STA-MCA bypass surgery for internal carotid artery occlusion--comparative follow-up study.

Sixty-three patients with internal carotid artery occlusion manifesting as transient ischemic attack or minor stroke received superficial temporal artery-middle cerebral artery bypass surgery and medical treatment (n = 27) or medical treatment only (n = 36). Long-term follow-up showed that there was no significant difference in the outcomes. However, positron emission tomography studies suggested that patients with misery perfusion in the chronic stage benefited from extracranial-intracranial bypass surgery.     

Extra-intracranial bypass and internal carotid artery ligation in one-stage operation for intracavernous and giant carotid aneurysm

The combined one-stage operations, STA-MCA anastomosis and internal carotid artery (ICA) ligation (or trapping) were carried out in 11 cases (Age): 18-79 yrs, Av.: 45.8 yrs) of ICA aneurysms which were inaccessible for a direct operation because of their locations and sizes. First the STA-MCA anastomosis was performed under general anesthesia. Then the patient was awaken and thereafter under local anesthesia the ICA was temporarily clamped for 30 min. under induced hypotension to check whether any ischemic signs appeared. This was followed by proximal ICA ligation when no ischemic signs were observed. In all 11 cases, the anastomosis was patent. The aneurysms disappeared. Neither cerebral ischemia nor rebleeding from the aneurysms was seen during the long follow-up. The mean value of the bypass flow was 119 m/min which was twice as much as that in the cases of other occlusive cerebrovascular diseases and which was about one third of the blood flow of the ICA. Cerebral blood flow measurements through 133Xe inhalation method revealed that there was no difference in rCBF values between the operated and non-operated sides and that their values were within normal limits. The postoperative blood pressure was unchanged in 42% of our 11 cases, temporarily elevated and thereafter normalized in 33% and persistently elevated in 25%. Ophthalmodynamometry showed that the pressure of the central retinal artery decreased postoperatively in a degree of 5-10% in comparison to the non-operated side. No visual impairment was observed postoperatively (except case 3, see the text). These combined operations, STA-MCA anastomosis and ICA ligation were beneficial in preventing the potential postoperative cerebral ischemia. Intra-arterial pressure measurements of the STA and MCA suggested that the one-stage operations of these two procedures are better than the two-stage operations for the patency of the anastomosis because the pressure gradient between the donor and recipient vessels is increased (from 10.3 mmHg to 49.3 mmHg) by this technique. Temporary ICA clamp for 30 min. under induced hypotension in local anesthesia is useful to check whether the one-stage operations can be tolerated or not. EC/IC bypass with an interposed saphenous vein graft is a more beneficial surgical technique than a routine STA-MCA anastomosis, because an immediate and larger amount of bypass flow can be obtained.     

Extracranial aneurysm of the internal carotid artery

The Authors present a case of extracranial internal carotid aneurysm of atherosclerotic nature. They review the most common pathogenetic factors of this uncommon disease and they focus attention on its natural history. The neurological complications in untreated patients are very high (50-70%). The treatment should be carried out with a revascularization technique after removal of the aneurysm; leaving ligature for difficult situations or to memories of the past.     

Rupture of previously unruptured giant carotid aneurysm after superficial temporal-middle cerebral artery bypass and internal carotid occlusion

A 51-year-old woman with an unruptured giant aneurysm of the internal carotid artery was treated by gradual occlusion of the internal carotid artery in the neck combined with a superficial temporal artery to middle cerebral artery bypass graft. Visual field defects improved after the operation, and thrombosis of the aneurysm was confirmed by angiography and computed tomography. Nevertheless, a fatal hemorrhage occurred 34 days after the final turn of the Selverstone clamp. The possible mechanism of rupture of the apparently thrombosed aneurysm is discussed. There is a risk of rupture of the aneurysm as long as the aneurysmal lumen remains after proximal ligation, no matter how small it may be.     

Direct surgery for paraclinoid aneurysm arising from the anterolateral wall of the internal carotid artery

The internal carotid aneurysm (ICA) arising from the paraclinoid region is associated with the origins of the superior hypophyseal artery and the ophthalmic artery. Recently, other aneurysms which can arise in this region without imvolvement of the arterial branches has been reported. Among those aneurysms, there are very rare type of aneurysms located on the anterolateral aspect of the internal carotid artery. In this report, we described our experience with direct surgery for five cases of the unruptuted paraclinoid aneurysm arising from the anterolateral aspect of the ICA. Firstly, the common carotid artery was exposed to carry out proximal flow control. We used the pterional approach. The anterior clinoid process was deleted after having confirmed aneurysm and the dural ring was incised. Extreme care had to be taken during this step. All patients underwent successful neck clipping. In recent two cases we employed the neuroendoscope (EndoArm) to observe the unrecognized area of surgical microscope and untrasonic bone curette (SONOPET) to perform the safe removal of the anterior clinoid process. This procedure is very useful for carrying out the neck clipping for aneurysms which are located on the anterolateral aspect of the internal carotid artery.     

Unbranched-site aneurysm of intracranial internal carotid artery]

Most intracranial saccular aneurysms arise from the angle between a parent vessel and an arterial branch. Saccular aneurysms without relation to any arterial branch are rare. During the last 24 years, 210 patients with intracranial internal carotid artery (ICA) aneurysms were directly operated on at our institution. We found eight saccular aneurysms arising from intracranial ICA without relation to any arterial branch. So we call them unbranched-site aneurysms of intracranial ICA, and describe their unique characteristics. Of the eight cases with unbranched-site aneurysm of intracranial ICA, three were men and five were women. The age ranged from 31 to 61 years with an average age of 48. Seven cases suffered a subarachnoid hemorrhage due to ruptured unbranched-site aneurysm, and the other case had been admitted to our department because of accompanying ruptured left internal carotid-posterior communicating aneurysm. All cases of unbranched-site aneurysm presented intraoperative and/or angiographic findings of arteriosclerosis, and five of the patients had a past history of hypertension. Of the four unbranched-site aneurysms at the C2 portion of ICA, two arose from the lateral wall, one arose from the superior wall and the other arose from the infero-lateral wall of ICA. Of the four unbranched-site aneurysms at the C1 portion of ICA, three arose from the superior wall and the other arose from the supero-medial wall of ICA. Radical operation was performed in all cases and intraoperative rupture occurred in two cases. It was suggested that arteriosclerotic change in the arterial wall, and local hemodynamic stress played important roles in the development of unbranched-site aneurysms of intracranial ICA.     

Nondysplastic saccular aneurysm of the internal carotid artery

An unusual case of nondysplastic saccular aneurysm associated with elongation of the extracranial internal carotid artery is reported. The artery was normal except for a punch-hole defect in the media, which distinguished it from true fibromuscular dysplasia. Although neurologic symptoms and treatment were not specific, this case is interesting in that the exact cause of the aneurysm remains unknown.     

Traumatic internal carotid artery aneurysm and massive epistaxis

A case of traumatic internal carotid artery aneurysm (ICAA) is described. Although rare, the occurrence of rupture of traumatic ICAA with epistaxis has a high mortality. Successful management requires an awareness of the entity, prompt recognition, and aggressive first aid procedures. Definitive treatment involves trapping of the internal carotid artery either by a direct approach, or by balloon embolization.     

Iatrogenic dissecting aneurysm of the internal carotid artery

Summary A secondary dissecting aneurysm after arterial injury has been reported as a complication of surgery. We encountered this phenomenon in a patient with a meningioma of the sphenoid ridge. Despite successful clipping of a small rupture in the anterior wall of the proximal portion of the internal carotid artery, the patient became drowsy 30 days after surgery and developed right hemiparesis followed by fatal bleeding from the internal carotid artery. Histological examination revealed a traumatic dissecting aneurysm which had developed from the tear in the intima and extended into the dural ring and the bifurcation of the carotid artery. The characteristic clinical and histopathologic findings are shown. Methods for early recognition and the possibility of immediate treatment are briefly discussed.     

Surgical treatment of extracranial internal carotid artery aneurysm

Aneurysms of the extracranial internal carotid artery are rare but can be responsible for severe complications such as rupture, thrombosis, or embolism. Between 1961 and 1985 we operated on 38 aneurysms of the extracranial internal carotid artery in 35 patients, 22 males and 13 females, whose ages ranged from 6 to 73 years. The underlying causes of aneurysm included atherosclerosis (12 cases), fibromuscular dysplasia (eight cases), a congenital defect (five cases), infection (one case), and trauma (six cases); in six cases aneurysm was secondary to spontaneous dissection. Signs of cerebral ischemia were present in 26 (74%) patients and a cervical mass was found in six. The aneurysm was proximal (i.e., below the angle of the mandible) in 16 patients and distal (i.e., above the angle of the mandible) in 22. After resection of the aneurysm, arterial continuity was restored in 37 patients by resection and grafting (12 cases), resection and anastomosis (11 cases), or arteriorrhaphy (14 cases). One death occurred 13 days after operation due to myocardial infarction. Two patients experienced a reversible neurologic event. Transient paresis of cranial nerves was observed in eight patients. During a follow-up period that ranged from 6 to 30 years, four patients were lost to follow-up and 25 patients remained asymptomatic. Three patients had asymptomatic thrombosis of the carotid artery detected at follow-up investigations. The potential risks of cerebral ischemia and rupture and the satisfactory long-term results achieved with surgery are strong arguments in favor of surgical treatment for aneurysms of the extracranial internal carotid artery.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Reims, France, June 19– 20, 1992.     

Simultaneous carotid endarterectomy, coronary artery bypass grafting and abdominal aortic aneurysm surgery.

A case with a disease triad of an ulcerative lesion in the left internal carotid artery (LICA), severe coronary insufficiency, and an infrarenal abdominal aortic aneurysm (AAA) is presented in whom we performed simultaneous carotid endarterectomy (CEA), coronary artery bypass grafting (CABG), and Y-graft replacement of the AAA. The operative technique is detailed and justification of the simultaneous approach in such patients is discussed.