Ischemic stroke: carotid and vertebral artery disease

Ischemic strokes may have distinct aetiologies, including several different intrinsic arterial pathological disorders. The diagnosis and understanding of these arterial diseases is critical for the correct management of stroke as different treatment approaches are undertaken according to the aetiology. Atherosclerosis is by far the most common arterial disease among adults, and other pathological processes include arterial dissection, small vessel disease, inflammatory and non-inflammatory vasculopathy and vasomotor disorders. In children, there are several vasculopathies responsible for vaso-occlusive disease such as sickle-cell anemia, acute regressive angiopathy and Moya–Moya disease, neurofibromatosis, dissections, vasculitis associated with intracranial and systemic infections. An overview of the major carotid and vertebral pathological diseases responsible for ischemic stroke in adults and children, highlighting the accuracy of the different imaging modalities for its diagnosis and the imaging appearance of these diseases, is given.     

Abnormal origin of the vertebral artery from the common carotid artery.

An abnormal origin of the vertebral artery from the common carotid artery (VA-CC) may occur on the right or left side with different embryonic mechanisms. We describe a patient with a double developmental anomaly, a right VA-CC and a right aortic arch. The rotation of the aortic arch caused a "twist" of the embryonic mechanisms of VA-CC and misdirected the differential diagnosis of the embryonic mechanisms at first glance. We discuss the pivotal points in differentiating the embryonic mechanisms of VA-CC.     

A rare congenital anastomosis between the vertebral artery and internal carotid artery

A case of congenital anastomosis between the vertebral artery and internal carotid artery is presented. This rare anomaly was an incidental finding at cerebral angiography in a patient with a suspected ruptured cerebral aneurysm with subarachnoid hemorrhage.     

Radiation-induced large intracranial vessel occlusive vasculopathy

Two patients who developed large intracranial vessel occlusion after standard radiation therapy for brain tumor are described. This form of vascular occlusion is usually seen in patients who have previously been treated by radiotherapy for intracranial tumor who then develop a relatively acute change in neurologic status. Histology of the lesion mimics accelerated focal arteriosclerosis. The clinical and radiographic manifestations of one case were highly atypical. The vasculopathy became evident shortly after termination of radiation therapy for a fourth ventricular ependymoma, and the angiographic picture stimulated a diffuse arteritis. The second patient was more typical, with clinical symptoms developing 12 years after radiation therapy for an oligodendroglioma. Occlusion of a proximal vessel that had been included in the radiation port was demonstrated radiographically and confirmed by pathologic examination. The clinical, angiographic, and histologic features of these two cases are discussed and previously reported cases are reviewed.     

Radiation-induced myelopathy and vertebral necrosis

Radiation-induced myelopathy is often a diagnosis of exclusion. In addition to the classic criteria needed to support the diagnosis, the presence of another radiation-induced lesion, such as aseptic vertebral necrosis, is useful to confirm the cause of the spinal cord lesion.     

颅内外缺血性多血管病变的介入治疗选择

目的：通过选择性介入治疗颅内外缺血性多血管狭窄性病变,评价多血管病变介入治疗的安全性。方法：对150例颅内外缺血性多血管病变介入治疗的相关资料进行系统性回顾。结果：1150例多血管病变者,双侧颈内动脉同时狭窄〉70%者47例;单侧颈内动脉狭窄并单（或双）椎动脉狭窄〉70%者61例;双侧椎动脉狭窄〉70%者23例;单侧血管颅内外串联病变均需处理者19例。2共成功植入支架218枚,围手术期并发症5例（3.33%）,126例患者术后6-12个月随访无短暂性脑缺血发作及新发脑梗死。结论：通过对颅内外缺血性多血管狭窄性病变的介入治疗选择,可减少围手术期及远期并发症。     

Right vertebral artery originating from the right common carotid (author's transl)]

In the study of 273 aortic arch angiograms, one case of right vertebral artery arising from the right common carotid artery was encountered. The embryology of this anomaly and its clinical significance are discussed.     

Injury of the carotid and vertebral arteries

Summary A knowledge of the normal anatomy and anatomic relationships of the carotid and vertebral arteries, as well as the biomechanics by which traumatic injury occurs to these vessels, is important both in the interpretation of diagnostic arteriograms and in the clinical assessment of the injured patient.     

颅外段颈/椎动脉夹层及动脉瘤的介入治疗观察

目的评价介入治疗颅外段颈/椎动脉夹层及动脉瘤的安全性和疗效。方法收集住院病例11例,其中男性7例,女性4例,发病年龄32~54岁,平均年龄(42±5)岁。临床表现:合并高血压者8例;同时合并高血压、糖尿病者3例;合并痛风1例;余3例未发现明显的危险因素。11例患者均在造影同时行血管成形术,包括对狭窄的颈内动脉/椎动脉进行球囊扩张和置放支架。其中7例颈内动脉植入自膨式血管支架9枚,4例椎动脉植入支架4枚。术后均抗血小板、抗凝治疗。术后及出院后随访3~29个月。结果 11例患者介入治疗均获成功,临床症状明显减轻或消失。无并发症及死亡病例。狭窄的动脉血流通畅,内径渐恢复正常,夹层动脉的动脉瘤也明显缩小。术后随访,均未见相关临床症状复发。结论介入治疗颅外段颈/椎动脉夹层及动脉瘤,损伤小、安全、有效。     

Use of intravascular stents in the treatment of internal carotid and extracranial vertebral artery pseudoaneurysms.

The management of extracranial carotid or vertebral artery pseudoaneurysms is controversial. Although some of these lesions resolve spontaneously, many clinicians opt to treat them with trapping procedures that result in vessel sacrifice. We describe two cases in which an intravascular stent was used to obliterate an aneurysm of the extracranial vertebral artery and the internal carotid artery, respectively, while maintaining the patency of the parent vessel. The technique, which has been successful in experimental animal models, shows promise for application in humans.     

Extracranial internal carotid and vertebral artery dissections: angiographic spectrum,course and prognosis

We reviewed the clinical and radiological findings of 93 consecutive patients with 111 extracranial internal carotid (ICAD) and vertebral artery (VAD) dissections and one concomitant intracranial VAD; 83% of the patients had unilateral and 17% multiple vessel dissections. The diagnosis was made by intra-arterial digital subtraction angiography in 92 patients and MR angiography in one. Follow-up angiography was performed in 77 cases (83%): of 49 initially stenotic arteries, 40 became completely or almost completely normal, while three showed slight improvement. Of 30 initially occluded arteries, nine had completely or partly recanalised. Of 12 pseudoaneurysms eight were unchanged at follow-up. The proximal vertebral artery was involved as often as the C1-C2 level. Recurrences were rare: a new dissection in another vessel was found in three patients. Kinking or coiling was found in 23% of the dissected internal carotid arteries.     

Imaging the vertebral artery

Although conventional intraarterial digital subtraction angiography remains the gold standard method for imaging the vertebral artery, noninvasive modalities such as ultrasound, multislice computed tomographic angiography and magnetic resonance angiography are constantly improving and are playing an increasingly important role in diagnosing vertebral artery pathology in clinical practice. This paper reviews the current state of vertebral artery imaging from an evidence-based perspective. Normal anatomy, normal variants and a number of pathological entities such as vertebral atherosclerosis, arterial dissection, arteriovenous fistula, subclavian steal syndrome and vertebrobasilar dolichoectasia are discussed.     

彩色多普勒超声检查颈动脉硬化患者椎动脉供血不足的价值

<正> 颈动脉硬化患者可表现出椎-基底动脉供血不足造成的一过性头晕,我们用彩色多普勒超声方法,对颈动脉硬化椎-基底动脉供血不足患者进行颅外段的椎动脉检查,通过声像图及其血流动力学参数的改变观察其变化。1资料与方法1.1一般资料收集2004～2008年我院住院及门诊100例颈动脉硬化患者,临床无耳科及眼科疾病     

Percutaneous transluminal angioplasty (dilatation) of carotid,vertebral, and innominate artery stenoses

Over a period of 5 years, 51 stenoses of brachiocephalic arteries were successfully dilated, and one subclavian occlusion recanalized in 42 patients. Among 24 patients there were 21 stenoses of the internal carotid artery, two stenoses of the common carotid artery, two stenoses of the innominate artery, five stenoses at the origin of the vertebral artery, and four stenoses of the subclavian artery. There were 17 patients who had stenoses of the subclavian artery. In 12 cases several arteries were affected. In 9 patients multiple (2–3) stenoses in these supraaortic arteries were dialated. In 4 cases bilateral dilatetion of internal carotid arteries was performed. There were transient, minor complications in 2 patients.     

Interventional neurovascular treatment of traumatic carotid and vertebral artery lesions: results in 234 cases

Traumatic injuries to the head and neck that result in arteriovenous fistulae are often difficult to treat by direct surgical access. This is because of anatomic location, instability of the acutely injured patient, and difficulty in localizing the exact site of injury. Between 1974 and 1988, 234 consecutive cases of traumatic injuries to the carotid or vertebral artery were evaluated by our group for intravascular embolization therapy. This included 206 cases of direct and seven cases of indirect carotid-cavernous sinus fistulae and 21 cases of traumatic vertebral fistulae. A variety of devices including detachable balloons, liquid tissue adhesives, microcoils, and silk suture were used with the goal of fistula occlusion and preservation of the parent vessel. This was achieved in 193 cases (82%). In the remaining 41 cases (18%), the carotid or vertebral artery had to be occluded by endovascular occlusion techniques because of extensive vascular injury in 28 cases and subtotal occlusion of the fistula in 13 cases. Complications included transient cerebral ischemia in six cases, pseudoaneurysm formation in five cases, stroke in five cases, and peripheral nerve injury in one case. The development of interventional neurovascular techniques has altered the management of these acutely injured patients. The preferred method for treatment has shifted from direct surgical access under general anesthesia to endovascular therapy under local anesthesia.     

Subclavian artery angioplasty and the origin of the vertebral artery

Percutaneous transluminal angioplasty of the subclavian artery was performed in 35 patients. In 50% of all dilations, the angioplasty balloon was inflated across the origin of the vertebral artery. No complications occurred. All subclavian steals were corrected. The relationship between the subclavian artery stenosis and the vertebral artery origin should be determined; if the vertebral artery originates from a healthy segment of the subclavian artery or from a segment with poststenotic dilatation, the angioplasty balloon can safely be distended across the vertebral artery origin.