Bilateral agenesis of internal carotid arteries

The authors present angiographic and computed tomographic demonstration of bilateral agenesis of internal carotid arteries. The patient was a seventy-six years old man who had been admitted to our hospital because of right hemisparesis and disorientation. In addition to the left chronic subdural hematoma, computed angiotomography showed the dilated basilar artery and dilated posterior communicating arteries. However, the bilateral internal carotid arteries were not recognized. Burr hole and irrigation were performed, then neurological deficits and symptoms were disappeared. Hematoma was 150 ml. Though axial transverse computed tomograms of base of skull demonstrated the absence of bilateral carotid canals. On aortography, the right common carotid artery and vertebral artery were supplied from the innominate artery and the left common carotid artery and vertebral artery were supplied from the left dilated subclavian artery. Bilateral retrograde brachial angiograms demonstrated the internal carotid circulation, which was supplied through bilateral dilated posterior communicating arteries. Basilar artery was also in a large caliber. Bilateral ophthalmic arteries were opacified from external carotid artery via the middle meningeal artery. Ten cases of bilateral agenesis of internal carotid arteries have been reported previously. The findings of angiograms and computed tomograms on the agenesis of bilateral internal carotid arteries were discussed. This anomaly is important on cerebral hemodynamics and embryology.     

A 10-year follow-up of extracranial–intracranial bypass for the treatment of bilateral giant internal carotid artery aneurysms in a patient with fibromuscular dysplasia: case report

Cervicocephalic fibromuscular dysplasia (FMD) is an idiopathic, non-inflammatory and non-atherosclerotic arteriopathy which usually affects small- and medium-sized cervical arteries distributed at the atlas and axis interspace. Few cervicocephalic FMD patients are associated with multiple intracranial aneurysms which may rupture or develop. So the authors describe a cervicocephalic FMD patient with a history of right oculomotor palsy in 2000. Angiography revealed bilateral internal carotid artery (ICA) aneurysms and a fusiform aneurysm in right vertebral artery. Typical “string-of-beads” phenomenon was observed in V2 segment of left vertebral artery. The right ICA giant aneurysm was treated by right ICA occlusion and superficial temporal artery (STA)-middle cerebral artery (MCA) bypass at that time. Five years later, the patient presented with paroxysmal weakness in right limbs. The subsequent angiography showed the enlargement of left ICA aneurysm. It was treated satisfactorily with left external carotid artery-saphenous vein-MCA bypass and left ICA ligation. During the long-term follow-up, the patient kept no neurological deficit and the angiography showed good patency of bilateral grafts and the lesions in bilateral vertebral arteries remained unchanged.     

Penetrating injury of the common carotid artery: report of a case]

An eighty-year-old man slipped in the bathroom and received a deep slash wound in his left neck caused by a broken fragment of the bathroom door. A fragment of the glass stuck into his left neck. He was carried to our clinic after 20 minutes in a state of shock and showed right hemiparesis and aphasia. Following immediate orotracheal intubation and emergent therapy for shock, he was transferred to the operation theater for massive arterial bleeding from the wound. The left common carotid artery and internal jugular vein were exposed by extending the skin incision from the cervical wound along the anterior border of the left sternocleidomastoideus. The left common carotid artery and the internal jugular vein were simultaneously transected, and end-to-end anastomosis of the carotid artery was performed under the administration of 300 ml of Sendai Cocktail. The occlusion time of the left common carotid artery was approximately 50 minutes. Right hemiparesis and total aphasia did not change immediately after the surgery. The postsurgical CT scan showed an infarction in the posterior portion of the left middle and posterior cerebral arteries. However, after undergoing rehabilitation for a month, the patient could walk alone, and his aphasia improved. Many large series of penetrating injuries to the carotid artery were reported after World War II. Most casualties were younger males injured by gunshot. In middle cervical injury, the common carotid artery is the most vulnerable vessel, although other large vessels such as the external and internal carotid arteries as well as the internal jugular vein may be involved, often causing neurological deficits and shock.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case report of fibromuscular dysplasia presenting symptoms like moyamoya disease: "string of beads" appearance of the pericallosal artery

We report a case of fibromuscular dysplasia (FMD) presenting a transient ischemic attack (TIA) like Moyamoya disease. The patient, a 16-year-old woman, had recurrent attacks of right hemiparesis induced by hyperventilation. Neurological examinations revealed no abnormality. Angiography showed severe stenosis of both anterior cerebral arteries at the proximal portion with "string of beads" appearance in the left pericallosal artery, and tubular stenosis of the left internal carotid artery at the level of the second cervical vertebra. Renal artery stenosis was not seen. A cerebral-blood-flow (CBF) study with 133Xe SPECT showed marked reduction of CBF in the left cerebral hemisphere at times of hyperventilation. Extracranial-intracranial bypass surgery was performed and histological examination of the superficial temporal artery (STA) revealed intimal fibroplasia which was compatible with FMD. Postoperative angiography showed good filling of the middle cerebral arteries from the STA. The patient has had no recurrence of TIA for a year since the operation. CBF study showed mild low CBF in the region of the left anterior cerebral arterial circulation at hyperventilation. There is no report of intracranial FMD presenting an ischemic symptom induced by hyperventilation. Clinical diagnosis of Moyamoya disease should be made carefully when extracranial vascular lesion accompanies it.     

Percutaneous transluminal angioplasty in fibromuscular dysplasia of the internal carotid artery: case report

We report a case of symptomatic cervical carotid artery stenosis associated with fibromuscular dysplasia (FMD) successfully treated by percutaneous transluminal angioplasty (PTA). A 49-year-old female presented with repeated ischemic attacks of right hemiparesis and aphasia. Digital subtraction angiography revealed a string of beads appearance of the left internal carotid artery typical of the medial type of FMD, at the level of the C2 vertebra. Similar findings were also evident in the right internal carotid artery at the level of the C1 vertebra, but without significant narrowing. MR angiogram of the left carotid artery revealed a marked flow gap, suggestive of severe stenosis. Forty days after onset PTA was indicated for symptomatic FMD of the left internal carotid artery because of the relative difficulty in approaching and repairing this highly located lesion surgically. The stenotic lesion was very easily dilated without any procedural complications. Although angiography just after PTA showed slight residual irregularity of the wall, this smoothed up with time. Follow-up MR angiography 7 years after PTA demonstrated long-term patency without clinical evidence of deterioration. Patients with the medial type of FMD in the carotid artery seem to be excellent candidates for PTA.     

A case of fibromuscular dysplasia with middle cerebral aneurysm

A case of cervico-arterial fibromuscular dysplasia (FMD) associated with an aneurysm of middle cerebral artery was reported in a women aged 54. On December 12, 1983, she was admitted to our hospital, who had been diagnosed as head injury (cerebral concussion) and a cerebral aneurysm. On admission, her general condition was favorable, her conscious was clear and neurological examination was normal. The four vessels cerebral angiograms showed right M1M2 aneurysm and FMD which was characterized as typical changes of form "string of beads" in the extracranial internal carotid and vertebral arteries of both sides. Clipping of aneurysm was performed and favorable post-surgical progress was observed. FMD of the cervico-cephalic arteries has been seen rarely in Japanese, but the detection frequency of FMD from cerebral angiography is 0.3-0.9% and the frequency of complication with aneurysm is high at 13-51% on literature. The histologic similarities between intracranial aneurysms and the aneurysmal dilatations of FMD are the absence of the muscular media and a defective interval elastic lamella. This paper suggested strong relationship between FMD and cerebral aneurysm.     

Ruptured large carotid artery aneurysm

Carotid artery aneurysms are rare [1]. Bifurcation of the common carotid artery is most frequently reported site of true aneurysm in the extracranial carotid system. Blunt injury of the neck involves high cervical portion of the internal carotid artery. Large aneurysms of the carotid artery can distort the anatomy and one can anticipate the intubation difficulties during anesthesia induction. A man aged 25 years, weighing 35 Kilograms was admitted in emergency with a large swelling (bleeding) on the right side of neck, covered with a bandage. In a rural hospital, biopsy was attempted, wounds were packed with gauze as there was profuse bleeding and referred the patient to our hospital. Spiral CT angiogram showed a large aneurysm arising from the bifurcation of the right common carotid artery. He complained of dysphagia for the past 20 days. In the CT scan the internal carotid artery was found to be occluded without neurological deficit. During surgery the common carotid, external carotid arteries were dissected out, clamped, ligated and thrombi were evacuated. The unhealthy and inflamed tissues were debrided. The wound was closed with a drain. Postoperative recovery was uneventful without neurological deficits.     

Subclavian artery to internal carotid artery bypass with saphenous vein graft in the treatment of bilateral common carotid artery occlusion; a case report]

A case of left common carotid artery occlusion, which was treated by a saphenous vein graft, is reported. A 49-year-old right handed male was admitted to the hospital because of right hemiparesis and aphasia. These symptoms disappeared spontaneously two weeks after admission. However, visual acuity remained impaired on the left side due to occlusion of the central retinal artery. Angiography revealed complete occlusion of the common carotid arteries as well as patency of the internal carotid arteries on both sides. PET and 123I-IMP-SPECT studies showed hypoperfusion in the left cerebral hemisphere. To restore the blood flow as well as to remove the source of the emboli, endarterectomy was performed on the left internal carotid artery. This was followed by a saphenous vein graft between the left subclavian and the internal carotid artery. Postoperative angiography revealed patency of the bypass, and a SPECT study revealed increased blood flow in the left cerebral hemisphere. The patient has remained in stable condition during the following 30 months with no neurological problems. We conclude that in the treatment of complete occlusion of the common carotid artery and subsequent cerebral hypoperfusion, a bypass graft between the internal carotid and the subclavian artery is quite effective, and that the site of the bypass graft should carefully be sought for by using preoperative angiographic studies.     

Dural arteriovenous fistula of the anterior cranial fossa associated with occlusion of the internal carotid artery: a case report]

We reported a case with dural arteriovenous fistula (dAVF) of the anterior cranial fossa associated with occlusion of the left cervical internal carotid artery. A 73-year-old man was admitted with total aphasia and right hemiparesis. Computed tomography showed an ischemic lesion of the left cerebral hemisphere and old infarction of the left occipital lobe. Angiography revealed occlusion of the left cervical internal carotid artery and dAVF of the anterior cranial fossa, fed by the left middle meningeal and the right anterior ethmoidal artery. Follow-up angiography revealed spontaneous recanalization and severe arteriosclerosis of the left internal carotid artery. After marked improvement of neurological deficits, the patient underwent surgical clipping of the draining veins to occlude the dAVF of the anterior cranial fossa. We speculated that marked development of the collateral circulation from the external carotid system might result in the occurrence of dAVF of the anterior cranial fossa.     

Post-irradiation vasculopathy of intracranial major arteries in children--report of two cases.

We report two rare cases of post-irradiation vasculopathy of intracranial major arteries in children. A 13-year-old girl suffered from transient right hemiparesis 1 year after irradiation for suprasellar germinoma. Left carotid angiograms revealed marked stenoses of the intracranial internal carotid, middle cerebral, and anterior cerebral arteries, which were previously normal, and moyamoya vessels. A 2.5-year-old girl underwent internal irradiation with 198Au colloid for cystic craniopharyngioma. At the age of 10 years, she suddenly became unconscious after vomiting. Computed tomographic scans showed a right frontal intracerebral hematoma. Right carotid angiograms disclosed complete obstruction of the intracranial internal carotid, middle cerebral, and anterior cerebral arteries and moyamoya vessels, previously not present. The danger of radiation therapy causing occlusive vasculopathy in small and major cerebral arteries in children is emphasized. To prevent permanent ischemic neurological deficits, vasculopathy should be treated either medically or surgically as early as possible.     

Ischemic events due to intraoperative microemboli developing in the cerebral hemisphere contralateral to carotid endarterectomy in a patient with preoperative cerebral hemodynamic impairment

A 74-year-old man with a history of asymptomatic right internal carotid artery (ICA) occlusion experienced amaurosis fugax in the left eye. Angiography showed left cervical ICA stenosis in addition to right cervical ICA occlusion. The right anterior and middle cerebral artery (MCA) territories were perfused from the left ICA via the anterior communicating artery. Brain perfusion single-photon emission computed tomography revealed reduced cerebral blood flow and reduced cerebrovascular reactivity to acetazolamide only in the right cerebral hemisphere. The patient underwent left carotid endarterectomy (CEA). Transcranial Doppler monitoring showed microembolic signals in the left MCA during dissection of the left ICA, but intraoperative monitoring suggested absence of global hypoperfusion or ischemia in the bilateral cerebral hemispheres during left ICA clamping. Transient and slight motor weakness of the left upper extremity was noted on recovery from anesthesia. Diffusion-weighted magnetic resonance imaging demonstrated the development of new spotty ischemic lesions only in the right cerebral hemisphere. The present case suggests that intraoperative cerebral embolism causing postoperative neurological deficits can develop exclusively in the cerebral hemisphere contralateral to CEA if the hemisphere has preoperative hemodynamic impairment and collateral circulation via the anterior communicating artery from the ICA ipsilateral to CEA.     

Intracranial atypical fibromuscular dysplasia with ruptured aneurysm--case report

A 53-year-old woman was admitted with severe subarachnoid hemorrhage due to rupture of an aneurysm associated with atypical intracranial fibromuscular dysplasia (FMD). Angiography demonstrated the aneurysm and very irregular form of the left internal carotid artery (ICA), the right ICA, and right proximal middle cerebral artery (MCA). Other arteries showed signs of atherosclerosis. The aneurysm was treated by embolization, but she subsequently died of shock of unknown cause. Detailed examination of serial angiograms detected enlargement of the aneurysm and progression of the irregular appearance of the ICA. FMD is a non-inflammatory and non-atheromatous arteriopathy that commonly affects the cervical ICA and sometimes the intracranial ICA. The association with saccular aneurysm is widely known and the prevalence of incidental aneurysms is higher than that in the general population. The common "string of beads" finding is easily distinguished from other vascular diseases, but non-specific findings such as "tubular stenosis" and "diverticular-like outpouching" are harder to differentiate. FMD is associated with various complications and appropriate periodic follow-up examination is required. Detailed analysis of serial angiograms may facilitate diagnosis of this condition.     

Perioperative management for carotid endoarterectomy with induced mild hypothermia: a case report

We report perioperative management for carotid endoarterectomy with induced mild hypothermia in a patient with severe stenosis of the bilateral carotid arteries. The patient was a 47 year-old male with familial hyperlipidemia and history of coronary artery bypass surgery. Angiography revealed severe stenotic lesions of the right internal carotid artery (ICA) and total occlusion of the left ICA. Endoarterectomy for the right ICA was planned. Anesthesia was induced and maintained with fentanyl, midazolam, pancuronium and sevoflurane. Electroencephalogram and near-infrared cerebral oxymetry were employed for monitoring intraoperatively. Temporary shunting was used during clamping of the right carotid artery because collateral blood flow could not be expected due to total occlusion of the left ICA. Furthermore, mild hypothermia down to 34 degree C was induced for brain protection with the use of a cooling blanket. After the surgery, the patient was transferred to ICU under deep anesthesia and controlled ventilation. Anesthesia was lightened gradually after rewarming to prevent postoperative shivering. The patient left ICU on the second postoperative day without any neurological deficits.     

Carotid dissecting aneurysm due to blunt (rubbing) injury of the Kendo protector

A case of dissecting aneurysm of the cervical internal carotid artery due to rare mechanism by non-penetrating injury is described. A 45-year-old right-handed man had complaints of the right lateral neck pain during exercise of KENDO wearing a tight headneck protector. Following sudden dysarthria and left hemiplegia, he developed loss of consciousness and generalized convulsion. Five hours after admission, he became alert and had no neurological deficits. Four days after these episodes, he loss visual acuity of the right eye, and a few days later he showed left hemiplegia, hypotension, hypersomnia and right-sides Horner's syndrome. Right retrograde brachial angiography revealed so-called "string sign" in the right extracranial internal carotid artery and delayed circulation in the right cerebral hemisphere. He was diagnosed as having traumatic dissecting aneurysm due to blunt (rubbing) injury. He was treated with STA-MCA anastomosis 3 weeks after the accident. Usually, carotid dissecting aneurysm due to blunt injury is produced by hyperextension and contralateral rotation of the neck or direct blow to the neck, but our case shows a possible mechanism of rubbing injury such as simple anteroposterior flexion under tight neck fixation.     

External carotid-basilar anastomosis: case report (author's transl)]

The occipital-vertebral anastomosis is one of the anastomotic channels between the external carotid system and the intracranial vessels. In this paper, we have reported a large, left external carotid-basilar anastomosis which was incidentally revealed in a patient with left hemiparesis due to arteriosclerotic occlusion of the right internal carotid artery. A 55-year-old man suddenly developed left hemiparesis without headache, unconsciousness or vomiting on the morning of January 15, 1973. When he was referred to our service on April 11, the noticeable neurological findings were left hemiparesis and left homonymous hemianopsia. The right carotid angiogram revealed occlusion of the internal carotid artery associated with collateral channels from the external carotid artery. Also a segment of the vertebral artery was visualized via the muscular branch of the occipital artery. In the left carotid angiogram, the posterior circulation was markedly visualized throught the left vertebral artery originating from the external carotid artery trunk. This anastomotic vessel had a large branch with constant caliber leading to the occipital fossa. But the posterior cerebral artery was directly visualized from the internal carotid artery without connection to the basilar artery. Repeated bilateral brachial angiograms revealed hypoplasis of the vertebral arteries. It was suggested that the persistent external carotid-basilar anastomosis might be constantly associated with hypoplasia or aplasia of the bilateral vertebral arteries.     

"True" aneurysm of the posterior communicating artery as a possible effect of collateral circulation in a patient with occlusion of the internal carotid artery. A case study and literature review.

"True" posterior communicating artery (PCoA) aneurysms are extremely rare. A case of a 63-year-old patient with a ruptured "true" aneurysm of the right PCoA associated with the occlusion of the right internal carotid artery is presented. For nine years before he suffered from subarachnoid hemorrhage, the patient had developed symptoms of transient ischemic attack (TIA) due to the occlusion of the right internal carotid artery. The left vertebral angiogram demonstrated a "true" right PCoA aneurysm and collateral flow from the right posterior communicating artery to the right internal carotid artery. The right internal carotid system was also fed by collateral circulation from the left carotid artery through the anterior communicating artery. Transcranial colour-coded real-time sonography (TCCS) demonstrated increased velocity and turbulent blood flow in both communicating arteries. The patient was operated on and the aneurysm was clipped successfully. This case report suggests that the blood flow disturbances resulting from the collateral circulation through the PCoA could be a conductive factor in the formation and development of the aneurysm. This is the first described case of a "true" aneurysm of the PCoA coexistent with the occlusion of the internal carotid artery.     

A case of persistent primitive proatlantal intersegmental artery (proatlantal artery I) with aneurysm--a case report

A 70-year-old woman was admitted to our hospital with attack of SAH. On admission, she was semi-comatose with no other neurological deficit. Left carotid angiography revealed an aneurysm of the anterior communicating artery and a large abnormal vessel connecting the left external carotid artery and the left vertebral artery. This large anastomotic vessel was thought to be primitive proatlantal intersegmental artery (proatlantal artery I). Right carotid angiography revealed a coiling of the right internal carotid artery and hypoplasia of the right A1 portion. Left retrograde brachial angiography revealed aplasia of the left vertebral artery. After admission her consciousness gradually improved but 17 days after admission she died of rerupture of the aneurysm. Autopsied brain showed that the left vertebral artery, namely proatlantal artery, was almost as large as the basilar artery and its macroscopical appearance was similar to other arteries. It was also obvious that the right vertebral artery was hypoplastic. As the rate of combination of the persistent artery with the intracranial aneurysm is relatively high, the authors think that some congenital factor may affect the occurrence of intracranial aneurysms.     

Isolated Iliac Artery Aneurysm Caused by Fibromuscular Dysplasia: Report of a Case

Fibromuscular dysplasia (FMD) can develop in many different arteries, but iliac artery aneurysms are rare. A 69-year-old Japanese woman was admitted to our hospital for treatment of a right common iliac artery aneurysm. Aortography revealed aneurysms in both the right common iliac artery and the left internal iliac artery. Notably, the right common iliac artery aneurysm had a string-of-beads appearance. At surgery, the aneurysms were resected, and replaced with Y-shaped vascular prostheses. The histopathological diagnosis was fibromuscular dysplasia (FMD). We report this case of common iliac artery aneurysm caused by FMD due to its rarity.     

Subarachnoid hemorrhage due to a ruptured intracranial vertebral artery aneurysm associated with cerebrovascular fibromuscular dysplasia: case report

Fibromuscular dysplasia (FMD) is comprised of a group of nonatherosclerotic and noninflammatory arterial diseases. Cerebrovascular FMD occurs more frequently in women, and the mean age at which it is diagnosed is 50 years. The most common angiographic pattern of cerebrovascular FMD is the "string-of-beads" deformity at the extracranial internal carotid artery. We report the case of a 52-year-old woman who presented with a sudden severe headache and went into a deep coma. She had been complaining of headaches for 2 weeks, but no specific imaging findings were obtained. A computed tomography scan obtained on admission showed a diffuse subarachnoid hemorrhage (SAH) from the cerebellomedullary cistern to the basal cistern with evidence of clot in the fourth and third ventricles. We performed digital subtraction angiography and made the diagnosis of cerebrovascular FMD. Right carotid angiography and left vertebral angiography showed the classic "string-of-beads" pattern with multiple constrictions of the lumen. Left carotid angiography showed a long segment of tubular stenosis. Right vertebral angiography also revealed the "string-of-beads" pattern and a ruptured aneurysm at the intracranial segment, which presented as a diverticulum-like outpouching. The patient was treated with conservative measures but passed away on the 23rd day of hospitalization. An autopsy was not performed. To our knowledge, during the last three decades, there are only four previous reports which showed intracerebral ruptured aneurysms of the vertebral artery or its branch in adults with cerebrovascular FMD. We demonstrate and discuss the radiologic findings here.     

Positional symptomatic occlusion of the internal carotid artery: evaluation and surgical management

A 42-year-old woman developed right arm and right leg weakness when turning her head to the left. A carotid angiogram, in the neutral position, demonstrated anterior deviation of the left internal carotid artery and complete occlusion of the left internal carotid artery when the head was rotated to the left. During surgery, our patient had redundant left internal carotid artery and was treated by resection and reanastomosis of the internal carotid artery. The patient's Doppler 4 months postoperatively showed widely patent arteries, and she has subsequently been asymptomatic.