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.     

Aneurysm dissection of the extracranial internal carotid artery

Aneurysm of the extracranial internal carotid artery is a rare event. This is a pathology with an elevated mortality of 70%. The most important etiologic factor is atherosclerosis. Here we report a case of surgically treated extracranial internal carotid artery (ICA) aneurysm. A 77-year-old man noticed a laterocervical pulsatile mass. Color Doppler ultrasonography revealed an ICA aneurysm related to a parietal thrombosis. The ICA aneurysm was confirmed by intra-arterial digital subtraction angiography, and cerebral computer tomography (CT) was negative. Surgical treatment reconstruction with the interposition of a part of the great saphenous vein was indicated. Exploration of the aneurysmatic wall revealed a posterolateral dissection. In this paper are discussed clinical and therapeutic implications.     

Giant aneurysm of the high internal carotid artery: surgical treatment.

We report the successful surgical treatment of a patient with a giant aneurysm of the high internal carotid artery by resection of the aneurysm and end-to-end anastomosis at the skull base, after resection of the styloid process and section of the stylohyoid and digastric muscles. No shunt was used and no major neurologic deficits resulted. Thirty months after operation the repaired artery is patent, with no evidence of stenosis or residual aneurysm and with good distal perfusion. Surgical treatment of high carotid artery aneurysms is possible with rather simple techniques; excision of the aneurysm followed by restoration of continuity of the carotid ends should be the treatment of choice regardless of the location of the aneurysm.     

The elongation of the internal carotid artery. Diagnosis and surgical treatment

Cerebro-vascular insufficiency is rarely caused by an abnormal elongation of the internal carotid artery (the ratio is 15% to 17% of symptomatic patients). The anomalies can be defined as: tortuosity, when the artery has a "C" or "S" shape; coiling, when the elongation is more evident and the artery forms one or more loops; kinking, when there is a sharp angulation of the first portion of the internal carotid artery. The etiology of these peculiar arterial modifications seems to be related to a congenital basis which may become exaggerated with ageing of the artery. Surgical correction should include intra-arterial inspection (TEA) as well as eliminating the pathological elongation. The Authors presents their 9 cases surgical experience.     

Anteposition of the internal carotid artery for surgical treatment of kinking

BACKGROUND: Kinking of the extracranial portion of the internal carotid artery (ICA) requires surgical reconstruction when it causes neurological symptoms. We suggest a simple surgical reconstruction without arteriotomy. METHOD: Anteposition of the ICA ventral to the digastric muscle has been performed in three patients. Kinks in the ICAs, proved by angiography, were thought to be responsible for clinical signs and symptoms. RESULTS: The operations resulted in improvement, both clinically and radiologically. CONCLUSION: The complications of arteriotomy can be avoided using the technique of ICA antepositioning described in this paper.     

Aneurysm of the cervical internal carotid artery associated with Marfan's syndrome--case report.

An aneurysm of the internal carotid artery associated with Marfan's syndrome occurred in a 23-year-old female with a 2-year history of a pulsating lesion in the left neck, which progressively increased in size. Left carotid angiography demonstrated a giant saccular aneurysm at the origin of the internal carotid artery. The aneurysm was excised and end-to-end anastomosis performed without postoperative morbidity.     

Aneurysm of internal mammary artery.

A fusiform non-sclerotic aneurysm of the left internal mammary artery was found in an otherwise healthy young woman. Aneurysms such as this seem to be extremely rare since no published case could be found.     

Aneurysm of the extracranial internal carotid artery caused by fibromuscular dysplasia

A case of aneurysm of the extracranial internal carotid artery (ICA) caused by fibromuscular dysplasia (FMD) is reported. The patient also had an aneurysm of the contralateral intracranial ICA, but the renal arteries were normal. A review of the literature shows extracranial ICA aneurysms to be uncommon, with only 3% caused by FMD. The surgical management of such difficult lesions at the base of the skull is discussed.     

Long-term results of surgical treatment of patients with asymptomatic carotid artery stenosis

Results of treatment of 148 patients with asymptomatic carotid stenosis were analyzed in terms from 5 to 180 months. 75 (51%) patients were operated, 73 (49%)--were not operated. Non-operated asymptomatic patients with more than 90% stenosis and patients with prolonged (more than 18 mm) stenosis have the highest risk of cerebral events (4% annually and more). In long-term period (from the 70th month of follow-up) patients with the 70-90% stenosis are the group of high risk of cerebro-vascular symptoms.     

颈内动脉完全闭塞的手术治疗

目的 探讨颈动脉血运重建治疗完全性颈内动脉闭塞的临床疗效.方法 2001年6月～2010年4月,收治颈动脉狭窄患者397例,术前行磁共振血管造影(MRA)检查,确诊并行颈动脉内膜切除术(CEA)治疗颈内动脉闭塞患者28例,术中切除标本送病理检查,术后复查颈部MRA,并对术后情况进行随访.结果 术后即时通畅率为92.8％,术后平均随访时间10个月,22例颈内动脉通畅,通畅率为78.5％,无脑缺血事件发生;6例颈内动脉闭塞患者中,2例在术后4个月发生短暂性脑缺血及腔隙性梗死;3例术后仍偶有头晕,其中2例单侧肢体麻木;1例记忆力减退.结论 对于有症状的颈内动脉闭塞患者,CEA加取栓术是安全有效的方法.     

Surgical treatment of internal carotid artery occlusion

PURPOSE: Nonoperative treatment of recent internal carotid artery (ICA) occlusion is associated with increased recurrent stroke rates. We analyzed our results of carotid endarterectomy (CEA) for treatment of symptomatic recent ICA occlusion to evaluate its feasibility, safety, and outcomes. METHODS: From 1990 to 2002, all patients with transient ischemic attack (TIA), amaurosis fugax, and minor stroke underwent duplex ultrasound (US) scanning and arteriography to confirm the diagnosis of ICA occlusion. Within 2 weeks of symptom onset, patients underwent operative exploration with attempted CEA. ICA occlusion was detected at preoperative angiography and confirmed at surgery. Patients with extensive ICA plaque not amenable to endarterectomy underwent external CEA with ICA ligation. RESULTS: Over 12 years, 87 patients with symptomatic ICA occlusion underwent 90 operations for ICA exploration. In 30 patients (18 men, 12 women) with TIA (45%), amaurosis fugax (19%), or minor stroke (36%), CEA to treat ICA occlusion was technically successful. There was 1 postoperative stroke, 2 asymptomatic internal carotid occlusions, and no restenoses (mean follow-up, 26 months; range, 1-93 months). In 57 patients (37 men, 20 women) with TIA (41%), amaurosis fugax (27%), or stroke (32%) in whom CEA was unsuccessful, external CEA was performed. In this group there were no postoperative strokes, 2 asymptomatic external carotid artery occlusions, and 1 restenosis (>70%) (mean follow-up, 22 months; range, 1-73 months). There were no late strokes in either group. CONCLUSION: Operative exploration and endarterectomy to treat symptomatic ICA occlusion is feasible and safe. Patients with symptomatic ICA occlusion should be considered candidates for CEA.     

Aneurysm of the internal carotid artery and cervical mega-dolicho-arteries in Marfan syndrome

The authors describe the case of a Marfan syndrome who presented a giant intracranial internal carotid aneurysm associated with elongation and tortuosity of internal carotid and vertebral arteries on both sides. The skin microscopic examination showed fragmentation and distorsion of elastic fibers. There was no microscopic study of the vessels. Extra and intracranial vascular abnormalities are rarely reported in marfan syndrome: cardiovascular changes are seen mostly in aorta and pulmonary artery. In the literature are reported some giant aneurysms, dissections and dilatations of carotid, basilar and vertebral arteries. Usually the microscopic examination of the vessels show cystic medial necrosis. Other connective tissue diseases (pseudo-xanthoma elasticum, Ehlers-Danlos syndrome, progeria) are described with such clinical abnormalities. Reference is made to the possibility of unknown histological and chemical lesions weakening the vessels in patients without connective tissue disorders and presenting with arterial dissection or arterial aneurysm. So vessels would be more sensible to aging, arteriosclerosis or hypertension.     

Direct surgical treatment of intracavernous internal carotid artery aneurysms: report of four cases

The authors have operated directly on four cases of intracavernous internal carotid artery aneurysms by opening the cavernous sinus. Surgery was performed using a semisitting position, in which the upper half of the patient's body was elevated approximately 20 degrees from the horizontal plane. The superior wall of the cavernous sinus was opened through the pterional approach, and an aneurysmal neck clipping was successfully performed on three patients. A coating of the aneurysm was carried out on one patient. The results obtained were excellent in all cases. The authors believe that the operative technique reported is useful for surgical treatment of intracavernous lesions.     

Bilateral internal carotid artery occlusion: natural history and surgical alternatives.

PURPOSE AND BACKGROUND: Bilateral internal carotid artery occlusion is an extremely rare entity, therefore, studies of the natural history of this disease are lacking in the English literature. The purpose of this study is to analyze the natural history and surgical alternatives for patients with bilateral internal carotid artery occlusion. PATIENT POPULATION AND METHODS: Twenty-one patients with bilateral internal carotid artery occlusion were encountered with a mean age of 61 years (range of 48-73 years). Their clinical presentations included eight with hemispheric transient ischemic attacks, three with amaurosis fugax, five with strokes and five with non-hemispheric transient ischemic attack. Diagnosis was confirmed using carotid duplex ultrasound and angiography. The majority of patients had more than one risk factor for atherosclerosis: smoking in 100%, hyperlipidemia in 14/21 (67%), hypertension in 17/21 (81%), coronary artery disease in 15/21 (71%) and diabetes mellitus in 7/21 (33%). In addition to the usual medical treatment, 13 patients underwent surgical intervention: eight had an external carotid endarterectomy, four had a carotid-subclavian bypass (to increase external carotid or vertebral flow for tight stenosis or occlusion of the common carotid or subclavian artery) and one patient had an ascending aorta to innominate artery bypass. At a mean follow-up of 6 years (range 1-11 years), the overall mortality rates were 11/21 (52%), in the surgical group it was 5/13 (38%) and 6/8 (75%) in the medical group. The causes of death included seven myocardial infarctions (four in the surgical group and three in the medical group) and four strokes (one in the surgical group and three in the medical group). In the surgical group, 2/13 (15%) had late neurological deficits (one hemispheric transient ischemic attack and one stroke), in contrast to 6/8 (75%, three strokes and three hemispheric transient ischemic attacks) in the medical group. CONCLUSIONS: Bilateral internal carotid artery occlusions have grave prognoses and should be considered a marker for severe systemic disease. Various cerebrovascular reconstructive procedures, if feasible, may be beneficial for some of these patients.     

Dorsal internal carotid artery aneurysm: classification,pathogenesis, and surgical considerations

Despite the rarity of dorsal internal carotid artery (ICA) aneurysms they still offer surgical challenge to achieve a safe successful clipping due to their peculiar projection.In the past 13 years, 24 cases of dorsal ICA aneurysm were operated upon in our hospitals. Three separate groups of such aneurysms could be identified: group 1; where the aneurysms were located most proximally at the carotid-ophthalmic region, group 3; in which the aneurysms were present most distally just proximal to the ICA bifurcation, and group 2; where the aneurysms were located inbetween. All cases in this surgical series will be reviewed stressing upon the classification, pathogenesis, and surgical tactics of such a rare type of aneurysm.     

Clinical relevance of intraplaque hemorrhage in the internal carotid artery.

In this study the correlation between hemispherical ischemic symptoms and the presence of intraplaque hemorrhage in carotid plaques has been evaluated. 38 patients who had undergone carotid endarterectomy were examined clinically and the specimens obtained from operation were studied morphologically. The patients were divided into two groups, asymptomatic and symptomatic regarding the territory of the supplying carotid artery. The presence of intraplaque hemorrhage, shown by Ladewig's Trichrom stain, as well as evidence of iron, immunohistochemical stain of hemoglobin and native fluorescence microscopy was noted, and, according to their extension, classified into three degrees. As a result, there was neither a correlation between history of ischemic brain symptoms and the presence of intraplaque hemorrhage, nor between clinical symptoms and extension of hemorrhage. The plaques were high degree stenotic (greater than 80%) in most of the patients and showed various degenerative changes. In 97% of all plaques with hemorrhages surface defects were seen. Our results confirm that intraplaque hemorrhage is one out of a series of pathological events which occurs during advanced atherosclerosis. Blood inflow from the lumen through an already damaged plaque surface is a common event and a correlation with the onset of symptoms is unlikely.