neurophysiologic evaluation of this movement disorder would be useful, but the attack is rare and typically lasts less than 5 minutes.2 Thus, few reports have investigated this hyperkinetic phenomenon under neurophysiologic assessment.3