Cases reported "Carotid Stenosis"

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1/93. Is there a potential role for hyoid bone compression in pathogenesis of carotid artery stenosis?

    BACKGROUND: blood flow turbulence and increased shear stress, particularly at sites of sudden, marked arterial wall changes, are significant hemodynamic parameters in the pathogenesis of atherosclerosis. We present a case in which we found the hyoid bone protruding into the carotid vessels and may have been contributing, in part, to atherosclerotic carotid stenosis. CASE PRESENTATION: An 85-year-old woman presenting with left arm and leg weakness consistent with right hemispheric transient ischemic attack. Magnetic resonance arteriography (MRA) and carotid non-invasive studies revealed a 90% stenosis of the right internal carotid artery. At surgery, the hyoid bone on the right side was projecting into the internal carotid artery, causing indentation. There was associated rotation of the internal and external carotid arteries from their normal position. Right carotid endarterectomy was performed and the lateral one-third of the hyoid bone excised to alleviate the external compression. Postoperative spiral computerized tomography (CT) scan of the carotid vessels demonstrated the extent of hyoid resection as well as rotation of the external and internal carotid arteries. CONCLUSIONS: We suggest the possible contribution of hyoid bone compression to the pathogenesis of atherosclerotic carotid artery stenosis. This report also highlights the diagnostic value of CT angiography in the assessment of carotid artery occlusive disease.
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ranking = 1
keywords = operative
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2/93. Treatment of carotid tandem stenosis by combined carotid endarterectomy and balloon angioplasty: technical case report.

    OBJECTIVE AND IMPORTANCE: Cervical internal carotid artery disease associated with high-grade carotid siphon stenosis poses a therapeutic challenge. This report describes the combination therapy of carotid end-arterectomy and intraoperative transluminal balloon angioplasty of the carotid siphon. CLINICAL PRESENTATION: A 67-year-old man sustained repeated left hemispheric and retinal transient ischemic attacks. Results of a diagnostic examination, including angiography, disclosed a 70% ulcerative stenosis of the left extracranial internal carotid artery as well as a 90% stenosis of the left intracavernous carotid artery. The decision was made for combined open and endovascular therapy. INTERVENTION: After standard endarterectomy, an introducer for the dilation catheter was placed into the common carotid artery before final closure of the arteriotomy and recirculation. Under intraoperative fluoroscopy, a 3-mm dilation balloon was navigated into the carotid siphon stenosis and inflated several times. A 30% residual stenosis in the carotid siphon was obtained as a final result. The intervention was completed without complications. No further neurological symptoms were observed during the follow-up period of 30 months. CONCLUSION: Carotid endarterectomy, combined with intraoperative transluminal angioplasty of carotid siphon stenosis, is a feasible procedure for selected patients with carotid tandem stenosis.
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ranking = 3
keywords = operative
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3/93. Intraoperative stenting of the internal carotid artery after unsuccessful eversion endarterectomy.

    Stenting of the internal carotid artery (ICA) has been shown to be feasible in atherosclerotic lesions, in restenosis after carotid endarterectomy, and in spontaneous carotid dissections. To correct an intimal flap that detached distal occlusion of the ICA after eversion carotid endarterectomy, as shown with intraoperative completion angiography, we successfully used stenting of the ica with a self-expandable stainless steel stent placed during surgery through the common carotid artery.
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ranking = 5
keywords = operative
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4/93. Persistent primitive hypoglossal artery associated with cerebral aneurysm and cervical internal carotid artery stenosis--case report.

    A 71-year-old female had vertigo attacks once or twice a day secondary to vertebrobasilar insufficiency. Left carotid angiography revealed persistent primitive hypoglossal artery (PPHA) associated with a large internal carotid artery (ICA) aneurysm and severe stenosis of the ICA. The bilateral vertebral arteries were hypoplastic. The basilar artery was opacified via the PPHA but not via vertebral arteries. Clipping of the aneurysm was performed first because the risk of rupture of the aneurysm was not negligible. One month after clipping, carotid endarterectomy using a T-shaped shunt system was successfully performed. The postoperative course was uneventful and the vertebrobasilar ischemic attacks did not recur. Left carotid angiography demonstrated complete obliteration of the aneurysm and disappearance of the carotid artery stenosis. Low ICA flow (70 ml/min) and low stump pressure of the PPHA (25 mmHg) strongly suggested low perfusion of the posterior circulation. Carotid endarterectomy may be essential for augmentation of the posterior circulation in patients with PPHA associated with ICA stenosis.
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ranking = 1
keywords = operative
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5/93. Improved cerebral perfusion after stenting of a petrous carotid stenosis: technical case report.

    OBJECTIVE AND IMPORTANCE: Atherosclerotic occlusive disease of the intracranial vasculature is associated with increased risk of systemic vascular occlusive disease and stroke. Therapeutic options have included anticoagulation therapy, antiplatelet therapy, or, in a limited number of patients, extracranial-intracranial vascular bypass procedures. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after endovascular stenting of a severe petrous segment carotid stenosis. CLINICAL PRESENTATION: A 73-year-old man with severe coronary artery disease and unstable angina was referred for treatment of a 90% right petrous carotid artery stenosis before coronary artery bypass grafting. A brain single-photon emission computed tomographic scan using 99mTc-bicisate revealed diminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones. TECHNIQUE: The patient underwent transfemoral placement of a 7-French introducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No changes were noted in lesion morphology after this infusion. A microguidewire was navigated across the lesion. Subsequent balloon angioplasty with a coronary artery balloon was performed twice, followed by placement of a 4- x 12-mm coronary stent. CONCLUSION: Selective internal carotid artery angiography after stenting revealed markedly improved flow. A brain 99mTc-bicisate single-photon emission computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were noted; both were clinically silent. The patient had uncomplicated coronary artery bypass grafting 72 hours later. Five months postoperatively, he remains at home, living independently and with intact neurological function. Intracranial stenting for severe atherosclerotic stenosis is technically possible. However, its ultimate clinical role remains to be determined.
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ranking = 1
keywords = operative
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6/93. Assessment of outcome by EC/IC bypass with 123I-iomazenil brain SPECT.

    We report two patients with occlusive cerebrovascular disease who were examined by means of benzodiazepine receptor SPECT(BZR-SPECT) with 123I-iomazenil (IMZ) before extracranial-intracranial bypass surgery (EC/IC bypass). Preoperative low perfusion areas detected by cerebral blood flow SPECT (CBF-SPECT) were divided into two parts on BZR-SPECT images. In the low perfusion areas where the BZR were preserved, regional cerebral blood flow (rCBF) increased on postoperative CBF-SPECT, but where the BZR were not preserved, rCBF did not increase on postoperative CBF-SPECT. On visual inspection, the SPECT images of postoperative CBF-SPECT appeared similar to those of preoperative BZR-SPECT. For evaluation of the ischemic brain condition itself, instead of the cerebral metabolism, the distribution and activity of cerebral neurons indicated by BZR-SPECT with IMZ might be utilized.
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ranking = 5
keywords = operative
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7/93. Pseudo-occlusion and/or pseudo-stenosis of the intracranial internal carotid artery.

    This report summarizes our recent experience with two patients who presented with symptoms ipsilateral to a severe carotid stenosis at the bifurcation, with one having a severe stenosis at the siphon and the other an occlusion of the internal carotid artery in its intracranial portion. These lesions were documented on preoperative angiography. In both instances, persistence of symptoms, despite maximal medical therapy, led us to proceed with carotid endarterectomy. In both cases, intraoperative angiography confirmed a normal intracranial internal carotid artery, contrary to what had been seen on preoperative angiography. Carotid endarterectomy was performed, with resolution of clinical symptoms in both cases. This experience suggests that the appearance of the intracranial portion of the carotid artery can be significantly affected by the presence of a proximal lesion at the bifurcation. Stenosis and/or occlusion of the intracranial portion of the carotid artery may appear on preoperative angiography secondary to flow alterations as a result of the more proximal lesion. This, in part, may explain why many patients with combined extracranial and intracranial arterial disease improve after carotid endarterectomy and suggests that, in the presence of a severe extracranial lesion, further evaluation be undertaken to exclude the possibility of pseudo-stenosis or pseudo-occlusion of the intracranial carotid artery.
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ranking = 4
keywords = operative
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8/93. Surgery and stenting As combined treatment of a symptomatic tandem stenosis of the carotid artery.

    International co-operative studies have demonstrated a benefit from surgery for symptomatic and asymptomatic patients affected by internal carotid artery stenosis of 60-70%. The presence of a tandem lesion, intracranial or extracranial, may annul the benefit of surgery. Such patients may thus represent a challenging problem for management if age, good general conditions and a normal neurological status favour a therapy. A 54-year-old man developed transient ischaemic attacks of the left hemisphere; his general condition was good, and neurological status was normal. angiography showed a tight stenosis at the left common carotid artery near the ostium and at the homolateral carotid bifurcation. At first, a self-expanding wall stent was placed at the level of the common carotid artery stenosis, and immediately after a standard endarterectomy under general anaesthesia was performed. The postoperative course was normal and was complicated only by the presence of a mild deficit of the hypoglossal nerve due to the presence of a high bifurcation. The early and late outcome of our case suggests that stenosis of the proximal common carotid artery may be successfully treated by stenting. While awaiting additional data about this new technology, endovascular techniques and surgery may be complementary in the management of patients suffering from such tandem lesions.
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ranking = 2
keywords = operative
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9/93. Immediate postoperative thrombolytic therapy: an aggressive strategy for neurologic salvage when cerebral thromboembolism complicates carotid endarterectomy.

    A 42-year-old man with a high-grade left internal carotid artery (ICA) stenosis demonstrated on a duplex scan was referred to us. A cerebral arteriogram confirmed a greater than 90% left internal carotid stenosis, but with the unexpected finding of a moderate amount of thrombus in the proximal ICA. He underwent emergent left carotid endarterectomy, but during the operation, only a small amount of thrombus was identified as adherent to the atherosclerotic plaque. he awakened in the operating room with a dense right hemiplegia and aphasia. Immediate reexploration demonstrated a patent endarterectomy site, a distal thromboembolectomy was performed without extraction of thrombus, and urokinase (250,000 Units) was infused into the distal ICA. He reawakened with an unchanged right hemiplegia and aphasia. The patient then underwent an urgent postoperative carotid and cerebral arteriogram that demonstrated an embolus to the middle cerebral artery. he was treated with the superselective infusion of urokinase (500,000 Units), with almost complete resolution of the clot. Over the course of the next 48 hours, the patient made a nearly complete neurologic recovery, and he was discharged from the hospital with only a slight facial droop. At 2 months' follow-up he was completely neurologically healthy. To our knowledge this is the first reported case of urokinase administered in the immediate postoperative period in the angiography suite to treat a thromboembolus complicating a carotid endarterectomy.
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ranking = 6
keywords = operative
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10/93. Bypass surgery using a radial artery graft for bilateral extracranial carotid arteries occlusion.

    A patient presenting with recurrent ischemic attacks was demonstrated to have complete occlusion of the right common and left internal carotid arteries. An external carotid angiogram showed a large left superficial temporal artery (STA) supplying both sides of the scalp. 123I-IMP single photon emission computed tomography (SPECT) revealed hypoperfusion of the both hemispheres, especially the left cerebral hemisphere. An extracranial-intracranial (EC-IC) bypass was performed using a radial artery graft interpositioned between the proximal part of the STA and the M2 segment, thus preserving blood flow to the scalp through the STA. Postoperative angiography after 1 year showed good circulation through the anastomosis, and 123I-IMP SPECT studies demonstrated increased cerebral perfusion. The patient improved clinically. The surgical technique is described below.
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ranking = 1
keywords = operative
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