Stroke with internal carotid artery stenosis

BACKGROUND: Stroke patterns in patients with different degrees of carotid stenosis have not been systematically studied. OBJECTIVE: To determine first-ever stroke subtypes in nonselected patients with extracranial internal carotid artery (ICA) stenosis, based on a primary care hospital stroke registry. METHODS: One hundred seventy-three patients who experienced their first-ever stroke and who had 50% or greater (North American Symptomatic Carotid Endarterectomy Trial method) ipsilateral extracranial ICA stenosis, corresponding to 6.5% of 2649 patients with anterior circulation stroke included in the Lausanne Stroke Registry, were studied. All these patients underwent Doppler ultrasonography, carotid angiography (conventional or magnetic resonance angiography), neuroimaging (computed tomography or magnetic resonance imaging), and other investigations from the standard protocol of the Lausanne Stroke Registry. RESULTS: We found the following types of infarct in the middle cerebral artery territory: anterior pial in 54 (31%) of the patients; subcortical, 34 (20%); posterior pial, 32 (19%); large hemispheral, 20 (12%); and border zone, 17 (10%). There were multiple pial in 14 (8%) and multiple deep infarcts in 2 (1%) of the patients. Moderate (50%-69%) ICA stenosis was significantly associated with large hemispheral infarcts and a normal contralateral ICA (P =.04 and P =.02, respectively). Seventy percent to 89% of ICA stenosis was associated with prior transient ischemic attacks (P =.02). After adjusting for cardioembolism, border zone infarcts showed a strong trend to appear mostly in patients with 90% to 99% ICA stenosis (P =.06). CONCLUSIONS: The association of a large hemispheral infarct with moderate ICA stenosis suggests a large embolism and/or an inadequate collateral supply. While an embolism may also contribute, the association of border zone infarcts with 90% to 99% ICA stenosis emphasizes the significance of hemodynamic disturbance in the pathogenesis of these types of infarct.     

Prevalence of asymptomatic internal carotid artery stenosis

The prevalence of internal carotid artery stenosis was studied with continuous wave Doppler and Duplex scanning in 526 subjects aged 45-84 years of age. They were devoid of any cerebrovascular symptoms or signs and were not referred to us because of risk factors or manifestations of atherosclerosis. The prevalence of stenosis, whatever the grade, was low in both sexes aged under 65 years: 2.4% in males aged 55-64 years. It increased sharply with age, reaching 30.3% for stenosis of less than 50% and 6.1% for stenosis of greater than 50% in males aged 75-84 years. The prevalence of minimal lesion (plaque with less than 15% diameter reduction) was high: 32.1% in males aged 45-54 years and 48.5% in the 75- to 84-year age range.     

Circulating adhesion molecules in patients with internal carotid artery stenosis

To study the association of plasma concentrations of soluble adhesion molecules (sICAM-1, sVCAM-1 and sE-selectin) with atheroslerotic lesions at the origin of the internal carotid artery (ICA). 179 subjects were investigated by color Doppler ultrasound of whom 133 had and 46 had no plaques at the ICA origin. Stepwise logistic regression analysis revealed that hypertension (p < 0.001), sICAM-1 concentrations (p < 0.01) and smoking (p < 0.05) were independently associated with the presence of ICA plaques. Multivariate regression analysis revealed that sICAM-1 concentrations in subjects with plaque were negatively associated with the degree of ICA stenosis (p < 0.01) and positively associated with previous cerebral ischemia (p < 0.01), coronary heart disease (p < 0.05) and peripheral artery disease (p < 0.05). In conclusion, elevated sICAM-1 concentrations are independently associated with atherosclerosis of the ICA origin and are predominantly increased in patients with low-grade lesions and with clinical manifestations of vascular disorders.     

High rate of restenosis after carotid artery stenting in patients with high-grade internal carotid artery stenosis

OBJECTIVE: Carotid endarterectomy (CEA) is the gold-standard procedure for the majority of patients with high-grade symptomatic internal carotid artery stenosis and also for specified high-grade asymptomatic stenoses; however, a proportion of patients are treated with carotid endovascular therapy. We aimed to document medium-term clinical and neurosonographical outcome after carotid artery stenting (CAS). METHODS: 53 patients (mean age: 65 +/- 8 years) with high-grade (> or = 70 % by means of duplex sonography) carotid artery stenosis were enrolled into the study. Nineteen patients had asymptomatic, 34 patients had symptomatic stenoses. All patients had a pre-interventional CT, Doppler and duplex sonography, and digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) prior to the procedural DSA. All patients were offered CEA as the gold-standard procedure and as an alternative to CAS. Both clinical and Duplex sonographical follow-up was obtained at day 1 and 7, month 1, month 3, month 6, month 12, and every subsequent 6 months after the procedure. Mean follow-up time was 22 +/- 1.6 months (+/- SEM). RESULTS: 2/53 patients suffered from stroke. A further 2 patients suffered from carotid artery occlusion shortly after CAS. The cumulative rate of restenosis during follow-up was 24.5 % (13/53). Four of these (7.5 %) were of high-grade and led to further interventional or surgical therapy. CONCLUSIONS: A high rate of restenosis was found during follow-up after CAS. Our analysis of non-selected patients emphasizes that CEA remains the gold-standard procedure for the treatment of symptomatic internal carotid artery stenosis. The frequently performed endovascular treatment of carotid stenosis outside the setting of a randomized controlled trial is not supported by our data.     

颈动脉内膜斑块剥脱术治疗颈内动脉重度狭窄

目的 探讨颈动脉内膜斑块剥脱术在颈内动脉重度狭窄治疗中的临床应用价值。方法 回顾性分析2016年5月至2018年11月在我院神经外科实施颈动脉内膜斑块剥脱术治疗的40例颈内动脉重度狭窄的临床资料。所有病人经颈动脉超声多普勒、头颈部CTA或DSA诊断为颈内动脉重度狭窄。结果 所有病人均顺利完成手术,术后无脑梗死、死亡。1例术后出现短暂性脑缺血发作,4 h内恢复;1例有鼻咽癌放疗史,术后吻合口渗血,经二次手术后完全恢复。术后随访1~20个月,所有病人血管通畅、狭窄解除,无脑血管事件发生。结论 颈动脉内膜斑块剥脱术是治疗颈内动脉重度狭窄简单、安全、有效的方法,对防治缺血性脑卒中有重要意义。     

无症状性ICA患者行颈动脉支架置入术对认知功能的影响

目的 探讨颈动脉支架置入术对无症状性颈动脉高度狭窄患者认知功能的影响。方法 以本院2012年2月～2014年2月治疗的96例行颈动脉支架置入术的无症状性颈动脉高度狭窄患者为研究组,以同期90例行常规内科治疗的无症状性颈动脉高度狭窄患者为对照组,分别在治疗前3 d和治疗后3个月采用连线测验(TMTa、TMTb)、简易智能量表(MMSE)、阿尔茨海默病评估量表认知部分(ADAS-Cog)评估患者的认知功能。结果 研究组患者治疗前3 d颈动脉狭窄为(79.51±6.02)%,治疗后3个月残余狭窄为(13.52±6.01)%,治疗后3个月狭窄程度较治疗前3 d有明显改善(P<0.05); 治疗后研究组狭窄程度显著低于对照组(P<0.05)。与治疗前3 d相比,研究组治疗后3个月患者的MMSE评分明显增加(P<0.05),TMTa、TMTb和ADAS-Cog评分均明显降低(P<0.05); 治疗3个月研究组各指标均显著优于对照组(P<0.05)。结论 颈动脉高度狭窄可能造成患者认知功能损伤,即使是无症状的此类患者,行颈动脉支架置入术对患者的认知功能也具有一定的改善作用,并且可降低颈动脉狭窄程度。     

Post-radiotherapy stenosis of the supraclinoid internal carotid artery. Moyamoya network

A 36 year-old caucasian woman was operated and then irradiated for a pituitary adenoma. Two years later, a left anterior temporal lobectomy for a grade I astrocytoma was performed. Four years later, she experienced right hemiparesis and aphasia. CT scan showed a left temporo-occipital low density area. A left carotid angiogram showed a narrowing of the left carotid artery beginning in the lower part of the siphon and progressing to a complete supraclinoid occlusion. There was a collateral circulation of the Moyamoya type. Radiation-induced narrowing or occlusion of the intracranial internal carotid artery is an infrequent finding. Most cases appear in young subjects, several years after a high dose of radiation therapy (30 to 60 grays). Some cases may show a network of the Moyamoya type. Usually, the absence of vascular abnormalities prior to radiation cannot be demonstrated. In our case, as in 3 other cases of the literature, the intracranial vessels were of normal appearance before irradiation. The vascular lesions can thus be considered as acquired and secondary to radiation therapy.     

Blood-brain barrier impairment by low pH buffer perfusion via the internal carotid artery in rat

Summary Krebs-Ringer bicarbonate buffer (KRB) adjusted by lactic acid to low pH levels (6.6, 6.2, 6.0, 5.8, 5.5) was perfused via the internal carotid artery as a bolus into rat brain hemispheres. In one group of animals, the fluid phase tracer horseradish peroxidase (HRP) was perfused immediately following the low pH treatment. In the other group of animals, the brain hemispheres were fixed and the endothelial cells were stained with colloidal iron (CI) at pH 1.8.Widespread extravasation of HRP was detected indicating blood-brain barrier (BBB) opening to this tracer in hemispheres perfused with KRB at pH 6.2, 6.0, 5.8, or 5.5. HRP was seen in pools of endothelial tight junctions. Endothelial cell injury reflected by swelling and influx of HRP into the cytoplasm was occasionally encountered. CI evenly decorated the negatively charged surface of endothelial cells in the control brains, in contrast to markedly diminished iron binding capacity of endothelial cells in low pH-treated hemispheres.Our results suggest that the ionic milieu influences the negatively charged cell surface sialoglycoproteins and glycolipids, which are integral parts of the BBB system.Supported by the Medical Research Council of Canada, grant Mt-5958, and by the Hungarian Ministry of Health, grant 06/1-44/313     

204例颈动脉重度狭窄患者的临床特点

目的明确颈动脉重度狭窄患者的临床特点。方法采用回顾性病例分析方法,收集204例颈动脉重度狭窄患者的临床资料,从危险因素、临床表现和颈动脉狭窄节段分布等方面对数据进行分析。结果 204例颈动脉重度狭窄患者的主要病因为动脉粥样硬化;危险因素包括高血压、吸烟和大量饮酒等;头部MRI显示的病灶类型包括腔隙性脑梗死、基底节梗死、分水岭梗死和大面积脑梗死。204例颈动脉重度狭窄患者中,狭窄部位在颅外段158例(77.45%),颅内段36例(17.65%),岩段2例(0.98%),全程节段性狭窄或纤细8例(3.92%)。结论中国北方人群的颈动脉重度狭窄患者中,男性多于女性,病因多为动脉粥样硬化,高血压和吸烟是最主要的危险因素,患者发生脑梗死和TIA比率明显高于无临床症状患者,头部MRI显示的病灶多为腔隙性脑梗死,其次是基底节梗死和分水岭梗死;颈动脉重度狭窄的部位多位于颅外段。     

Duplication of the internal carotid artery presenting with severe atherosclerotic stenosis

Duplication of the extracranial internal carotid artery is a rare anatomic variant. We present the first patient with unilateral duplication of the cervical internal carotid artery with severe stenosis. Stent-assisted percutaneous transluminal angioplasty was successfully performed to restore blood flow. We discuss the angiographic findings and endovascular treatment.     

Markers of lacunar stroke in patients with moderate internal carotid artery stenosis

The benefits of surgical correction of moderate internal carotid artery stenosis have been demonstrated only in symptomatic subjects. It is debatable whether patients with lacunar infarct ipsilateral to a moderate carotid stenosis may be considered symptomatic like those with large–artery stroke. The aim of the study was to seek markers capable of differentiating patients with lacunar or non–lacunar stroke ipsilateral to a moderate internal carotid artery stenosis.We enrolled 95 patients with a first stroke ipsilateral to a moderate (50–69 %) stenosis of the internal carotid artery and divided them into lacunar and non–lacunar stroke based on clinical presentation and neuroradiological findings; 34 subjects with asymptomatic moderate carotid stenosis and 31 normal individuals were also studied. Baseline characteristics; risk factors, cerebrovascular reactivity to hypercapnia evaluated by means of the breath–holding index (BHI), the presence and severity of carotid stenosis and intimamedia thickness (IMT) of the common carotid arteries were determined. There were 36 patients with lacunar and 59 with non–lacunar stroke. Degree of stenosis, and IMT and BHI ipsilateral to symptomatic stenosis were found to be significant independent predictors as each 10 % increase of stenosis carried a 4.3 higher probability of non–lacunar stroke (95 % CI: 1.91–9.51); each decimillimeter increment in IMT increased this probability by 1.45 (95 % CI: 1.10–1.92); and the risk odds ratio associated with each 0.1 increase in BHI was 1.88 (95 % CI: 1.33–2.66). A decrease in BHI of 0.1 thus carried a 90% greater probability of having a lacunar stroke. The results show that patients with moderate internal carotid artery stenosis and lacunar stroke can be differentiated from those with non–lacunar stroke on the basis of distinctive ultrasonographic findings. Further studies are needed to clarify whether our findings have pathogenetic implications and may be of help for the planning of different therapeutic strategies in patients with moderate internal carotid stenosis and lacunar or non–lacunar ipsilateral stroke.     

Patterns of cerebral perfusion in patients with asymptomatic internal carotid artery disease

BACKGROUND: The perfusion profile of patients with asymptomatic internal carotid artery (ICA) disease has not been well studied. The purpose of this study is to describe the perfusion patterns of patients with asymptomatic ICA disease using computed tomography perfusion (CTP) and its potential value in identifying patients at higher risk for transient ischemic attacks (TIAs) or strokes. METHODS: We analyzed 32 patients with asymptomatic high grade ICA disease who had CTP and computed tomography angiography (CTA) of the head and neck. Twenty-four patients had severe ICA stenosis and eight had ICA occlusion. The degree of ipsilateral external carotid artery (ECA) and contralateral ICA stenosis, patency of the anterior communicating artery (ACOM), A1 segment and posterior communicating artery (PCOM) were evaluated in all patients. RESULTS: Sixteen patients had normal CTP and the other 16 patients had cerebral hypoperfusion, characterized by abnormalities in one or more of the three perfusion maps. Ipsilateral hypoplastic A1 segment was more frequent in the group with cerebral hypoperfusion (p = 0.025). Ipsilateral TIAs occurred in two patients, both with cerebral hypoperfusion. CONCLUSION: Cerebral hypoperfusion is present in half of the patients with asymptomatic ICA disease, predominantly in patients with a hypoplastic ipsilateral A1 segment. These patients likely represent a higher-risk group for symptomatic brain ischemia.     

Tinnitus and stenosis of the cavernous internal carotid artery

We report a case of isolated unilateral pulsatile tinnitus. Cerebral angiography showed a right intra-cranial internal carotid artery stenosis. Treatment by dilatation and stenting resulted in symptom resolution.     

颈内动脉内膜剥脱术治疗症状性颈内动脉狭窄临床研究

目的探讨颈内动脉内膜剥脱术在症状性颈内动脉狭窄治疗中的临床应用价值。方法对2012年6月~2014年6月间在我院行颈内动脉内膜剥脱术的症状性颈内动脉狭窄病人的23例临床资料进行回顾性研究并随访。结果术后出现暂时性声音嘶哑1例,术侧多发小梗塞灶1例,颈部血肿保守治疗后恢复2例,未见肢体瘫痪、神志不清等严重并发症;术后CTA、DSA检查示颈动脉通畅;随访6月~2年未见血管再狭窄、严重脑缺血表现。结论颈内动脉内膜剥脱术治疗症状性颈内动脉狭窄是一种简单、安全、有效的治疗方法。     

Anterior cerebral artery dilation to increase cerebral perfusion in a patient with chronic internal carotid artery occlusion

Chronic internal carotid artery occlusions (CICAO) increase the risk of stroke recurrence and cognitive dysfunction. Here, we describe the case of an adult patient with ipsilateral CICAO who underwent endovascular treatment of anterior cerebral artery stenosis to improve cerebral perfusion. First, the patient presented ataxia and left facial palsy. Magnetic resonance imaging (MRI) showed right hemispherpe cerebral infarct, right CICAO, and sub-occlusive stenosis of the left bulbar internal carotid artery. Stenting of the left carotid artery was performed. One year later, she experienced acute walking imbalance and left hemiparesis. MRI showed new watershed and anterior cerebral artery infarctions, worsening of the right hemisphere hypoperfusion, and a new severe stenosis of the right anterior cerebral artery. Dilation of this stenosis was performed. Perfusion parameters, clinical deficit, and cognitive functions improved after the endovascular treatment, and the patient had no stroke recurrence.     

颈内动脉狭窄性短暂性脑缺血发作的磁共振波谱研究

目的 利用磁共振波谱(1H magnetic resonance spectroscopy, 1H-MRS)探讨单侧颈内动脉(internal carotid artery, ICA)重度狭窄或闭塞性短暂性脑缺血发作(transient ischemic attack, TIA)的脑代谢改变.方法 28例经数字减影血管造影(digital subtraction angiography, DSA)证实为单侧ICA重度狭窄或闭塞性TIA患者,应用3.0T MRI行1H-MRS检查, 测量患侧和对侧大脑半球半卵圆中心的代谢物氮-乙酰天门冬氨酸(N-acetylaspartate, NAA)、胆碱(choline, Cho)、肌酸(creatine, Cr)的波峰下面积,比较两侧各代谢物峰下面积比值NAA/Cho、NAA/Cr和Cho/Cr的差异,并观察有无乳酸(lactate, Lac)峰.结果 28例单侧ICA重度狭窄或闭塞的TIA患者,1H-MRS显示患侧半卵圆中心的NAA/Cho、NAA/Cr比值显著低于病变对侧(P＜0.05),Cho/Cr比值显著高于病变对侧(P＜0.05),5例患者于患侧出现Lac峰.结论 1H-MRS能够早期发现ICA重度狭窄或闭塞性TIA患者的脑代谢异常, 对于早期治疗和判断预后具有重要价值.     

Clinical outcome in patients with high-grade internal carotid artery stenosis after irradiation

The authors followed up 41 consecutive patients (21 symptomatic) with internal carotid artery stenosis > or =70% and previous neck irradiation. After 28 months, 15 patients (36.6%) had died, five (12.2%) had had an ischemic stroke, and 15 (36.6%) had a new malignancy. Having a new malignancy was the only independent predictor of death. The major risk for patients with ICA stenosis > or =70% and previous neck irradiation is malignancy, not stroke.