Bilateral extracranial internal carotid artery injury due to non-penetrating trauma--report of three cases.

Angiographic features of three patients with bilateral internal carotid artery injury (spasm/dissection/thrombosis) due to non-penetrating trauma are reported. All three patients were involved in motor vehicle accidents. Focal-localizing neurological signs were present and the patients were suspected of having extracerebral haematomas. The diagnosis of traumatic spasm/dissection/thrombosis of the cervical portion of the internal carotid arteries was made following angiography. The need to include views of the cervical carotid arteries in cases of traumatic hemiparesis is stressed and possible effect of cranial CT scanning in these patients on diagnosis of carotid artery injury discussed.     

Peripatetic carotid artery simulating a carotid dissection on catheter angiography and CT angiography: a case report

Retropharyngeal carotid arteries are a common clinically relevant anatomic variant. “Peripatetic” carotid arteries refer to change in position to and from a retropharyngeal location, and are a newly described finding. Knowledge of this phenomenon is important to avoid potential procedural complications as well as misdiagnosis. We present a unique case of a peripatetic carotid artery simulating a carotid artery dissection during a catheter angiogram and subsequent CT angiogram. To our knowledge, this has never been described in the medical literature.     

Carotid and vertebral artery dissection: Magnetic Resonance findings in 15 cases

PURPOSE: Spontaneous dissection of the carotid and vertebral arteries represents a rare pathology. Its pathogenesis, probably multi-factorial, can be related to neck trauma and to a genetic basis, extensively demonstrated in the cases of association with type IV fibromuscular dysplasia, Ehlers-Danlos syndrome, Marfan's syndrome, pseudoxanthoma elasticum and osteogenesis imperfecta. Onset symptoms include neck, facial pain and diffuse headache. Cranial nerve palsy has been also described. The aim of this study was to evaluate MR angiography and MR findings in a population of patients with carotid and vertebral artery dissections. MATERIALS AND METHODS: We reviewed the MR angiography and MR exams of 15 patients (10 males, 5 females, average age 42.0, age range 30-55) with carotid and/or vertebral artery dissection; the serial MR follow-up studies were also examined. RESULTS: Twelve internal carotid arteries (ICA) showed the presence of an irregular stenosis; three of these showed complete occlusion. In two patients both ICA were involved. Six vertebral arteries (VA) showed irregular stenosis (only one patient suffered from both CI and VA dissection); in one case there was also a pseudoaneurysm of the VA. Follow-up studies showed vessel lumen re-opening in 5/11 ICA (one patient underwent vascular stent positioning) and in 3/6 VA. CONCLUSIONS: The present study confirms the usefulness of MR angiography and MR in the diagnosis and follow-up of patients with carotid and vertebral artery dissection.     

Triple spontaneous cervical artery dissection

A 39-year-old healthy man had several transient ischaemic attacks suggesting left internal carotid artery (ICA) occlusion. There were no vascular risk factors and no preceding trauma. Colour-coded duplex sonography suggested a pseudo-occlusion of the left ICA, and cerebral angiography demonstrated dissection of the left ICA and both vertebral arteries. Angiography 6 months later was completely normal. This underlines the importance of four vessel angiography in young patients with dissections of cervical arteries. Received: 27 August 1998 Accepted: 13 November 1998     

The emerging role of multidetector row CT angiography in the diagnosis of cervical arterial dissection: preliminary study

Introduction Cervical artery dissection is an important cause of ischemic stroke, particularly in young patients. The diagnosis can be made with invasive catheter angiography or non-invasive imaging, either with MRI in conjunction with MR angiography (MRA) or CT angiography (CTA). Both modalities have been shown to have a high specificity and sensitivity. New developments such as multi-slice CTA (MSCTA) are emerging as an alternative methods for imaging the cervical and intracranial arteries. However, the contribution of modern MSCTA to carotid artery dissection has not been reported.Methods We present a retrospective series of seven patients in whom both MSCTA and cervical axial T1 MRI and MRA were performed in the acute to subacute setting of internal carotid artery dissection.Results Carotid artery dissection was identified in all seven patients by MSCTA. The combination of MRI and MRA identified dissection in five of the seven patients. Additionally, a pseudoaneurysm was identified by MSCTA that was missed by MRI and MRA.Conclusion Our findings confirm that MSCTA is a complementary technique in comparison to cervical axial T1 MRI and cervical MRA for diagnosing carotid artery dissection, and at times may provide additional information that can impact patient management.     

Spontaneous dissection of the cervical internal carotid artery: correlation of arteriography, CT, and pathology

Spontaneous dissection of the internal carotid artery is being recognized as a more frequent cause of acute neurologic deficit, particularly in young persons. Saccular pseudoaneurysm formation may be an associated finding, especially in the presence of tortuosity (coiling) of the cervical internal carotid artery. Of eight patients with nine vessels demonstrating internal carotid artery dissection on arteriography, pseudoaneurysms were found in five arteries. Four of the five pseudoaneurysms occurred in tortuous (coiled) arterial segments. Thin-section contrast-enhanced dynamic incremental CT showed close agreement with the findings on selective arteriography and provided additional information on the presence and configuration of arterial wall thickening as well as the extent of the pseudoaneurysm. Our experience indicates that CT may play an important role in the diagnosis, management, and follow-up of this lesion.     

Systemic Hypertension and Transient Ischemic Attack in a 6-Year-Old Girl with Fibromuscular Dysplasia Treated with Percutaneous Angioplasty

We describe a 6-year-old girl with arterial hypertension secondary to fibromuscular dysplasia with stenoses of both renal arteries and transient ischemic attack due to extracranial right internal carotid artery subtotal occlusion as well as left internal carotid artery stenosis. She was treated with percutaneous angioplasty of both renal and both carotid arteries.     

Basilar and bilateral carotid dolichoectasia with spontaneous dissection of C2 segment of the internal carotid artery

We describe a previously unreported case of cranial arterial dolichoectasia associated with spontaneous dissection of the petrous (C2) segment of the internal carotid artery (ICA) with 2 patent lumena. Dolichoectasia of the cranial arteries and different types of double lumen of ICA are discussed. A review of previously reported cases is included.     

Separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage

Agenesis of the left common carotid artery with separate origins of the left internal and external carotid arteries from the aorta is an extremely rare anomaly. This anomaly is typically asymptomatic unless associated with other conditions. We report a case of separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage. A 42-year-old man was transferred to our hospital by ambulance because of left hemiparesis. Computed tomography scan revealed right putaminal hemorrhage. Computed tomography angiography and digital subtraction angiography demonstrated independent origins of the left internal carotid artery and external carotid artery from the aortic arch. Right internal carotid angiography revealed blood supply to the left anterior cerebral artery and middle cerebral artery via the anterior communicating artery. The separate origins of the left internal and external carotid arteries from the aorta may cause hemodynamic stress to the contralateral side, leading to right intracerebral hemorrhage.     

Ultrasound examination of carotid and vertebral arteries

Ultrasound is the most widespread diagnostic procedure in obstructive disease of the arteries supplying the brain. The combined non-invasive information on morphology and function makes duplex ultrasound the procedure of choice in screening and follow-up of carotid artery disease. This review deals with all relevant aspects of color duplex ultrasound of the carotids and the vertebral arteries. After a short introduction into the clinical background, the paper focuses on aspects of examination technique. In the main part of the review the relevant ultrasound findings in carotid artery disease are discussed. The different methods for grading stenoses of the internal carotid artery are explained in detail. Other relevant pathologies, such as vertebral artery disease, dissection and aneurysms, are briefly mentioned. The clinical value of ultrasound in the work-up of carotid and vertebral artery disease is briefly discussed in comparison with other imaging procedures.     

Moyamoya disease mimicking a spontaneous internal carotid artery dissection on Doppler ultrasound

Moyamoya disease and spontaneous internal carotid artery dissections are rare conditions, but both tend to affect young adults with potentially devastating consequences. A 43-year-old non-Japanese patient presented with neurological symptoms, which, following carotid Doppler ultrasound and angiography, was labelled as being due to a spontaneous internal carotid artery dissection. Repeat imaging at 3 months showed normalisation of the carotid Doppler findings which coincided with the formation of „moyamoya” vessels on the angiogram. This case report illustrates the changes on carotid ultrasound in early moyamoya disease which may mimic the appearances of an internal carotid artery dissection and demonstrates the change of the spectral Doppler waveform that occurs with the formation of new vessels at the base of the brain. Received: 20 August 1998; Revision received: 23 November 1998; Accepted: 23 December 1998     

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.     

Treatment of Internal Carotid Artery Dissections with Endovascular Stent Placement: Report of Two Cases

Extracranial carotid artery dissection may manifest as arterial stenosis or occlusion, or as dissecting aneurysm formation. Anticoagulation and/or antiplatelet therapy is the first-line treatment, but because it is effective and less invasive than other procedures, endovascular treatment of carotid artery dissection has recently attracted interest. We encountered two consecutive cases of trauma-related extracranial internal carotid artery dissection, one in the suprabulbar portion and one in the subpetrosal portion. We managed the patient with suprabulbar dissection using a self-expandable metallic stent and managed the patient with subpetrosal dissection using a balloon-expandable metallic stent. In both patients the dissecting aneurysm disappeared, and at follow-up improved luminal patency was observed.     

Bilateral aberrant internal carotid arteries with bilateral persistent stapedial arteries and bilateral duplicated internal carotid arteries

A 5-year-old boy was evaluated for a left retrotympanic mass found at otoscopy. Subsequent petrous bone CT and MR angiographic examinations demonstrated bilateral aberrant internal carotid, bilateral stapedial artery persistence, and bilateral duplicated internal carotid arteries. Imaging findings and their clinical relevance are discussed. A second case of unilateral aberrant internal carotid artery with a persistent stapedial artery is included for comparison.     

Persistent proatlantal intersegmental artery and occipital artery originating from internal carotid artery

Summary A case of a combined anomaly of persistent hypoglossal and proatlantal intersegmental arteries, proved on arteriogram obtained by the insertion of a needle into the common trunk of both arteries, is presented. In addition, a case of anomalous occipital artery arising from the internal carotid artery associated with an intracranial aneurysm and arteriovenous malformation is presented. Based upon analysis of the persistent proatlantal intersegmental artery and the anomalous occipital artery, we conclude that both arteries have an identical embryological origin.     

Spontaneous dissection of the cervical internal carotid artery. Diagnosis by MRI

A case of spontaneous dissection of the cervical internal carotid artery documented by angiography and MRI is reported. Angiography showed an irregular stenosis of the upper part of the cervical internal carotid artery extending up to the base of the skull, suggestive of spontaneous dissection. The diagnosis was confirmed beyond doubt by MRI which showed a sub-intimal collection of blood with a typical hyperintense appearance.     

Diffusion-weighted magnetic resonance imaging in carotid angioplasty and stenting with balloon embolic protection devices

We compared the results of two procedures to protect against distal embolism caused by embolic debris from carotid angioplasty with stent deployment (CAS) using diffusion-weighted magnetic resonance imaging (MRI). The study group comprised 39 men and 3 women (42 and 3 CAS procedures, respectively) with severe carotid stenosis (average age 70.0±6.6 years). During 20 CAS procedures the internal carotid artery was protected with a single balloon. A PercuSurge GuardWire was used for temporary occlusion. During 25 CAS procedures the internal and external carotid arteries were simultaneously temporarily occluded with a PercuSurge GuardWire and a Sentry balloon catheter, respectively. Diffusion-weighted MRI was performed 1 to 3 days after CAS. Data from 26 patients undergoing conventional angiography for diagnosis of cerebral ischemic disease, cerebral aneurysm or brain tumors were included as controls. Diffusion-weighted MRI after conventional diagnostic angiography showed ischemic spots in 3 of the 26 controls (11.5%). Ischemic spots were observed during 11 of 20 CAS procedures with the internal carotid artery protected with a single balloon (55.0%), and were observed during 9 of 25 CAS procedures with both the internal and external carotid arteries protected (36.0%). This difference was significant (P=0.0068). Ischemic lesions appeared not only ipsilateral to the carotid stenosis but also in the contralateral carotid artery (31.9%) and vertebrobasilar territory (25.3%). Better protection was obtained with simultaneous double occlusion of both the internal and external carotid artery than with single protection of the internal carotid artery during CAS.     

Basilar bifurcation aneurysm associated with bilateral internal carotid occlusion

Summary A case of subarachnoid hemorrhage from ruptured aneurysm of the basilar bifurcation associated with occlusions of both internal carotid arteries at the neck is presented. Each internal carotid artery mainly received collateral flow at the cavernous portion from the internal maxillary artery through anastomotic artery of the foramen rotundum. Posterior circulation also supplied collateral blood flow via the right posterior communicating artery. This case report suggests that hemodynamic stress may be regarded as an important factor in the formation or development of cerebral aneurysm.     

Accordion effect during carotid artery stenting

Introduction The term “accordion effect” is used to describe a mechanical distortion of tortuous arteries mimicking spasm or dissection. This phenomenon has been reported in patients undergoing percutaneous coronary intervention. To our knowledge, this is the first documentation of the accordion effect during carotid artery intervention. Methods Two patients who developed the accordion effect during carotid artery stenting (CAS) are described. Results Angiograms obtained just after CAS showed a stenosing lesion with wall irregularity at the distal part of the stent. This lesion disappeared and tortuosity of the internal carotid artery developed after withdrawing the guidewire until its floppy segment rested equally on the lesion. In another patient, the lesion did not disappear completely until the guiding catheter had been withdrawn to the proximal portion of the common carotid artery. We conclude that these stenosing lesions reflected the accordion effect. Conclusion It is essential to differentiate the accordion effect from dissection, spasm, and thrombosis because the management is importantly different. We report our findings and present a review of the literature.     

Angioplasty of the occluded internal carotid artery.

PURPOSETo review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful.METHODSWe reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed.RESULTSAll four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent.CONCLUSIONIn acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.