Dural arteriovenous fistula between inferolateral trunk of the internal carotid artery and superficial sylvian vein

A 40-year-old Brazilian man presented with headache followed by consciousness disturbance. Computed tomography showed subarachnoid hemorrhage with right frontal hematoma. Angiography revealed a dural arteriovenous fistula (dAVF) fed by the inferolateral trunk of the internal carotid artery and draining into the superficial sylvian vein with varix formation. The shunting point was directly obliterated through a pterional approach. Postoperative angiography showed complete disappearance of the fistula. A ventriculoperitoneal shunt was needed for normal pressure hydrocephalus during his hospitalization. The modified Rankin scale at discharge was grade 2 with mild cognitive dysfunction. This case of dAVF may represent congenital dAVF.     

Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms

OBJECTIVE: Aneurysms at nonbranching sites in the supraclinoid internal carotid artery (ICA), known as blood blister-like aneurysms or ICA anterior or dorsal wall aneurysms, are not well understood. To clarify this clinical entity, 7408 patients with subarachnoid hemorrhage who were treated during a 5-year period were analyzed. METHODS: Forty-eight patients had aneurysms that were intraoperatively confirmed to be located at a nonbranching site in the supraclinoid portion of the ICA. Neuroradiological and clinicopathological features and outcomes were studied. RESULTS: The aneurysms were divided into the "blister type," with a blood blister-like configuration and fragile walls, and the "saccular type," with a saccular configuration and a relatively firm neck, like ordinary berry aneurysms. The most frequent origin was the anteromedial wall for both types. ICA dissection was associated only with the blister type, and hypertension was more frequent with the blister type (P = 0.0978). The preoperative conditions of the patients were the same, but the outcomes for patients with blister-type aneurysms were worse, because of frequent intra- and postoperative aneurysmal bleeding. Saccular-type aneurysms were safely clipped. Treatment of blister-type aneurysms by clipping on wrapping material achieved good results, but ICA trapping (P = 0.0952), clipping (P = 0.0146), and wrapping (P = 0.0110) were associated with much worse results. CONCLUSION: Blister-type and saccular-type aneurysms have different shapes and wall characteristics. The saccular type can be treated by clipping, whereas the blister type requires clipping on wrapping material. ICA trunk aneurysms may be a better designation to express the diversity of these aneurysms, rather than ICA blood blister-like or anterior or dorsal wall aneurysms.     

Anomalous branches of the cervical internal carotid artery: two cases of clinical importance

Anomalous branches of the cervical portion of the internal carotid artery are rare. Reports in which these anomalous branches are of any clinical importance are even more rare. We are reporting two cases in which the anomalous branch maintained patency of the cervical portion of the proximally occluded internal carotid artery. Both patients initially had hemispheric symptoms appropriate to the affected internal carotid artery. This article details angiographic methods to demonstrate the unusual anatomic and pathologic aspects of these cases and the successful operative approach.     

Agenesis of the left internal carotid artery, common carotid artery, and main trunk of the external carotid artery associated with multiple cerebral aneurysms

A case of agenesis of the left internal carotid artery, common carotid artery, and the main trunk of the external carotid artery with multiple cerebral aneurysms is presented. This case was diagnosed by angiography and computed tomography scanning and confirmed by operation. Correlation between the anomaly of the circle of Willis based on the absence of the internal carotid artery and the development of cerebral aneurysm is discussed on the basis of the reported cases.     

Agenesis of the left internal carotid artery, common carotid artery and main trunk of the external carotid artery associated with multiple cerebral aneurysms: case report

A case of agenesis of the left internal carotid artery, common carotid artery and main trunk of external carotid artery with multiple cerebral aneurysms is presented. No similar case has been reported before. A 70-year-old man who had severe headache was admitted to the neurological department of Matsuyama Shimin Hospital. On admission he demonstrated nuchal rigidity and motor aphasia. CT scan revealed subarachnoid hemorrhage with intracerebral hematoma in the left temporal area. Right common carotid angiography, bilateral retrograde brachial angiography and aortography demonstrated an agenesis of the left internal carotid artery, common carotid artery and main trunk of external carotid artery with aneurysms of the anterior communicating artery, left middle cerebral artery and basilar tip. And these revealed that the left middle cerebral artery was fed from the basilar artery via the dilated left posterior communicating artery, and the left ophthalmic artery was originated from the left middle cerebral artery. CT of the base of the skull revealed no carotid canal on the left side. We confirmed these findings by operation. The importance of altered hemodynamic forces on the circle of Willis produced by the agenesis of the internal carotid artery and the embryological considerations are discussed.     

Separate arch origin of the left external carotid artery with common trunk giving rise to the left internal carotid artery and left subclavian artery

We present a case of a 3-year-old boy with tetralogy of Fallot having the direct origin of the left external carotid artery from the aorta with a common trunk giving rise to the left internal carotid artery and left subclavian artery, in a right-sided aortic arch. We also highlight the potential implications in management.     

颈内动脉闭塞术的初步临床应用

目的探讨颈内动脉闭塞术治疗颈内动脉血管性病变的价值。方法共5例患者,1例鼻咽癌行放疗后清创术,并发难以制止的鼻咽部大出血,双侧后鼻孔填塞无效;1例巨大颈内动脉眼段动脉瘤,无法手术夹闭;3例外伤后颈内动脉海绵窦瘘,单纯闭塞瘘口失败。采用Seldinger技术经股动脉穿刺置管行全脑血管造影,经球囊闭塞试验或病变侧压颈试验,病人耐受良好后方行闭塞术。闭塞材料为3例应用可脱弹簧圈,2例应用可脱球囊,闭塞位置为病变近端及瘘口。结果所有病例闭塞颈内动脉后,即行对侧颈动脉造影复查,可见前交通动脉和/或后交通动脉代偿良好,患者无明显并发症发生,病变未见显影。临床症状消失、无合并症发生,病变未见复发。结论颈内动脉闭塞术作为一种治疗颈动脉血管性疾病的方法,可以在不危及病人生命、加重病人病情的情况下,取得良好的治疗效果。     

颈内动脉海绵窦段分支及其临床意义

目的　研究颈内动脉海绵窦段的分支的出现、起始、外径和分布等的显微外科解剖， 为海绵窦的显微手术的开展提供形态学依据。方法　采用经颈内动脉灌注苯乙烯的４６ 例成人头颅， 在手术显微镜（１０ 倍） 进行观察和测量。结果　颈内动脉海绵窦段由后向前分为后升部、后曲、水平部、前曲和前升部；颈内动脉此段分支有脑膜垂体干、小脑幕动脉、垂体下动脉、脑膜背侧动脉、海绵窦下动脉和垂体被囊动脉以及异常的眼动脉等， 其出现率分别为８７ ％ 、８７ ％ 、９４ ％ 、８１ ％ 、８８ ％ 、３２ ％ 和６ ％ 。结论　本文较系统、全面地阐明了海绵窦段的显微外科解剖，对临床进行显微外科手术、血管介入和影像学检查有指导意义     

Fenestration of the internal carotid artery

Fenestration of the internal carotid artery is very rare. The authors describe two cases of fenestration at the cervical portion of the internal carotid artery that were revealed by angiography. The embryological basis and clinical significance of this anomalous condition are discussed.     

Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: treatment and outcome

OBJECT: The object of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) trunk. METHODS: The authors performed a single-center, retrospective study. Data analyzed were patient age, sex, Hunt and Hess grade, Fisher grade, time from SAH to hospitalization, aneurysm size and location, collateral capacity of the circle of Willis, time from hospitalization to aneurysm repair, type of aneurysm repair, complications, and Glasgow Outcome Scale (GOS) score at follow-up. RESULTS: A total of 211 patients suffered SAH from ICA aneurysms. Of these, 14 patients (6.6%) had ICA trunk BBAs; 6 men and 8 women. The median age was 47.8 years (range 29.9-67.7 years). The Hunt and Hess grade was IV or V in 7 cases, and SAH was Fisher Grade 3 + 4 in 6. All aneurysms were small (< 1 cm), without relation to vessel bifurcations, and usually located anteromedially on the ICA trunk. Three patients were treated with coil placement and 11 with clip placement. Of the 7 patients in whom the ICA was preserved, only 1 had poor outcome (GOS Score 2). In contrast, cerebral infarcts developed in all patients treated with ICA sacrifice, directly postoperatively in 2 and after delay in 5. Six patients died, 1 survived in poor condition (GOS Score 3; p < 0.001). CONCLUSIONS: Internal carotid BBAs are rare, small, and difficult to treat endovascularly, with only 2 of 14 patients successfully treated with coil placement. The BBAs rupture easily during surgery (ruptured in 6 of 11 surgical cases). Intraoperative aneurysm rupture invariably led to ICA trap ligation. Sacrifice of the ICA within 48 hours of an SAH led to very poor outcome, even in patients with adequate collateral capacity on preoperative angiograms, probably because of vasospasm-induced compromise of the cerebral collaterals.     

Dissection of the internal carotid artery

Closed injury of the internal carotid artery is rare, as it represents only 4% of all the lesions affecting the carotid system. Diagnosis of this injury is difficult, the first signs often being missed as they usually occur in severely injured patients, with the neurological signs appearing later. The death rate remains high, and the sequelae very heavy. After a road traffic accident, three patients, all drivers wearing their seat-belts, presented with bone and/or abdominal lesions, a head injury and a left anterolateral flail chest. All three cases showed an unilateral mydriasis; the variations in their conscious levels led to further neurological investigations. The diagnosis was suggested in one patient by computerized axial tomography, and confirmed in all three by carotid arteriography. The results were excellent when early surgery could be performed (2 cases). However, in the absence of surgery, carotid dissection could only be a major contributing factor for the cerebral oedema associated with the previous hemispheric contusion. The mechanism of these carotid injuries would appear to involve rotation and extension or flexion movements of the neck, crushing the internal carotid artery against the transverse processes of the cervical vertebrae or the mandible: a possible part played by the seat-belt would explain the frequent association of the injury with chest trauma.     

Aplasia of the internal carotid artery

Summary.  Background: The majority of previous reports on this rare agenesis of the internal carotid artery (ICA) have been limited to reporting upon its association with other congenital anomalies case by case. In order to collectively summarize this congenital anomaly of ICA, we have reviewed nine cases of ICA aplasia and their associated abnormalities.  Method: Nine cases of ICA aplasia were reviewed. The diagnosis of aplasia or agenesis of the ICA was based on angiographic findings and the presence of an absent or hypoplastic bony carotid canal by temporal bone computed tomography (TBCT). Their presumable embryological aetiologies, initial presenting symptoms, unusual collateral circulations, as demonstrated by angiographies, and various associated anomalies are reviewed.  Findings: The initial presentations were; subarachnoid haemorrhage in three patients, headache in one patient and ischemic symptoms and signs in three patients. The remaining two cases were found incidentally during angiography for other diseases. Collateral circulations to the middle cerebral artery ipsilateral to the ICA aplasia were via posterior communicating artery (P-com) or anterior communicating artery (A-com). On TBCT, all cases but one demonstrated agenesis of the bony carotid canal and the remaining case showed a hypoplastic canal. Cerebral aneurysms were found in six patients, four with A-com aneurysm, one with a basilar bifurcation aneurysm, and one with both a right P-com and a left cavernous ICA aneurysm; two incidentally found cases had no aneurysm. Other associated abnormalities were found in four cases; one case of hypoplasia of the common carotid artery (CCA) with an arachnoid cyst at the temporal pole, one case of abnormal origin of the right CCA from the aorta and the right subclavian artery from the descending aorta, one case of congenital temporomandibular joint (TMJ) ankylosis, and one case of nasopharyngeal angiofibroma with atresia of the upper basilar artery. Except for the atresia of the upper basilar artery, all such abnormalities were found on the same side as the ICA aplasia.  Interpretation: Agenesis or aplasia of ICA may be entirely harmless. However, associated conditions such as cerebral aneurysm or abnormal collateral channels should alert clinicians to the possibility of deterioration to life-threatening conditions, such as subarachnoid haemorrhage or irreversible ischemia. Other associated anomalies are commonly depicted on the same side as the ICA aplasia and may also give rise to issues of clinical importance. Published online February 10, 2003 Acknowledgment  This work is supported in part by a grant from the Seoul National University Hospital Research Fund.  Correspondence: Chang Wan Oh, M.D., Department of Neurosurgery, Seoul National University Hospital, 28 Yongon-dong, Chongno-ku, Seoul, 110-744, South Korea.     

External carotid endarterectomy with internal carotid artery transposition flap angioplasty for symptomatic internal carotid artery occlusion

The external carotid artery is an important collateral pathway for cerebral perfusion when the internal carotid artery is occluded. After internal carotid artery occlusion, there is a definite risk of ipsilateral neurological events. The authors retrospectively examined their experience with endarterectomy of the external carotid artery for symptomatic internal carotid artery occlusion. Results based on the authors' experience and on historical data show external carotid endarterectomy to be a safe procedure. Obliteration of the cul-de-sac appears to be a very important factor in the prevention of reocclusion or recurrence of symptoms after external carotid endarterectomy. Use of the internal carotid artery stump for patching of the endarterectomized external carotid artery is both safe and effective in treating symptomatic internal carotid artery occlusion.     

Aneurysm of the extracranial internal carotid artery

Aneurysm of the extracranial internal carotid artery is a rarely observed condition. Intra-aneurysmatic thrombosis, cerebral embolism with possible neurological consequences, and rupture are the most common complications. Operations were performed on 20 patients for aneurysm of the internal carotid artery. The cases included 14 "genuine" arteriosclerotic aneurysms and seven "false" aneurysms in the wake of shell splinter injuries, tonsillectomy, thrombo-arteriectomy, and blunt traumata. Pulsating tumour was the most important clinical symptom in all aneurysm cases. Arterial continuity was restored by resection of aneurysm in all cases. Sixteen patients were dehospitalised without any complaint. Two patients with preoperative cerebral infarction were left with residual paresis. One patient died of pulmonary embolism, and one patient operated on for rupture died in shock.     

Traumatic dissection of the internal carotid artery

Two patients with posttraumatic dissection of the internal carotid artery were referred to the neurosurgical department with secondary neurological deterioration following a minor head injury with concussion. Both developed aphasia and right hemiparesis during the first few hours after the accident; one patient also had right focal seizures. On admission, both were only mildly lethargic, which contrasted with the severity of the focal neurological signs. Early CT scan was normal in both cases, whereas cerebral blood flow (CBF) studies by single photon emission computerized tomography (SPECT) with Tc-HMPAO (Ceretec) showed perfusion defects in the region supplied by the left middle cerebral artery (MCA), correlating with the clinical picture. Doppler sonography disclosed pathologic flow patterns, and carotid angiography demonstrated dissection of the internal carotid artery, in one patient on the left only and in the other bilaterally, with embolic occlusion of a branch of the left MCA in the latter case. Clinical features, pathogenesis, diagnostic workup and possible treatment (medical, as in our two cases, versus surgical) of this rare pathology are briefly reviewed.     

Fibromuscular dysplasia of the internal carotid artery

Sixty-eight patients underwent 104 operations for symptomatic fibromuscular dysplasia between 1965 and 1977. In 8 of the early operations, the artery was resected and primarily anastomosed or replaced with saphenous vein. The remainder of the patients had graduated dilatation of the carotid artery combined, if necessary, with a bifurcation endarterectomy. Four patients had a contralateral endarterectomy for atherosclerosis. There were no operative deaths. Two patients had neurologic deficits after operation, while 7 had 1 transient ischemic attack or amaurosis in the early postoperative period. The follow-up period extends from 6 months to 12 years. One patient developed a deficit that could be attributed to the carotid artery at the site of the prior dilatation, and 2 patients developed neurologic difficulties secondary to subarachnoid hemorrhage. The exact nature of the disease, its incidence in the community, and the mechanism of symptom production remain unknown. Symptomatic fibromuscular dysplasia is not a benign disorder, and there are no data available to confirm or deny the benefit of medical treatment. Intraluminal dilatation, however, is a safe, durable operation that relieves symptoms and offers prophylaxis against further neurologic sequelae.

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Résumé Entre 1965 et 1977, nous avons réalisé chez 68 patients 104 opérations pour dysplasie fibromusculaire symptomatique. Dans 8 cas, au début de la série, l'artère a été réséquée et réanastomosée ou remplacée par un segment de veine saphène. Les autres patients ont subi une dilatation graduée de la carotide, combinée, si nécessaire, à une endartériectomie de la bifurcation. Une endartériectomie controlatérale pour athéromatose a été faite dans 4 cas. Il n'y a pas eu de décès postopératoire. Deux malades ont des séquelles neurologiques et 7 ont présenté, dans la période post-opératoire précoce, un épisode d'ischémie transitoire ou une amaurose. Le follow-up est de 6 mois à 12 ans. Un malade a présenté un accident vasculaire cérébral qui peut être attribué à une lésion carotidienne à l'endroit oú la dilatation avait été faite; 2 autres ont eu des troubles neurologiques par hémorragie sousarachnoïdienne. La nature exacte de la maladie, sa fréquence, les mécanismes d'apparition des symtomes restent inconnus. La dysplasie fibromusculaire symptomatique n'est pas une maladie bénigne et aucune donnée ne permet de préciser la valeur du traitement médical. Mais la dilatation vasculaire intra-luminale est une opération sans risque, aux résultats durables, qui soulage les symptomes et prévient les séquelles neurologiques.