Role of carotid stenosis in ischemic stroke

Using Doppler ultrasonography, we evaluated the frequency and severity of carotid artery stenosis in 261 patients with carotid ischemic strokes, 813 patients with carotid transient ischemic attacks, 500 patients with asymptomatic neck bruits, and 500 controls. Most patients with strokes and transient ischemic attacks had no associated carotid artery disease (55% and 64%, respectively), and such patients without neck bruits were even more likely to be without carotid artery disease (69% and 77%, respectively). Carotid stenosis was more frequent and more likely to be severe in symptomatic than in asymptomatic patients (p less than 0.0002), even after adjusting for age and sex. Carotid stenosis is present in only a minority of patients with strokes and transient ischemic attacks, especially if neck bruits are absent, and the cause of the ischemic cerebral events in most of these patients remains unexplained.     

Concurrent moyamoya disease and Graves' thyrotoxicosis: case report and literature review

Coexistence of thyrotoxicosis and moyamoya disease is extremely rare. A 23-year-old woman who had a history of migraine, suffered from frequent right carotid transient ischemic attacks, followed by an ischemic stroke after taking ergotamine for migraine. Magnetic resonance angiography revealed a tubular stenosis of the right internal carotid artery (ICA) and bilateral strictures of the supraclinoid segments of the ICAs. A concomitant thyrotoxicosis was found. A second stroke occurred three weeks later, when the dosage of antithyroid medication was increased and phenylpropanolamine-containing cold remedies were taken. Moyamoya disease was confirmed by cerebral angiography which showed irregular tubular stenosis of the right cervical ICA just above the bifurcation and nearly complete occlusion of bilateral supraclinoid ICAs with collateral flows from posterior circulation. The complexity of the cerebral hemodynamics of this patient is discussed.     

External Carotid Artery Angioplasty and Stenting Followed by Superficial Temporal Artery to Middle Cerebral Artery Anastomosis

A 31-year-old man presented with right hemiparesis, and magnetic resonance imaging revealed a small infarct at left basal ganglia. Digital subtraction angiography showed left cervical internal carotid artery (ICA) occlusion and severe stenosis of the ipsilateral external carotid artery (ECA) with collateral cerebral circulation fed by ECAs. Based on the results of a functional evaluation of cerebral blood flow, we performed preventive ECA angioplasty and stenting for advanced ECA stenosis to ensure sufficient blood flow to the superficial temporal artery. Eight weeks later, superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was performed. His postoperative course was uneventful and no additional transient ischemic attacks have occurred. To our knowledge, this is the first report of preventive angioplasty and stenting for advanced narrowing of an ECA before STA-MCA anastomosis for ipsilateral ICA occlusion.     

A peculiar MRI findings in a case with slowly progressive cerebral ischemia caused by internal carotid artery stenosis possibly due to fibromuscular dysplasia]

A 47-year-old man developed progressive muscular weakness in the left arm. MR images revealed low intensity signal lesions with ring enhancement by Gd-DTPA in right fronto-parietal lobes. At that time cerebral angiography was not performed because he refused. A tuberculin skin test showed strongly positive reaction and then administration of anti-tuberculous drugs was started. His symptom had remained stable for one year, but left facial palsy and dysarthria added about two years later. MR images revealed expansion of the lesions in right parietal lobe, adding cortical high intensity signal lesions with Gd-DTPA enhancement on T1-weighted images. Angiography disclosed tubular stenosis of right internal carotid artery at the portion of cervical to petrous segment and the local stenosis at right renal artery. These lesions were considered to be caused by fibromuscular dysplasia, but not atherosclerosis, because we could not find any atherosclerotic lesions in other arteries including right carotid bifurcation. His manifesting symptoms were ascribed to slowly progressive cerebral ischemia. And peculiar MRI findings in his early stage resembled those of inflammatory granulomatous diseases.     

Vasospastic cerebral infarction induced by smoking: a case report]

A 31-year-old man was admitted to our hospital because of frequent transient ischemic attacks (TIAs). The first episode involved right amaurosis fugax and left hemiparesis at the age of 26. Treatment with aspirin did not reduce frequency of TIA. Cerebral angiography at the age of 29 showed a significant stenosis in the right internal carotid artery with a string-of-beads-like appearance. This pattern suggested fibromuscular dysplasia. TIAs persisted despite of prophylactic medication with ticlopidine. When cerebral angiography was repeated at age of 28, stenosis in the right internal carotid artery had almost disappeared. At the present admission, MR angiography showed stenoses of bilateral internal carotid arteries and middle cerebral arteries, which had disappeared when the study was repeated after 5 days. Vasospasm was suspected based on reversibility of changes in both conventional and MR angiographies. The patient was treated with a calcium antagonist to prevent vasospasm as well as cessations of smoking. The patient had a history of 20 cigarettes a day for 12 years and neurologic deficits often occurred after smoking. Therefore, smoking is considered to be a main trigger for TIAs in this patient.     

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.     

Intracranial internal carotid artery stenosis with vulnerable plaques successfully treated by stenting under cerebral protection

Percutaneous transluminal angioplasty with stenting (PTA/stenting) for intracranial atherosclerotic stenoses is usually performed without any protection devices. We report a unique case of atherothrombotic stenosis with the vulnerable plaque in the cavernous portion of the internal carotid artery (ICA), which was successfully treated by PTA/stenting under cerebral protection with the flow reversal system.A 68-year-old woman presented repetitive transient ischemic attacks in the right ICA territory. Cerebral angiography revealed 80% stenosis in the cavernous portion of the right ICA. High-resolution magnetic resonance imaging (HR-MRI) demonstrated lipid-rich plaques at this lesion. PTA/stenting was performed with a proximal protection device under flow reversal. A filter device captured much amount of atherothrombotic debris with lipid-rich macrophages and leukocytes, which was consistent with HR-MRI findings.Some selected cases of intracranial atherothrombotic ICA stenoses may need endovascular treatment with cerebral protection system. HR-MRI is useful to evaluate plaque characteristics even in the cavernous portion of the ICA.     

A case of ischemic oculopathy followed by border zone infarction

We reported a 72-year-old male with ischemic oculopathy due to ophthalmic artery stenosis followed by ipsilateral border zone infarction due to internal carotid artery stenosis. The patient had history of hypertension and diabetes mellitus. He had severe headache and visual disturbance of the right eye. He was diagnosed right neovascular glaucoma and left diabetic retinopathy (simple type), and received diuretics, beta-blockade and other anti-hypertensive drugs. One month later, he noticed left mild hemiparesis in a morning, and he experienced progression of left hemiparesis over a week. He was admitted to our hospital on the 11th day. He showed left complete hemiplegia, left sensory disturbance, anosognosia and left unilateral spatial neglect. His right eye was diagnosed neovascular glaucoma but left eye was normal. The 5th days CT showed low density area in the right terminal zone and bilateral periventricular lucency. At the same area, the 46th days MRI showed high intensity area in the T2-weighted image and low intensity area in the T1-weighted image. Cerebral angiography performed on the 33rd day, disclosed severe kinking at the cervical segment and 50% stenosis at the intracavernous segment in the right internal carotid artery, and 90% stenosis and post-stenotic dilatation of the right ophthalmic artery. Left internal carotid artery had each 60% stenosis at the cervical segment and the intracavernous segment. Left ophthalmic artery had severe stenosis from its beginning to distal part. This infarction was considered berder zone infarction by it's localization (terminal zone) and internal carotid artery stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Perfusion insufficiency in limb-shaking transient ischemic attacks

We describe a 63-year-old man with severe bilateral internal carotid artery disease who presented with repeated, brief attacks of left limb shaking precipitated by his standing up. Cerebral blood flow measured by xenon-133 inhalation showed reduced resting flows and a focal perfusion deficit in the right dorsofrontal and upper rolandic regions. Blood flow velocity and pulsatility index of the right middle cerebral artery measured by transcranial Doppler ultrasonography were also reduced. With hypercapnic challenge, both hemispheric tissue perfusion and blood flow velocity showed impaired reactivity. With induced hypotension, the focal perfusion deficit in the right dorsofrontal region was accentuated. Following right internal carotid endartectomy, resting cerebral blood flow and blood flow velocity improved, as did hypercapnic vasoreactivity. These reversible deficits in cerebral blood flow and vasoregulation, which were maximal in the dorsofrontal region, are consistent with low perfusion in the border zone territory or the distal fields and demonstrate that hemodynamic failure is the likely mechanism for limb-shaking transient ischemic attacks from severe carotid artery disease.     

Volume therapy in orthostatic transient ischemic attacks

We report the case of an 83-year-old man with recurrent orthostatic transient ischemic attacks despite anticoagulation and crystalloid therapy. An initial cerebral angiogram revealed a nearly occluded right carotid artery with a string sign. Following aggressive volume expansion with albumin, the patient became asymptomatic. A second angiogram demonstrated the resolution of the carotid string sign and unmasked a high-grade, very tight, surgically approachable stenosis. The role of a high intravascular volume status is discussed.     

Cerebral revascularization for transient ischemic attacks

Thirty-one patients with cerebral transient ischemic, attacks and ipsilateral internal carotid artery occlusion without contralateral internal carotid artery occlusion or stenosis were treated with a surgical anastomosis between a superficial temporal artery and a cortical branch of the middle cerebral artery of the symptomatic hemisphere. The anastomosis was successful in 28 patients. Recurrent transient ischemic attacks were abolished in 23 patients and reduced in three. Two patients, one with a patent anastomosis, had strokes during the follow-up period. Of seven patients who refused the operation, two had strokes, two noted a reduction of transient ischemic attacks, two noted no change, and one became asymptomatic.     

Are Limb‐Shaking Transient Ischemic Attacks a Risk Factor for Postendarterectomy Hemorrhage? Case Report and Literature Review

Postoperative intracerebral hemorrhage occurs in about 0.5% of all carotid endarterectomies. There are no recognized risk factors for this complication. We report on a 74-year-old woman with right sided limb-shaking transient ischemic attacks and severe stenosis of the left internal carotid artery. She suffered a fatal intracerebral hemorrhage 11 days after endarterectomy. This case prompted a review of the literature to determine if limb-shaking transient ischemic attacks might be a risk factor for postoperative intracerebral hemorrhage. We propose that patients with limb-shaking transient ischemic attacks have loss of vasomotor reactivity placing them at high risk for carotid reperfusion syndrome and hemorrhage into the revascularized territory.     

颈动脉超声、磁共振血管成像在短暂性脑缺血发作病因学方面的研究

目的:探讨颈动脉超声、MRA、DSA对短暂性脑缺血发作(TIA)的病因学方面的价值。方法:回顾分析43例TIA患者颈动脉超声与MRA检查结果,其中18例有DSA对比验证。结果:①38例(88.4%)患者颈动脉超声显示血管异常,有粥样斑块形成,20例(46,51%)有低回声或溃疡型斑块,15例(34.88%)示有管腔狭窄。②30例(69.8%)患者MRA示有脑动脉狭窄,以颅外动脉狭窄居多,同一病人可同时存在多条血管狭窄。结论:TIA最常见的原因是血管的动脉粥样硬化和动脉狭窄,因此对脑血管状况进行评估具有重要的意义。     

Repeated Cerebral Ischemia Caused by Extracranial Carotid Artery Dolichoectasia

We report the case of a 67‐year‐old man with repeating cerebral embolism caused by a dolichoectatic right common carotid artery. The patient had a history of hypertension, hypercholesterolemia, cigarette smoking, and a postoperative abdominal aortic aneurysm. He presented with a sudden onset of weakness of the left arm and leg. Magnetic resonance imaging revealed old and fresh infarction in the right cerebral hemisphere. Carotid duplex ultrasonography showed a dolichoectatic right common carotid artery with a maximum diameter of 39 mm with thick plaque and strong spontaneous echo contrast. The flow velocity was considerably reduced, which caused thrombus formation, and strong antithrombotic therapy was required. This case provides a rare example of ischemic stroke caused by extracranial carotid artery dolichoectasia.     

Limb Shaking Transient Ischemic Attacks with Normal Neurovascular Ultrasound may Herald Cardioembolic Stroke: A Case Report

Our objective is to highlight that the rare occurrence of limb shaking in transient ischemic attacks may be underpinned by etiologies other than critical internal carotid stenosis/occlusion. We describe a 74 year-old woman with abrupt left arm jerking and normal urgent computed tomography scan, electroencephalography (EEG) as well as carotid and transcranial ultrasound. Two days later she developed an overt ischemic stroke, with left mesencephalon and left cerebellar hemisphere lesions at brain magnetic resonance imaging and paroxysmal atrial fibrillation at Holter-EKG. Transient ischemic attacks should be considered in the differential diagnosis of limb shaking even in patients with normal carotid and transcranial ultrasonography.     

Bilateral ballism as limb-shaking transient ischemic attacks treated with unilateral carotid artery stent placement

Bilateral limb-shaking transient ischemic attack (LS-TIA) is a rare disease involving carotid artery stenosis, characterized by ballism-like involuntary movements of the arms and legs. We describe the case report of a male patient in his 80s presented with continuous bilateral ballism in the arms and legs and tongue dyskinesia. Magnetic resonance imaging showed no ischemic lesions, while cerebral angiography revealed right internal carotid artery (ICA) occlusion and 80% stenosis of the left ICA. 99mTc-ethyl cysteinate dimer single-photon emission computed tomography demonstrated hypoperfusion in the right cerebral cortex but hyperperfusion in both basal ganglia. Left ICA stenting was performed, and involuntary limb shaking disappeared. This case report highlights the importance of accurate diagnosis and treatment of bilateral ballism as LS-TIA.     

Focal motor crises: a transitory ischemic attack?

A 65-year-old man with hypertension and coronary artery disease presented with a history of 6 tonic fits of right upper limb and 2 clonic fits of the right side of the face with language suspension, each lasting for only 2 to 3 minutes. CT with contrast showed a right occipital low density area, a probable old infarct, and left carotid angiography showed an ulcerated cervical stenosis. Based on reported experimental data, it is suggested that these paroxysmal manifestations are related to transient ischemic attacks, are of epileptic nature and due to an ischemic mechanism.     

短暂性脑缺血发作与颅内外血管狭窄的关系

目的 探讨短暂性脑缺血发作(TIA)与颅内外血管狭窄的关系.方法 对130例TIA患者的CT血管成像(CTA)进行分析,观察TIA患者颅内外段血管有无狭窄及TIA发作次数与狭窄数量关系.结果 130例TIA中有血管狭窄94例(占72.3%).颈内动脉系统TIA患者80例中有血管狭窄者55例(占68.75%),颈内动脉颅...     

TIA与TIA形式的脑梗死的相关因素分析

目的分析TIA及TIA形式的脑梗死的临床特点,探索其临床相关因素。方法回顾性分析83例初步诊断为TIA并在症状首发后24 h内行常规MRI及DWI检查的患者,发病1周内行颈部动脉血管彩超、TCD。记录发病后7 d内的临床转归。根据DWI结果分为DWI+组及DWI-组,确定DWI阳性率。比较DWI+组及DWI-组临床特征差别。分析两组患者动脉粥样硬化斑块的部位、性质、数量及颅内外血管狭窄的部位、程度。结果DWI阳性率为36.1%。DWI阳性与动脉粥样硬化相关(P=0.03),与颈部动脉动脉粥样硬化斑块数目相关(P=0.04),TIA症状首发后7 d内,30.0%DWI+组患者TIA症状反复发作或表现为临床症状持续存在,高于DWI-组(22.6%)。结论临床表现为TIA的病例大于1/3急性期已经形成了脑梗死,动脉粥样硬化斑块数量越多,DWI阳性的可能性越大,DWI+的患者7 d内更易进展。