Cases reported "Carotid Stenosis"

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21/93. moyamoya disease in a Hispanic child: a case report.

    BACKGROUND: moyamoya disease was initially described by Suzuki and Takaku in 1963 as a radiographic phenomenon relating to the tiny collateral vessels characteristic of the disease that resemble a cloud or puff of smoke. The disease is rare and initially it was believed that the disease was confined to the Japanese population. It consists of occlusive vascular disease at the circle of willis with a tendency toward multiple ischemic neurological events and small strokes. In older populations it can often be associated with further vascular degeneration and intracerebral hemorrhage. This paper discusses the diagnosis, treatment, and management of moyamoya disease in a Hispanic child. CASE DESCRIPTION: The case of a Hispanic child who presented with transient ischemic attacks over a period of 1 year is reported. magnetic resonance imaging (MRI) revealed occlusive vascular disease in the posterior circle of willis. Digital subtraction cerebral angiography showed vascular occlusion at the base of the skull with collateral leptomeningeal and posterior circulation contribution in a pattern typical of moyamoya disease. technetium was injected for a SPECT study demonstrating less uptake in the left frontal and left parieto-occipital regions. The patient underwent a left superficial temporal-to-middle cerebral artery anastamosis followed by a right-sided anastamosis in a second operation. The patient tolerated the cerebral revascularization and was symptom-free at 6-month follow-up. cerebral angiography demonstrated improved perfusion in both cerebral hemispheres postoperatively. CONCLUSION: This article reports the occurrence of moyamoya in a Hispanic child. It illustrates the improved perfusion postoperatively as seen on digital subtraction cerebral angiography. Direct revascularization is felt to be difficult in children and alternatives such as encephaloduroarteriosynangiosis have been advocated. Direct revascularization was effective in treating moyamoya disease in this instance. Most of the discussion of moyamoya disease has been focused on the Japanese and far east population. This report confirms the entity as occurring in a Hispanic individual in the united states with no known Japanese ancestry.
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22/93. Stent placement in common carotid and internal carotid artery stenoses with use of an open transcervical approach in a patient with previous endarterectomy.

    In this article, a patient with extensive cerebrovascular disease who had previously undergone bilateral carotid endarterectomy and subsequent operative revision on the left side is described. The patient developed critical restenosis at the cephalic end of the previous left patch angioplasty as well as a severe stenosis of the left common carotid artery origin, which originated from a bovine aortic arch configuration. His right common and internal carotid arteries had become occluded. Endovascular treatment with two metallic stents was successfully performed through a surgical cutdown on the immediate supraclavicular portion of the left common carotid artery to establish antegrade and subsequently retrograde vascular access.
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23/93. Carotid endarterectomy in patients with contralateral internal carotid artery occlusion without intraoperative shunting.

    BACKGROUND: Controversy about the optimal method of performing a carotid endarterectomy (CEA) exists despite its widespread application and support from various randomized clinical trials. Many surgeons selectively or routinely use electroencephalography (EEG) monitoring as well as shunting when performing this operation. ETHODS: We conducted this retrospective study to assess the maximum carotid clamp time without shunting or EEG monitoring during a CEA without the development of neurological deficits in an already compromised cerebral circulation. RESULTS: Fifteen consecutive patients who underwent CEAs between 1988 and 1999 met our criteria of angiographically documented ipsilateral internal carotid artery (ICA) stenosis with contralateral ICA occlusion. The patient presentations included asymptomatic (14%), transient ischemic attack (TIA) (50%), and stroke (36%). All patients were operated under general anesthesia without shunting and only 4 patients underwent EEG monitoring. On angiography, all 15 patients had ipsilateral ICA stenosis (70-99%) and contralateral occlusion. In 54% of patients, the vertebral arteries (VAs) were both patent, while in 46% of patients only 1 VA was patent. Eighty-five percent of patients had at least 1 patent anterior communicating (Pcomm) artery, while 15% had nonvisualized Pcomm arteries bilaterally. Of the 15 patients, 14 had a patent anterior communicating artery. The mean clamp time of the CCA was 18.5 minutes (range 14-30 minutes). None of the 15 patients had new neurological changes immediately postoperatively or during the 6 weeks of follow-up. CONCLUSION: We propose that shunting may not be necessary during CEA for high-grade stenosis with contralateral ICA occlusion, presumably because of adequate distal small vessel collaterals.
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24/93. In situ confirmation of retinal blood flow improvement after carotid endarterectomy in a patient with ocular ischemic syndrome.

    PURPOSE: To report a patient with ocular ischemic syndrome due to an internal carotid artery stenosis in whom we confirmed improved retinal blood flow noninvasively after carotid endarterectomy. DESIGN: Observational case report. methods: Retinal flowmetry. RESULTS: In a 72-year-old hypertensive man with a transient ischemic attack including dysgraphia, carotid angiography revealed approximately 90% stenosis of the left internal carotid artery. Standard carotid endarterectomy was performed. Postoperatively, good patency of the left internal carotid artery was confirmed by magnetic resonance angiography. We measured tissue blood flow in the fundus of each eye using a Heidelberg retina flowmeter before and after endarterectomy. Preoperative measurements showed reduction of blood flow in the left fundus, while values 3 months after surgery indicated a significant improvement of blood flow (P <.05, one-factor analysis of variance [ANOVA]). CONCLUSIONS: Retinal flowmetry can noninvasively detect differences in retinal blood flow between eyes in a patient with unilateral internal carotid artery stenosis and also assess the improvement of retinal blood flow after carotid endarterectomy.
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25/93. Operative intervention for recurrent stenosis after carotid stent angioplasty: a report.

    Carotid artery angioplasty and stenting is gaining popularity, yet the natural history and optimal treatment for recurrent stenoses within stents are not known. Recurrent stenosis rates are not well characterized, with rates between 0 and 33% reported within the first year. Treatment of these lesions with repeat angioplasty may not be feasible or desirable, leading to operative interventions. We present two cases of asymptomatic high-grade in-stent restenosis treated successfully with carotid artery bypass using PTFE.
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26/93. Ruptured dissecting aneurysm of the vertebral artery associated with occlusive internal carotid artery dissection--case report.

    A 64-year-old male presented with subarachnoid hemorrhage. Angiography showed a dissecting aneurysm of the right vertebral artery (VA), and severe stenosis of the right internal carotid artery (ICA). He was treated conservatively in the early stage. Repeat angiography showed enlargement of the dissecting aneurysm of the VA and partial resolution of the stenosis of the right ICA. Intraaneurysmal coil embolization with proximal coil occlusion was performed following a balloon occlusion test. The postoperative course was uneventful. Based on the neuroradiological findings, the stenotic lesion of the right ICA was considered to be due to dissection. Analysis of serial changes in dissecting lesions in the craniocervical arteries is important for the correct choice of treatment, especially in patients with multi-vessel dissections. The surgical options should be determined on an individual basis.
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27/93. Early carotid endarterectomy after ischemic stroke improves diffusion/perfusion mismatch on magnetic resonance imaging: report of two cases.

    OBJECTIVE AND IMPORTANCE: The functional magnetic resonance imaging techniques of diffusion-weighted imaging and perfusion-weighted imaging allow for ultra-early detection of brain infarction and concomitant identification of blood flow abnormalities in surrounding regions, which may represent brain "at risk." CLINICAL PRESENTATION: We report two patients with acute ischemic stroke associated with ipsilateral high-grade carotid stenosis. The first patient, a 64-year-old woman with a remote history of ischemic stroke and a vertebral artery aneurysm, presented with worsening of her preexisting right hemiparesis. The second patient, another 64-year-old woman with known multiple intracranial aneurysms and bilateral high-grade internal carotid artery stenosis, was admitted for the elective microsurgical clipping of an enlarging giant left carotid-ophthalmic artery aneurysm. Postoperatively, she developed right hemiparesis and mild aphasia. Both patients showed progressive worsening of their neurological deficits in the setting of small or undetected diffusion-weighted imaging abnormalities and large perfusion-weighted imaging defects. INTERVENTION: After prompt carotid endarterectomy, symptoms in both patients resolved or improved. Follow-up magnetic resonance imaging scans demonstrated resolution or significant improvement in the perfusion abnormalities in both patients. CONCLUSION: Carotid endarterectomy in the setting of diffusion-weighted/perfusion-weighted imaging mismatch can lead to improvement in cerebral perfusion as evidenced by resolution of the perfusion-weighted imaging lesion. diffusion/perfusion magnetic resonance imaging may be useful in identifying patients with severe neurological deficits but without large territories of infarction who may safely undergo early surgical revascularization.
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28/93. Endovascular therapy for stenosis of the petrous or cavernous portion of the internal carotid artery: percutaneous transluminal angioplasty compared with stent placement.

    OBJECT: The effects of percutaneous transluminal angioplasty (PTA) and stent placement for stenosis of the petrous or cavernous portion of the internal carotid artery (ICA) were compared. methods: Twenty-four patients with symptomatic, greater than 60% stenosis of the petrous or cavernous portion of the ICA were treated using PTA or stent placement; 15 were treated with PTA and nine with stent insertion. Initial and follow-up results (> 3 months posttreatment) were compared in each group. Stenotic portions of the ICA were successfully opened in 13 of 15 patients in the PTA group, and in all nine patients in the stent-treated group. In one case in the PTA group stent delivery was attempted; however, the device could not pass through the vessel's tortuous curve, and PTA alone was performed in this case. Postoperatively, the mean stenotic ratio decreased from 72.1 to 29.6% in the PTA group, and from 75.6 to 2.2% in the stent-treated group. In four patients in the PTA group, stenoses greater than 50% were demonstrated on follow-up angiography performed at 3 to 6 months after PTA. In the stent-treated group, no restenosis was encountered, although in one case acute occlusion of the stent occurred; the device was recanalized with PTA and infusion of tissue plasminogen activator. This case was the only one of the 24 in which any neurological deficits related to the endovascular procedure occurred. Stent placement brought a greater gain in diameter than did PTA at the initial and late follow-up period; this gain was statistically significant. CONCLUSIONS: Stent placement is more effective than PTA for stenosis of the petrous or cavernous portion of the ICA from the viewpoint of initial and late gain in diameter.
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29/93. Double-lumen carotid plaque: a morbid configuration.

    During analysis of carotid plaque anatomy for a multicenter carotid imaging trial, we examined plaque specimens from 5 patients with double internal carotid artery lumina. Four of the 5 patients had symptoms referable to the lesion. The second lumen was noted when the plaque specimens were examined ex vivo with high-resolution (200 microm(3)) magnetic resonance imaging. Plaque structure was correctly identified in only 1 patient preoperatively. However, during retrospective review of the preoperative imaging studies, the second internal carotid artery lumen was identified in 3 patients.
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30/93. Correlation of MRI and CT data with outcome of cerebral revascularization after stroke.

    Sixteen patients with the occlusion of the internal carotid artery (ICA) underwent extra-intracranial bypass surgery. All patients had stroke in evolution or completed stroke with mild or moderate (n = 9) or severe (n = 7) neurological deficits. In each case, the clinical course, magnetic resonance imaging (MRI), computed tomography (CT) and angiographic (AG) findings were evaluated. patients were followed up from 9 months to 2.5 years postoperatively. MRI was much more sensitive than CT for appreciating the ischaemic tissue. The infarct volume determined by MRI had greater extent than previously detected by CT. If the difference of the infarct volume, detected by MRI and CT was more than 30% the patients appeared to have benefited from bypass surgery as demonstrated clinically as well as with postoperative MRI and AG studies. patients with lesser difference showed insignificant or no postoperative improvement.
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