Carotid and vertebral artery trauma: clinical and angiographic features.

Injury to the carotid or vertebral artery is an important clinical entity that requires angiography for definitive diagnosis and evaluation. The common carotid artery may be injured by penetrating trauma while the internal carotid artery is usually damaged by either trivial or blunt trauma. With trivial trauma extracranial internal carotid artery dissection should be considered if there is unilateral headache, Horner's syndrome or delayed transient ischaemic attack, and intracranial dissection if a profound neurological defect occurs immediately following trauma. Injury to the internal carotid artery following blunt trauma includes dissection of the extracranial internal carotid artery, carotid-cavernous fistula and pseudoaneurysm formation. These should be considered in a patient with delayed neurological deficit, mandibular or skull fracture, a constellation of orbital signs or diffuse subarachnoid haemorrhage, respectively. Vertebral artery injury is less frequent. Dissection typically follows abrupt cervical rotation and occurs at C1-2, whereas penetrating trauma may involve either the proximal or distal vertebral artery and occlusion, arteriovenous fistula or pseudoaneurysm may be found. Endovascular techniques may be used in either the carotid or vertebral artery to close fistulae or occlude an extensively damaged vessel.     

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.     

MR angiographic demonstration of bilateral duplication of the extracranial vertebral artery: unusual course and review of the literature

Duplication of the vertebral artery is a rare developmental anomaly. Duplication and fenestration are terms often used incorrectly and interchangeably in the literature. To the best of our knowledge, this is the first report to describe bilateral duplication of the extracranial vertebral artery. Bilaterally, there are 2 separate origins of each vertebral artery from the corresponding subclavian artery, with one duplicated segment entering the C7 foramen transversarium bilaterally and the other segment entering the carotid space on either side. The duplicated vessels join together at C5-C6 disk level on the left and at C4-C5 disk level on the right before continuing as one vessel in the foramina transversaria on either side. Duplication is thought to represent failure of controlled regression of 2 intersegmental arteries and a segment of the primitive dorsal aorta. This case was discovered on a 2D time-of-flight and contrast-enhanced neck MR angiogram in an 83-year-old man with cognitive decline and appears as an incidental finding without obvious clinical implications.     

Vertebrocarotid collateral in extracranial carotid artery occlusions: digital subtraction angiography findings

The internal and external carotid arteries are usually considered occluded distal to a common carotid artery occlusion but some collateral vessels may provide blood keeping the internal and external carotid arteries patent distal to the occlusion. Most common communication in such a case is diversion of blood from muscular branches of the vertebral artery to occipital branch of the external carotid artery which in turn could maintain blood flow into the internal carotid artery, a condition called carotid steal. We encountered vertebrocarotid anastomoses maintaining the patency of carotid circulation in six patients. Patients were four females and two males, ages ranging from 40 to 67 (mean age: 56) years. Five of the patients had ischemic cerebral symptoms. The origin of the external carotid artery was occluded in two and the whole common carotid artery in the remaining four patients. Two patients had double steal, carotid and subclavian at the same time. There was also severe stenosis or occlusion of at least one other major extracranial cerebral artery in all the cases. This concomitant involvement of the second extracranial cerebral artery was thought to be the main reason for the development of vertebrocarotid collateral. In contrast to most of the previously published reports claiming the inadequacy of angiography when compared with colour Doppler ultrasonography, angiography finely depicted the distal patency of the carotid circulation and all the collaterals in detail in every case. Selective injection of the vertebral artery ipsilateral to the occlusion, is the key to demonstrate distal patency of the carotid circulation in cases of proximal carotid occlusion. Demonstration of patency of the distal circulation is very important because some of the patients might get benefit from a reconstructive surgery.     

16层螺旋CT颈部血管成像的初步临床应用

目的:探讨颈部血管(颈动脉、椎动脉)16层螺旋CT血管造影成像技术及其临床应用价值。材料和方法:38例临床怀疑颈动脉及椎动脉狭窄者,经16层螺旋CT扫描后,用薄层横断面放大图像(MTI)及最大密度投影(MIP)、多平面重建(MPR)、曲面重建(CPR)等后处理方法,进行管腔及管壁斑块的形态学显示,并用高级血管分析软件测量狭窄段径线、狭窄段长度等作定量分析。结果:38例共计76支颈动脉、76支椎动脉CTA图像中,正常颈动脉血管40支,狭窄血管36支,其中1支颈总动脉中度狭窄者合并有动脉瘤;76支椎动脉中,6支椎动脉狭窄,受压于邻近椎体骨质;38例中有9例行颈动脉DSA检查,18例做了颈动脉多普勒超声(TCD),7例DSA和16例TCD对照结果一致,2例CTA轻度狭窄者TCD显示正常,11例颈动脉斑块均为混合密度斑块。结论:16层螺旋CT颈部血管成像图像质量满意,重建图像质量高,能较准确显示管腔狭窄及管壁斑块形态学改变,满足临床诊断需要,具有很好的临床筛查及实用价值。     

颈内动脉纤维肌肉发育不良的MSCT血管造影诊断(附9例报告)

目的:探讨颈内动脉纤维肌肉发育不良的多层螺旋CT血管造影(MSCTA)表现及诊断。方法:收集本院2003年~2005年6月经多层螺旋CT血管造影检查确诊的纤维肌肉发育不良9例。结果:9例中发生在颈内动脉颅内段5例,其中3例同时合并前、中动脉病变;岩骨段1例;单一中动脉3例。合并颈内动脉颅外整段狭窄、闭锁者2例,椎动脉整段性狭窄者2例,累计病灶17处。血管改变有:血管对称性狭窄,局限性偏心性狭窄,串珠样扭结状改变,狭窄伴动脉瘤。脑实质表现有:脑实质正常,脑梗塞,蛛网膜下腔出血。结论:本病无特异性临床症状,诊断依靠对本病的警惕,影像学特点是节段性血管腔狭窄及串珠样改变,使用MSCTA是生前诊断本病的简便有效方法。     

Assessment of steal syndromes with colour and pulsed Doppler imaging

The purpose of this study was to assess the incidence of and determine the types of steal phenomena occurring in the extracranial arteries of the head (common carotid artery [CCA], internal carotid artery [ICA], external carotid artery [ECA], vertebral artery [VA] and ophthalmic artery [OA]). A total of 3759 extracranial carotid artery sonographic examinations (7518 carotid arteries) of consecutive patients were reviewed. In every case an attempt was made to also evaluate the vertebral arteries. Reverse flow was found in 37 arteries in the examined regions in 36 patients. One of the most common findings was reversed flow in one of the VA as a sign of subclavian steal syndrome. This occurred in 17 cases (0.22%). The OA was examined in 15 cases when occlusion of the ICA was found in the neck region. In 14 (93.3%) of these cases the flow in the OA proved to be reversed. In 4 cases of occlusion of the CCA (0.05%) the ICA was fed through the main branch of the ECA, in which the flow was reversed. More rarely, in 2 cases (0.027%) both the CCA and ICA were occluded, and the main branch of the ECA was supplied through its dilated side branch, in which the flow direction was reversed. Colour and pulsed Doppler imaging are appropriate noninvasive methods for imaging these steal syndromes. Their diagnosis cannot only explain clinical signs, but can also lead to therapeutic consequences. Correspondence to: Z. Morway     

颅外颈动脉螺旋CT血管造影的临床意义(附45例报告)

目的 报告颅外颈动脉ＣＴ血管造影（ＣＴＡ）的初步经验,探讨该技术对各种颅外颈动脉病变的诊断意义,并在可能范围内与数字减影血管造影（ＤＳＡ）作小样本的对照。方法 ４５例颈动脉ＣＴＡ,经最大密度投影（ＭａｘＩＰ）及表面灰度成像法（ＳＳＤ）行三维重建,其中５例在１周内作了ＤＳＡ检查。结果 ４５例颈动脉ＣＴＡ检查,共得到９０支血管图像。其中正常血管５５支,狭窄血管３１支,闭塞血管２支,颈内动脉动脉瘤１支,     

颅外段颈/椎动脉夹层及动脉瘤的介入治疗观察

目的评价介入治疗颅外段颈/椎动脉夹层及动脉瘤的安全性和疗效。方法收集住院病例11例,其中男性7例,女性4例,发病年龄32~54岁,平均年龄(42±5)岁。临床表现:合并高血压者8例;同时合并高血压、糖尿病者3例;合并痛风1例;余3例未发现明显的危险因素。11例患者均在造影同时行血管成形术,包括对狭窄的颈内动脉/椎动脉进行球囊扩张和置放支架。其中7例颈内动脉植入自膨式血管支架9枚,4例椎动脉植入支架4枚。术后均抗血小板、抗凝治疗。术后及出院后随访3~29个月。结果 11例患者介入治疗均获成功,临床症状明显减轻或消失。无并发症及死亡病例。狭窄的动脉血流通畅,内径渐恢复正常,夹层动脉的动脉瘤也明显缩小。术后随访,均未见相关临床症状复发。结论介入治疗颅外段颈/椎动脉夹层及动脉瘤,损伤小、安全、有效。     

Prevalence study of proximal vertebral artery stenosis using high-resolution contrast-enhanced magnetic resonance angiography

PURPOSE: To evaluate the prevalence of proximal vertebral artery stenosis, compared wiith those of the distal vertebral/basilar artery and extracranial internal carotid artery, in a large population of stroke and non-stroke patients. MATERIAL AND METHODS: Nine-hundred-and-thirty-five patients who underwent high-resolution contrast-enhanced magnetic resonance angiography in a regional general hospital were categorized into six groups based on neurological symptoms and disease: an asymptomatic group (n = 182), a minor symptom group with headache or dizziness (n = 519), a cardiac group with coronary artery steno-occlusive disease (n = 15), a hemorrhagic group with old cerebral hemorrhage (n=26), an anterior circulation infarct group (n = 121), and posterior circulation infarct group (n = 72). Prevalence of stenosis of the proximal vertebral artery, distal vertebral/basilar artery, and internal carotid artery was analyzed. RESULTS: The prevalence of stenosis of the proximal vertebral artery, distal vertebral/ basilar artery, and internal carotid artery was 12.9%, 5.5%, and 7.2%, respectively, in the study population, and rose as the age increased (P < 0.0001 for all arteries). The prevalence of stenosis of the proximal vertebral artery, distal vertebral/basilar artery, and internal carotid artery was 3.3%, 0.5%, and 1.1%, respectively, in the asymptomatic group; 8.3%, 2.1%, and 3.7%, respectively, in the minor symptom group; 13.3%, 6.7% and 6.7%, respectively, in the cardiac group; 19.2%, 7.7%, and 7.7%, respectively, in the hemorrhagic group; 27.3%, 8.3%, and 25.6%, respectively, in the anterior circulation infarct group; and 44.4%, 36.1%, and 16.7%, respectively, in the posterior circulation infarct group. This increasing tendency of stenosis accordingly was statistically significant (P < 0.0001 for all arteries). CONCLUSION: The prevalence of proximal vertebral artery stenosis was highest, compared with those of the distal vertebral/basilar artery and internal carotid artery, although the clinical significance of proximal vertebral artery stenosis should be investigated in further studies.     

Unusual variant of persistent primitive hypoglossal artery

Here, we present a case of an unusual variant of a persistent primitive hypoglossal artery, which was found incidentally during an examination for a hypertensive thalamic haemorrhage. The anastomotic vessel arose from the external carotid artery and joined the vertebral artery through the hypoglossal canal. The embryology of the anomaly is briefly discussed.     

Dissecting aneurysms of all four cervicocranial arteries in fibromuscular dysplasia: treatment with self-expanding endovascular stents,coil embolization,and surgical ligation.

A patient with cervicocranial fibromuscular dysplasia (FMD) presented with subarachnoid hemorrhage. A ruptured dissecting distal vertebral artery aneurysm required clip ligation of the parent artery; a contralateral dissecting proximal vertebral aneurysm was occluded with detachable coils. Progressive dissecting, extracranial aneurysms of the internal carotid artery were treated with self-expanding stents. Subsequent angiography and intravascular sonography revealed patent stents, a smooth luminal surface, and total occlusion of the aneurysm. Clinical outcome was excellent.     

Cutaneous hemangiomas and vascular abnormalities: persistence of embryonic vascularization

A 2-year-old girl presented with cutaneous facial, palpebral, back, perianal, and perineal hemangiomas and a subcutaneous neck and parotid voluminous hemangioma, associated with several extracranial vascular abnormalities, such as the absence of the ipsilateral internal carotid artery and hypoplasia of the common carotid arteries. Both vertebral arteries showed an embryonic appearance, without completing their maturation and without obliteration of all the right and left longitudinal neural arteries.     

多支架治疗颅内外动脉狭窄

目的 探讨多支架治疗颅内外动脉狭窄的临床体会。方法 采用2枚或2枚以上支架对8例颅内外动脉狭窄的患者12支狭窄血管行血管成形术，共植入17枚支架，其中颈动脉颅外段狭窄使用自膨胀支架，颅内段和椎动脉使用球囊膨胀型支架。结果 所有患者的手术均成功，术后狭窄均明显改善，随访6～12个月，所有患者均无脑缺血发作，除1例动脉闭塞外，其余无再狭窄发生。结论 多个支架治疗颅内外动脉狭窄安全有效，但仍需长期随访。     

Delayed reperfusion therapy for ischemic stroke tandem occlusion with subsequent secondary prophylaxis of cerebral ischemic events: A case report and literature review

Mechanical thrombectomy is currently the gold standard treatment of large vessel occlusions, especially in anterior circulation acute ischemic stroke. At the same time, the problem of tandem occlusions seems especially important since most of the major clinical mechanical thrombectomy studies did not specifically evaluate patients with concomitant extracranial occlusions or critical stenoses.To date, there is no universally accepted optimal treatment strategy for such tandem lesions in acute ischemic stroke: it remains unclear which lesion – intracranial or extracranial – should be treated first. The selected reperfusion method should be based on the patients’ individual characteristics, data from non-invasive radiologic studies, and the stroke team experience.We present a case of successful reperfusion therapy of acute tandem occlusion of the right internal carotid artery, followed by contralateral carotid artery stenting in a patient with stenosing extracranial atherosclerosis.     

颅颈段夹层动脉瘤MRA与DSA诊断的初步对比研究

目的:探讨颅颈段血管夹层动脉瘤的3D-TOF-MRA与DSA表现,提高对该病的认识。方法:对我院近来经3D-TOF-MRA与DSA检查证实的5例颅颈段夹层动脉瘤进行回顾性分析。结果:5例中,单发3例,多发2例,MRA发现夹层动脉瘤7处,其中颈内动脉颅外段3处,颅内段1处,椎动脉V5段2处,基底动脉1处;病变段最短0.8cm,最长3.4cm;DSA表现为病变段血管管腔呈渐进性锥形狭窄4处,瘤样扩张2处,局限性充盈缺损1处。结论:3D-TOF-MRA与DSA均可以较好的显示颅颈段夹层动脉瘤,特别是3D-TOF-MRA简便易行,无需注射对比剂,无放射线损伤,是筛查颅颈段夹层动脉瘤最好的影像学检查方法。     

128层螺旋CT颈部血管成像的临床应用

目的:探讨128层螺旋CT颈部血管成像的临床应用价值.方法:搜集74例临床怀疑有颈部血管疾病行CT颈部血管成像检查的患者,应用高级血管分析(AVA),容积再现(VR),多平面重组(MPR)和最大密度投影(MIP)等技术进行重组.结果:74例颈部血管均显影良好,其中正常无病变8例,颈总、颈内动脉狭窄33例,椎动脉狭窄9例,单支血管病变4例,多支血管病变38例,发生钙化36例,椎动脉起源变异2例,单侧颈内动脉完全闭塞3例,单侧椎动脉完全闭塞1例,颈内动脉动脉瘤5例.结论:128层螺旋CT颈部血管成像检查是一种非常有效的检查方法,对颈部血管病变的诊断有方便、直观、准确的临床价值.     

Intraplaque haemorrhage mimicking carotid pseudoaneurysm on magnetic resonance angiography

Contrast-enhanced magnetic resonance angiography (CE-MRA) is a commonly used technique to assess the extracranial carotid arteries. We describe two patients (investigated for carotid artery atherosclerotic disease) who underwent CE-MRA. Results suggested pseudoaneurysms of the extracranial carotid arteries. Magnetic resonance direct thrombus imaging (MRDTI) showed that the appearances were due to intraplaque haemorrhage adjacent to the vessel, with the T1-shortening effect of methaemoglobin within the intraplaque haemorrhage mimicking blood flow on the CE-MRA sequence. The cases presented demonstrate this diagnostic pitfall and illustrate the contribution of simple magnetic resonance plaque imaging to establishing the correct diagnosis.     

The “dense artery sign” — major cerebral artery thromboembolism demonstrated by computed tomography

Summary A 4 years review of high resolution thin slice (3–5 mm) computed tomography performed within 24 h after cerebral infarction revealed increased density in a major cerebral artery segment in 28 patients. Arteries affected were the vertebral and basilar artery in 6 and 8 patients, the sphenoid course of the middle cerebral artery in 13 cases and the extracranial internal carotid artery in 1 patient. In 35.7% of cases the so called dense artery sign provided earliest evidence of the ensuing infarction documented by CT controls in most patients. Angiography carried out in 8 patients, density caculations in the course of the affected vessel and resolution of the increased density on subsequent CT examinations suggest thrombembolism as the most likely etiology. In the clinical setting of acute stroke increased artery density encompassing the entire vessel diameter may serve as an early indicator of major cerebral artery occlusion and prompt angiographic investigation of a lesion potentially amenable to lysis.     

Traumatic lesion of the extracranial vertebral artery a note-worthy potentially lethal injury

The autopsy findings from routine neuropathological investigations of the cervical spine after any history of trauma emphasized the vulnerability of the extracranial vertebral arteries. In 21 cases with trauma to the head and neck, normal autopsy procedures did not succeed in revealing an obvious cause of death. Traumatic lesions of the spinal cord such as contusion or neurorrhexis were seen in 10 cases. In 15 cases we observed different degrees and stages of traumatic lesions of the extracranial vertebral arteries. Sudden death due to acute brain stem ischemia might be considered as an explanation in some of these cases. Six case reports with traumatic vertebral artery (VA) lesions after severe or minor extracranial trauma are presented. A review of the literature revealed that this vascular injury has only rarely been directly established by gross pathological examination. Possible consequences of blunt trauma to the head and neck include angiorrhexis, subintimal, intramural and perivascular hemorrhage leading to a partial narrowing of the injured vessel. These processes can be complicated by thrombosis. Unilateral VA obliteration may be an occult risk of acute brain stem ischemia when associated with contralateral reduction of the posterior circulation.