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Introduction: Carotid near-occlusion (CNO) is a variant of severe stenosis where there is a distal luminal collapse of the internal carotid artery (ICA) beyond a tight stenosis. This study aimed to validate new visual extracranial diagnostic CT angiography (CTA) criteria, for the diagnosis of CNO. The new criteria include distal ICA diameter smaller than contralateral ICA and distal ICA diameter less than or equal to the ipsilateral external carotid artery (ECA). We also assessed the previously described CTA criteria: stenosis ≤ 1.3 mm, ipsilateral distal ICA ≤ 3.5 mm, ipsilateral distal ICA/contralateral distal ICA ratio ≤ 0.87, ipsilateral distal ICA/ipsilateral ECA ≤ 1.27., Methods: Fifty-eight patients with ICA stenosis (including the near-occlusion variant) or occlusion on digital subtraction angiography (DSA) were included. These patients had DSA and CTA studies completed within 30 days of each other. DSA was considered the reference test. Two neuroradiologists blinded to the DSA results assessed the CTA images and evaluated the new and previously published CNO diagnostic criteria., Results: Twenty-eight CNO were identified with DSA. The "distal ICA diameter less than or equal to the ipsilateral ECA" criterion had 79% sensitivity and 83% specificity with excellent interobserver agreement (kappa = 0.80), while three or more of the previously published criteria reached 82% sensitivity and 90% specificity, with a good interobserver agreement (kappa = 0.64)., Conclusions: CT angiography may be useful for CNO diagnosis. The new visual diagnostic criteria provide acceptable results of sensitivity and specificity with an excellent interobserver agreement. However, false-negative and positive results persist., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Purpose: The treatment of symptomatic carotid near-occlusion is controversial. Our aim was to analyze the results of carotid endarterectomy and carotid artery stent placement in patients with symptomatic carotid near-occlusion and to identify factors related to technical failure, periprocedural complications, and restenosis., Materials and Methods: We conducted a multicenter, prospective nonrandomized study. Patients with angiography-confirmed carotid near-occlusion were included. We assessed the revascularization rate and periprocedural stroke or death. Twenty-four-month clinical and carotid imaging follow-up was performed, and rates of carotid restenosis or occlusion, ipsilateral stroke, and mortality were analyzed. Carotid artery stent placement, carotid endarterectomy, and medical treatment were compared., Results: One hundred forty-one patients were included. Forty-four carotid artery stent placement and 23 carotid endarterectomy procedures were performed within 6 months after the event. Complete revascularization was achieved in 83.6%, 81.8% in the carotid artery stent placement group and 87% with carotid endarterectomy ( P = .360). Periprocedural stroke or death occurred in 6% (carotid artery stent placement = 2.3%; carotid endarterectomy = 13%; P = .077) and was not related to revascularization failure. The carotid restenosis or occlusion rate was 8.3% (5% restenosis, 3.3% occlusion); with carotid artery stent placement it was 10.5%; and with carotid endarterectomy it was 4.5% ( P = .419). The 24-month cumulative rate of ipsilateral stroke was 4.8% in the carotid artery stent placement group, 17.4% for carotid endarterectomy, and 13.1% for medical treatment ( P = .223). Mortality was 12%, 4.5%, and 5.6%, respectively ( P = .422). Revascularization failure and restenosis occurred more frequently in patients with full collapse compared with patients without full collapse (33.3% versus 5.6%, P = .009; 21.4% versus 2.9%, P = .032, respectively)., Conclusions: Carotid artery stent placement and carotid endarterectomy are associated with high rates of failure and periprocedural stroke. Carotid near-occlusion with full collapse appears to be associated with an increased risk of technical failure and restenosis. Carotid near-occlusion revascularization does not seem to reduce the risk of stroke at follow-up compared with medical treatment., (© 2022 by American Journal of Neuroradiology.)

Purpose: The ultrasonographic and hemodynamic features of patients with carotid near-occlusion (CNO) are still not well known. Our aim was to describe the ultrasonographic and hemodynamic characteristics of a cohort of patients with CNO., Methods: A prospective, observational, nationwide, and multicenter study was conducted from January/2010 to May/2016. Patients with digital subtraction angiography (DSA)-confirmed CNO were included. We collected information on clinical and demographic characteristics, carotid and transcranial ultrasonography and DSA findings, presence of full-collapse, collateral circulation, and cerebrovascular reactivity (CVR)., Results: One hundred thirty-five patients were analyzed. Ultrasonographic and DSA diagnosis of CNO were concordant in only 44%. This disagreement was related to the presence/absence of full-collapse: 45% of patients with CNO with full-collapse were classified as a complete carotid occlusion, and 40% with a CNO without full-collapse were interpreted as severe stenosis (p < 0.001). Mean velocities (mV) and pulsatility indexes (PIs) were significantly lower in the ipsilateral middle cerebral artery compared with the contralateral (43 cm/s vs 58 cm/s, p < 0.001; 0.80 vs 1.00, p < 0.001). Collateral circulation was identified in 92% of patients, with the anterior communicating artery (73%) being the most frequent. CVR was decreased or exhausted in 66% of cases and was more frequent in patients with a poor or absent collateral network compared with patients with ≥ 2 collateral arteries (82% vs 56%, p = 0.051)., Conclusion: The accuracy of carotid ultrasonography in the diagnosis of CNO seems to be limited, with significant discrepancies with DSA. Decreased ipsilateral mV, PI, and CVR suggest a hemodynamic compromise in patients with CNO.

Background:  Well-designed studies assessing the treatment outcome of brain arteriovenous malformations (AVMs) are infrequent and have not consistently included all of the available treatment modalities, making their results not completely generalizable. Moreover, the predictors of poor outcome are not well defined., Methods:  We performed an observational retrospective study of AVM patients. We included patients with clinical, radiologic, and outcome data, with a minimum follow-up of 1 year. Neurologic outcome was documented using the modified Rankin Scale (mRS) at the AVM diagnosis and 30 days after the treatment., Results:  There were 117 patients, with equal male/female proportion. The mean follow-up time was 51 months. Treatment distribution in the Spetzler-Martin grades I-III was as follows: 52 (54.6%) surgery, 31 (32.35%) radiosurgery, 2 (0.02%) embolization, and 11 (12%) conservative follow-up. Treatment distribution in Spetzler-Martin grades IV and V was as follows: 4 (20%) surgery, 7 (35%) radiosurgery, and 10 (45%) conservative follow-up. Poor neurologic outcome (mRS ≥ 3) was significantly associated with poor clinical status at diagnosis (Glasgow Coma Scale [GCS] score< 14; odds ratio [OR]: 0.20; 95% confidence interval [CI]: 0.001-0.396; p  = 0.010). The rupture of the AVM was associated with poor neurologic outcome. The Lawton-Young Supplementary scale (LYSS) proved to be the most effective in predicting poor outcome. The existence of seizures, treatment-related complications, and conservative treatment was associated with the worsening of the mRS score, whereas the existence of hemorrhage was associated with the likelihood of disability., Conclusion:  Our results suggest that poor neurologic status at diagnosis, AVM rupture, and conservative treatment were associated with worse outcome. Hemorrhage as initial presentation is related to disability, not with mRS worsening. The LYSS appeared to be the best method to predict outcome., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The clinical consequences and factors related to the progression from a carotid near-occlusion (CNO) to a complete occlusion are not well established. Our aim is to describe the rate, predictive factors and clinical implications of the progression to complete carotid occlusion (PCCO) in a population of patients with symptomatic CNO., Methods: We conducted a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed CNO were included. We collected information on demographic data, clinical manifestations, radiological and hemodynamic findings, and treatment modalities. A 24 month carotid-imaging follow-up of the CNO was performed., Results: 141 patients were included in the study, and carotid-imaging follow-up was performed in 122 patients. PCCO occurred in 40 patients (32.8%), and was more frequent in medically-treated patients (34 out of 61; 55.7%) compared with patients treated with revascularization (6 out of 61; 9.8%) (p<0.001). 7 of the 40 patients with PCCO (17.5%) suffered ipsilateral symptoms. Factors independently related with PCCO in the multivariate analysis were: age ≥75 years (OR 2.93, 95% CI 1.05 to 8.13), revascularization (OR 0.07, 95% CI 0.02 to 0.20), and collateral circulation through the ipsilateral ophthalmic artery (OR 3.25, 95% CI 1.01 to 10.48)., Conclusions: PCCO occurred within 24 months in more than half of the patients under medical treatment. Most episodes of PCCO were not associated with ipsilateral symptoms. Revascularization reduces the risk of PCCO., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

We report a case of traumatic intracranial carotid artery pseudoaneurysm treated with an equine pericardium-covered stent. The patient was admitted to the Emergency Department after sustaining severe polytrauma in a motor vehicle accident. A cavernous carotid pseudoaneurysm was detected after an episode of massive epistaxis that required emergent nasal packing. Treatment with parent vessel sacrifice was ruled out after an unfavourable balloon test occlusion. We opted for an equine pericardium-covered stent as a means to immediately seal the wall defect in the setting of massive bleeding secondary to an unstable lesion. We describe the potential benefits and drawbacks of these prostheses and the technical difficulties encountered in this particular case. To our best knowledge, this is the first published case report on a post-traumatic intracranial internal carotid artery pseudoaneurysm successfully treated with an equine pericardium-covered stent.

Background and Purpose: The thyrocervical trunk (TCT) is the second ascending branch of the subclavian artery. It is considered a 'border territory' between interventional vascular radiology and interventional neuroradiology because it gives rise to branches both cervical and to the upper limbs. We describe the TCT branches anatomy, the most frequent variants, and expose eight endovascular procedures performed through the thyrocervical trunk., Methods: A retrospective review of all the interventional radiology procedures carried out through the TCT in our tertiary care center from August 2014 to January 2017 is presented., Results: A total of eight endovascular procedures through the TCT including six preoperative embolizations: three paragangliomas, a cervical vertebral metastasis, a cervical vertebral aneurysmal bone cyst, and a very rare case of nerve root extradural cervical hemangioblastoma, as well as two emergency embolizations: a patient with a cervical traumatic active bleeding hematoma and a recurrent hemoptysis in a single ventricle patient., Conclusions: A correct knowledge of the vascular anatomy, anatomical variants, and anastomosis (especially with the anterior spinal artery) of the TCT is essential for a safe embolization, both preoperatively and on an emergency basis. In cases of recurrent hemoptysis and severe lower-neck injuries, the TCT should always be reviewed., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background The risk of recurrent stroke among patients with symptomatic carotid near-occlusion is not well established, and management of the condition remains controversial. Symptomatic carotid near-occlusion with full collapse has been identified as a strong predictor of early recurrence. We aimed to analyze the 90-day risk of recurrent ipsilateral ischemic stroke in medically treated patients with symptomatic carotid near-occlusion. Methods We performed a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed symptomatic carotid near-occlusion were included. The primary endpoint was ipsilateral ischemic stroke or transient ischemic attack (TIA) within 90 days after the presenting event. For this analysis, patients who underwent revascularization within 90 days after stroke were excluded. Results The study population comprised 141 patients from 17 Spanish centers; 83 patients were treated medically. Primary endpoint occurred in eight patients, resulting in a cumulative rate of 10.6% (95% CI, 3.7-17.5). Previous history of stroke or transient ischemic attack was identified as an independent predictor for recurrence in the multivariate Cox regression analysis (HR, 4.37 [95% CI, 1.05-18.18]; p = 0.043), while the presence of full collapse was not associated with an increased risk (HR, 0.81 [95% CI, 0.17-3.92]; p = 0.793). The risk of recurrence was also not affected by the presence of significant stenosis or occlusion of the contralateral carotid artery, or by the collateral circulation. Conclusions Patients with symptomatic carotid near-occlusion seem to have an increased risk of early ipsilateral recurrent stroke. Our results contrast with the low risk of symptomatic carotid near-occlusion reported to date. Full collapse did not increase the risk of recurrent stroke in our study.

Aims: The aim of this study was to carry out a review of the state of the art in the endovascular treatment of carotid disease, taking into account the findings currently available, its indications, the technical aspects linked to the intervention as well as those related to the occupational training of the specialists involved in performing the technique., Development: Surgical treatment of carotid artery disease can be of benefit to symptomatic patients with stenoses above 70% and to subgroups of patients with symptomatic stenoses between 50-69%. The benefit of carotid endarterectomy in asymptomatic patients is the object of a great deal of controversy that is concerned with the reduction in risk that is obtained and also the large number of patients to be treated in order to prevent the occurrence of ischaemic events. The endovascular treatment of carotid disease comes to the fore, then, as an alternative to surgical treatment. At the present time, a number of randomised multicentre studies are being conducted that will allow the two techniques to be compared in homogeneous groups of patients. Preliminary data nevertheless seem to suggest that this technique offers a number of benefits, especially in groups of subjects with a high surgical risk, and thus they could allow the indications for revascularisation to be extended. We analyse the technical and medical aspects linked to this procedure, the findings from studies carried out to date, its indications and the occupational training of the specialists involved in performing the technique., Conclusions: The endovascular treatment of carotid disease constitutes an alternative to surgical treatment in specifically selected patients. The potential increase in its indications is conditioned by the results from the multicentre studies currently being carried out.