Isolated complete orbital infarction: a common carotid artery occlusion syndrome

When blood flow through the internal and external carotid arteries is completely interrupted by ipsilateral common carotid artery occlusion, the arterial orbital circulation may be more compromised than the brain supply. We studied a pure and extreme example of this situation in a patient who presented with acute orbital infarction, but no cerebral ischemia on clinical, CT and single-photon emission computerized tomography (SPECT) grounds. Ipsilateral blindness corresponded to retinal, choroidal and optic nerve infarction. The pattern of ophthalmoplegia, with relative sparing of adduction, was more compatible with a muscle than a nerve dysfunction, but a reactive dilated pupil, corneal anesthesia, and orbital pain suggested that the intraorbital branches of the ocular motor nerves and ophthalmic division of the trigeminal nerve were not spared. In addition, signs of widespread ocular ischemia were present. Sequential examinations documented the evolution pattern over 1 year. The absence of an orbital collateral supply from the contralateral external carotid and muscular cervical arteries systems, which contrasted with an adequate middle cerebral artery supply via the contralateral internal carotid artery, may explain this isolated and complete form of orbital ischemia due to common carotid artery occlusion.     

内膜斑块剥脱术治疗颈动脉狭窄的临床分析

目的 探讨颈动脉狭窄的手术治疗方法及疗效。方法 2006年2月至2015年7月采用颈动脉内膜斑块剥脱术（CEA）治疗颈动脉狭窄18例,所有病人均经颅脑多普勒超声检查或MRA筛选,头颈部CTA或DSA确诊,均在全麻下进行CEA。结果 术后临床症状改善17例,1例术后6 d死于大面积脑梗死。术后17例随访1~24个月,2例手术部位再狭窄（其中1例因反复短暂性脑缺血发作行支架治疗好转）;3例仍有短暂性脑缺血发作,保守治疗后好转;其余12例无明显并发症,恢复良好。结论 CEA是治疗颈动脉狭窄安全、有效的方法,对防治缺血性脑卒中有重要意义。     

Novel brain ischemic change on MRI. Delayed ischemic hyperintensity on T1-weighted images and selective neuronal death in the caudoputamen of rats after brief focal ischemia

BACKGROUND AND PURPOSE: Specific change of persistent hyperintensity/hypointensity on T1-weighted (T1W) and T2-weighted (T2W) MRI, respectively, has been reported to develop in the human basal ganglia after brief hemispheric ischemia. We investigated whether this ischemic change observed in humans could be reproduced experimentally in rats after brief middle cerebral artery (MCA) occlusion (MCAO), and if so, what the neuroradiological change represented histologically. METHODS: The origin of the right MCA of male Wistar rats (n=25) was occluded for 15 minutes by inserting a silicon-coated nylon thread from the external carotid artery into the internal carotid artery. After 15 minutes' MCAO, coronal MR images (T1W, T2W, and T1W with fat saturation pulse) were obtained once at 3-day reperfusion (n=5) and twice at 3- and 7-day reperfusion (n=20). Brain specimens were examined histologically immediately after the last MRI study in all rats. RESULTS: Neither T1W nor T2W MRI showed marked signal changes 3 days after reperfusion following 15-minute MCAO. However, the ischemic change of hyperintensity and hypointensity on T1W and T2W MRI, respectively, appeared in the striatum following 7-day reperfusion after 15-minute MCAO (n=19/20). Histological examination revealed that the specific lesion in the rat striatum on MRI corresponded to selective neuronal death and proliferation of reactive astrocytes and microglia without infarct, hemorrhage, lipid accumulation, or calcification. CONCLUSIONS: Brief MCAO with reperfusion induces the delayed ischemic changes of hyperintensity and hypointensity on T1W and T2W MRI, respectively, in the rat striatum with high reproducibility. This specific ischemic change on MRI histologically corresponded to selective neuronal death and gliosis with preservation of the macroscopic structure of the brain. A similar MRI pattern reported in patients who have sustained brief ischemia may represent similar histology. We speculate that the ischemic change reflects some biochemical changes affecting the magnetic field as the brain tissue undergoes subtle structural changes.     

曲霉菌病性痛性眼肌麻痹

目的:讨论导致痛性眼肌麻痹的曲霉菌病的病例特点及诊断。方法:对1例患者进行临床相关资料分析和文献复习。结果:曲霉菌病是痛性眼肌麻痹的原因之一,导致痛性眼肌麻痹的曲霉菌病起病急骤,病变进展迅速,可累及海绵窦、鼻窦、眶尖、颈内动脉,而出现眼肌麻痹,眶后、眶周疼痛,视力障碍,偏瘫等临床表现。活检可确诊曲霉菌病。结论:导致痛性眼肌麻痹的曲霉菌病容易误诊,通过病史及体格检查,并结合CT、MRI、活检可以确诊。     

颈部夹层动脉导致缺血性脑卒中17例临床分析

目的:探讨颈部夹层动脉(CAD)缺血性脑卒中的临床表现。方法:收集我中心前瞻性登记数据库中的17例(共18支病变血管)经DSA全脑血管造影证实的、因CAD所致缺血性脑卒中患者的资料,对其归纳分析。结果:CAD所致缺血性脑卒中和短暂性脑缺血发作(TIA)占同期该年龄段缺血性脑卒中和TIA的7.49%(17/227)。所有患者均因TIA或局灶神经功能缺损就诊;头颅MRI和DSA均发现特征性征象,颈内动脉夹层(ICAD)与椎动脉夹层(VAD)的构成比为16/2;所有患者均接受抗凝、抗血小板聚集治疗,其中6例行支架置入术。随访2个月所有患者均获得一定程度的神经功能恢复。结论:ICAD较VAD常见,TIA或局灶神经功能缺损症候结合特征性的影像学改变是诊断CAD的主要线索和依据。     

肢体抖动短暂性脑缺血发作(LS-TIA)的临床及影像

目的 肢体抖动短暂性脑缺血发作（LS-TIA）临床少见,本文旨在提高临床医师对这一症候的认识.方法 总结北京协和医院诊断为肢体抖动短暂性脑缺血发作患者7例,行颈部血管超声、脑电图、头部核磁共振、经颅多普勒超声、核磁血管成像,4例行数字减影血管造影,2例行CT灌注成像检查.结果 均表现为发作性短暂不能控制的抖动,5例发作有明显诱因.全部患者均有抖动肢体对侧至少1条以上颅内和/或颅外动脉重度狭窄或闭塞.头部核磁共振4例显示抖动肢体对侧内分水岭脑梗死.脑电图均未见痫样放电,6例可见病变血管同侧额颞部慢波灶.经扩容和抗血小板聚集或者血管内支架治疗后,所有患者病情稳定.结论 肢体抖动短暂性脑缺血发作通常提示大血管严重的狭窄或闭塞,低灌注是其最可能的发病机制.     

The ocular ischemic syndrome

The ocular ischemic syndrome represents a serious blinding condition due to retinal ischemia secondary to hemodynamically significant carotid artery stenosis. However, this condition has received little attention in the neurological literature and is likely underdiagnosed. We here describe a patient with bilateral severe carotid stenosis and progressive visual loss due to ocular ischemia. The best management for this condition remains controversial and should be established by including these patients into randomized trials of carotid surgery.     

Painless abducens palsy disclosed by spontaneous dissection of the intracavernous internal carotid artery

A 63-year-old man presented suddenly and spontaneously an isolated painless oculomotor palsy of the nerve abducens. As no etiology could be suspected a head MRI was performed. It showed a T1 hypersignal of the intracavernous segment of the internal carotid artery with a double-lumen pattern typical of dissection. The patient was treated with aspirin and recovered from clinical symptoms in 10 weeks. A control MRI was performed 3 months after the onset of symptoms and showed the regression of the images of dissection. There was no ischemic lesion of the brain. This case underlines the diversity of the symptoms of spontaneous dissections of cervicocephalic arteries, especially absence of pain, palsies of cranial nerve that are not always limited to lower cranial nerve, and existence of dissections limited to the intracranial segment of the carotid artery. It suggests the interest of MRI in the diagnosis of isolated oculomotor nerve palsies.     

颈内动脉扭曲与脑缺血的相关性研究

目的研究颈内动脉扭曲与脑缺血的相关性,探讨脑缺血的危险因素。方法回顾性分析存在颈内动脉扭曲但无椎动脉扭曲患者51例(实验组),选取无颈内动脉及椎动脉扭曲患者45例为对照组;比较实验组和对照组脑缺血的发生率;对研究资料进行单因素和多因素回归分析。结果实验组脑缺血发生率明显高于对照组,差异有统计学意义(χ2=51.6,P=0.001)。年龄与脑缺血呈正相关(P=0.008)、动脉狭窄与脑缺血呈正相关(P=0.023)、动脉扭曲与脑缺血存在相关可能性(P=0.055)。动脉扭曲和动脉狭窄是脑缺血的危险因素(P=0.009,P=0.002),但年龄不是脑缺血的危险因素(P=0.107)。结论颈内动脉扭曲是脑缺血的危险因素之一,应列入临床干预的对象中。     

颈内动脉巨大动脉瘤的血管内治疗

目的探讨血管内栓塞方法治疗颈内动脉巨大动脉瘤的效果和安全性。方法回顾性分析3例应用弹簧圈进行瘤腔内栓塞和27例应用载瘤动脉闭塞方法治疗的颈内动脉巨大动脉瘤的结果和随访资料。结果2例瘤腔内栓塞动脉瘤的患者症状完全消失;1例患者出现缺血性并发症,半年后随访动脉瘤再通。球囊闭塞载瘤动脉的患者1例出现迟发缺血性症状;1例吻合支开放,3个月后患者出血死亡;其余患者症状均有不同程度改善。结论颅内巨大动脉瘤是否进行瘤囊内弹簧圈栓塞需要综合考虑各种条件,采用个体化的治疗方案。球囊闭塞载瘤动脉是比较安全有效的方法。     

A case of transient blindness due to severe stenosis of the internal carotid artery with persistent primitive hypoglossal artery (PPHA)]

We report a patient having transient blindness due to severe stenosis of the internal carotid artery (ICA) with persistent primitive hypoglossal artery (PPHA). This 73 year-old man was admitted because of the transient visual impairment. At first, he had bilateral blindness for a several minutes and after that the right amaurosis continued for an hour. MRI showed an old lacunar infarction of the right caudate nucleus. Carotid duplex ultrasonography and conventional angiography demonstrated severe stenosis of the origin of the right ICA, and PPHA was arising from the right ICA at the level of 2nd cervical spine. The left ICA was normal. Because of the aplasia of the right vertebral artery and hypoplasia of the left vertebral artery, almost all blood flow of the basilar artery was supplied from the right ICA via PPHA. We considered that transient ischemia of both the bilateral posterior cerebral arteries and the right ocular artery occurred due to stenosis of the right ICA which branching PPHA. When ischemic neurological symptoms of multiple vascular territories occurr at the same time, we often think that ischemic mechanism was cardiogenic embolism. But we should recognize that stenosis of the ICA with PPHA cause the complex neurological deficits.     

Diffusion and perfusion MRI for the assessment of carotid atherosclerosis

Atherosclerotic disease of the extracranial vessels is a frequent cause of cerebral ischemia and stroke. Many natural history studies and prospective treatment trials with large patient samples have focused on optimal patient assessment in regard to medical or interventional measures. Clinical decision making nowadays is largely based on the identification, visualization, and grading of the local stenosis, and the identification of neurologic symptoms related to carotid artery stenosis. MRI already has contributed considerably as many surgeons no longer require preoperative conventional contrast angiography but may use the combination of duplex ultrasound studies and MRA for visualization of the pathology. Besides MRA improvements, DWI and PWI are increasingly used in addition to conventional MR contrasts (PD, T2-, T1-weighted MRI) in attempts to gather information on tissue status and the pathophysiology of hemodynamic compromise and cerebral ischemia in patients with carotid artery stenosis. Obtaining background information using this array of MR data may eventually become a basis for optimal risk-benefit assessment in patients with carotid artery stenosis.     

Cerebral perfusion imaging.

There are multiple imaging techniques available to assess cerebral perfusion, including positron emission tomography (PET), xenon computed tomography (XeCT), single photon emission computed tomography (SPECT), perfusion-weighted MRI (PWI), and perfusion computed tomography (PCT). Current interest has focused mainly on their use in the setting of acute brain ischemia. Perfusion imaging may be able to distinguish infarcted from salvageable ischemic tissue as a guide to treatment. Perfusion techniques may also be helpful in cases of chronic ischemia, post-subarachnoid hemorrhage vasospasm, trauma, and contemplated therapeutic carotid artery occlusion.     

MRI评价改进的大鼠可逆性局灶性脑缺血模型

目的：通过ＭＲＩ来评价改进的线栓法大鼠可逆性大脑中动脉闭塞的局灶性脑缺血模型。方法：对栓线的制备及手术的操作进行改变,头端涂有石蜡的尼龙线作为栓线,从颈总动脉插入颈内动脉,阻塞ＭＣＡ,造成避灶性脑缺血。ＭＲＩ对缺血后的大鼠作间歇扫描,再灌注后作增强ＭＲＩ。     

肢体抖动性短暂性脑缺血发作临床分析

目的 通过3例典型患者的病史和辅助检查，结合文献复习，探讨肢体抖动性短暂性脑缺血发作的临床表现及诊断，以提高诊断的准确率。方法 采用动态脑电图、超声多普勒、磁共振成像、磁共振动脉血管造影、全脑血管造影等辅助检查，对3例肢体抖动性短暂性脑缺血发作患者进行临床表现、辅助检查及影像学资料分析。结果 3例患者均有肢体抖动的临床表现，其中2例曾被误诊为继发性癫痫，给予抗癫痫治疗无效，行全脑血管造影、脑电图等检查。全脑血管造影提示3例颈内动脉系统均存在严重闭塞或狭窄性病变，而发作期脑电图检查未见癫痫波释放。给予抗血小板聚集等药物治疗，但仍偶有发作。2例施行血管内支架植入术后发作完全停止，1例由于血管迂曲明显，手术未获成功，经内科保守治疗症状缓解出院。结论 肢体抖动性短暂性脑缺血发作为临床少见短暂性脑缺血发作，其发作形式常表现为发作性、无意识的一侧肢体无力及抖动，和局灶性运动性癫痫发作相似，易误诊为局灶性癫痫。通过脑电图及全脑血管造影等检查可以明确诊断，从而提高对该病诊断的准确率，防止漏诊及误诊。     

Internal carotid artery agenesis: diagnosis,clinical spectrum,associated conditions and its importance in the era of stroke interventions

Abstract

Background: Internal carotid artery (ICA) agenesis has been usually reported as an asymptomatic condition in association with other congenital anomalies. However, it is less well described in the context of clinical neurological syndromes.

Method: Five cases of ICA agenesis are reviewed. The diagnosis of ICA agenesis was based on the absence of bony carotid canal on computed tomography. Brain CT and magnetic resonance image (MRI) scans were done in all the patients and four vessels digital angiograms were obtained in two. Clinical presentation, coexistent radiological findings and associated abnormalities are reviewed.

Findings: The initial presentations were pulsatile tinnitus, ischemic stroke, migraine, Horner's syndrome, and subarachnoid hemorrhage. Collateral circulation was supplied via the posterior communicating artery and the anterior communicating artery. Ophthalmic artery was supplied by meningeal arteries. On CT, all cases demonstrated agenesis of the bony carotid canal. Smaller cavernous sinus were detected in all cases, enlargement of the foramen spinosum was found in three patients and hyper-pneumatization of the petrous apex was detected in two cases. In one patient a cerebral aneurysms was detected and treated with an endovascular approach. Other associated vascular abnormalities were aortic origin of the vertebral artery in two patients, ICA coiling in two cases and fenestration of basilar artery in one case.

Conclusion: ICA agenesis is usually asymptomatic but occasionally may be associated with ischemic stroke. Collateral supply is usually effective in preventing stroke but may become inefficient leading to ischemia. Associated anomalies such as cerebral aneurysms are commonly depicted on the same side as the ICA agenesis and may represent a potential life-threatening condition.     

急性缺血性卒中常规磁共振成像血管内高信号回顾性研究

目的 明确常规磁共振对于血管高信号的展示及其临床意义。方法 回顾总结浙江大学医学院附属第一医院2010年1-12月的急性缺血性卒中患者。所有患者均行常规磁共振检查。结果 我院神经内科共收住急性脑梗死患者280例,均符合脑血管病诊断标准。血管内异常信号患者共26例,出现率为9.29％。前循环异常信号14例,其中颈内动脉高信号11例,大脑前动脉高信号2例,大脑中动脉合并大脑前动脉高信号1例;在颈内动脉血管内高信号11例患者中,MRA证实14支颈内动脉血管狭窄,对血管病变的特异度100％,敏感度78.6％;后循环共12例,其中椎动脉高信号5例,基底动脉3例,基底动脉合并椎动脉高信号4例;1例患者未行MRA检查,11例患者MRA证实14支血管存在病变,椎动脉和基底动脉内高信号11例,特异度为100％,敏感度为78.5％。结论 常规磁共振序列对于血管内高信号的展示具有很高的临床特异度,其血管病变与MRA的结果具有一致性。     

Cognitive impairment in patients with carotid artery occlusion and ipsilateral transient ischemic attacks

Abstract. Although transient ischemic attacks (TIAs) by definition do not cause lasting neurological deficits, cognitive impairment has been suggested in patients with carotid artery disease who have suffered from a TIA. The purpose of our study was to assess whether patients with carotid artery disease and TIAs are cognitively impaired, to describe the frequency, nature and severity of this impairment, and to search for associated patient characteristics.Thirty-nine consecutive patients with carotid occlusion and ipsilateral cerebral or retinal TIAs, and 46 healthy controls underwent extensive neuropsychological assessment. Performances were compared group-wise with analysis of variance. In addition, the presence of cognitive impairment in the individual patient was determined. Associations between illness characteristics and cognitive impairment were explored with regression analysis.Fifty-four percent of patients were cognitively impaired. Cognitive deficits were non-specific in nature and mild in severity. Impairment occurred also in patients with isolated retinal symptoms and in those without visible ischemic brain lesions on MRI. Neither the presence of any vascular risk factor, the side of the symptomatic carotid occlusion, the uni- or bilaterality of carotid occlusion, nor the number of cerebral ischemic lesions were predictors of cognitive impairment.We conclude that about half of the patients with carotid artery occlusion and ipsilateral TIAs are cognitively impaired. The presence of cognitive deficits in patients with isolated retinal symptoms and in those without cerebral ischemic lesions on MRI argues against an exclusive role for structural brain damage in the pathogenesis of these deficits.     

A case of chorea gravidarum with moyamoya disease]

A 16-year-old girl developed acute left choreic movements during her fourth week of pregnancy. She had sometimes had transient ischemic attacks since she was 10 years old. During the eighth week of pregnancy, a brain MRI showed old ischemic lesions deep in the right frontal white matter. Her angiograph revealed a complete obstruction of the terminal portion of the right internal carotid artery with a developed moyamoya net work. After her abortion, all involuntary movements completely subsided. The choreic movements might have been caused not only by ischemia, but also by enhanced dopaminergic sensitivity mediated by elevations in female sex hormones due to pregnancy.     

Long-term changes of hemodynamics and metabolism after carotid artery occlusion

OBJECTIVE: To investigate whether in selected patients with internal carotid artery (ICA) occlusion and initially normal oxygen extraction fraction (OEF) measured with PET, subsequent changes of cerebral hemodynamics and metabolism occur during long-term follow-up and, if so, whether the changes are associated with atrophy of the corpus callosum or subsequent ischemic strokes. BACKGROUND: The course of the changes in cerebral hemodynamics and metabolism after ICA occlusion remain unclear. After ICA occlusion, an increase in OEF may increase the risk of cerebral ischemia, and an increase in cortical ischemia would cause progression of callosal atrophy. METHODS: The authors used PET and MRI to examine twice seven medically treated patients with unilateral ICA occlusion and initially normal OEF at intervals ranging from 24 to 64 (mean +/- SD, 42 +/- 17) months. No intervening ischemic attacks occurred between the two examinations. RESULTS: In the hemisphere with ICA occlusion, OEF increased and blood flow decreased during follow-up. At the follow-up evaluation, abnormally increased OEF values were found in three patients, in whom ipsilateral ischemic strokes occurred during subsequent follow-up (18 +/- 6 months). A decrease in oxygen metabolism also occurred and was significantly correlated with the decrease of callosal size. CONCLUSIONS: These preliminary findings in a small, selected patient sample suggest that in patients with ICA occlusion and initially normal OEF, deteriorations of cerebral hemodynamics and metabolism during long-term follow-up may be associated with callosal atrophy or subsequent ischemic strokes.