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Purpose: This study aimed to investigate the macro- and microstructural features of language in patients with ischemic stroke without aphasia. Method: Participants were grouped according to arterial system damage and given the Aphasia Language Assessment Test (ADD) to detect aphasia. A narrative sample was obtained and analyzed for macrostructural and microstructural features of the language. The study sample consisted of 31 participants with ischemic stroke (15 vertebrobasilar system [VBS] involvement and 16 carotid system [CS] involvement) and 31 healthy participants, totaling 62 individuals. Results: The healthy control group scored higher than the stroke group on the microstructural feature type–token ratio and mean length of utterance in the narrative analysis and on the auditory comprehension, repetition, naming, grammar, speech act, and writing subtests in ADD. Effort behavior, errors, edits, repetitions, and pauses among microstructural features and uncertainty, filler expression, and anomia among macrostructural features were significantly higher in the vertebrobasilar and CS groups than in the healthy control group. The total ADD score and speech fluency and reading subtest scores were significantly higher in individuals with VBS damage than in individuals with CS lesions (p < .05). Conclusions: Language components may be impaired differently in patients with carotid and vertebrobasilar lesions. Speech and language disorders in individuals who have experienced cerebrovascular accidents should be evaluated in the subacute and chronic phases, and the therapeutic needs of patients with ischemic stroke should be determined, regardless of the presence of a clinical aphasia diagnosis. [ABSTRACT FROM AUTHOR]

Background: Extracranial internal carotid artery (ICA) pseudoaneurysm is a rare condition that can be caused either by penetrating or blunt trauma, including dog bites, which is an uncommon occurrence. Together with the possibility of no symptoms or nonspecific ones such as cervical pain, hematoma, swelling, or mass, considering ICA pseudoaneurysm following a dog attack is of paramount importance to avoid life-threatening complications. Case presentation: We present a rare case of a 17-year-old male with a history of dog bites three months prior, who presented to the emergency department with left-sided neck pain, dizziness, and several episodes of blurred vision and diplopia. On physical examination, a palpable mass measuring approximately 20 × 30 millimeters was identified in the left neck region and multiple superficial lacerations were observed in this area. Laboratory tests yielded normal results. Doppler ultrasound revealed a pseudoaneurysm in the left internal carotid artery. Because the great saphenous veins were insufficient, the patient was successfully treated with synthetic graft patch arterioplasty, and no complications were seen in his one-year follow-up with computed tomography (CT) angiography. Conclusions: This report emphasizes the significance of thorough initial evaluation and imaging in cases of dog attacks, even without apparent significant trauma, to rule out hidden arterial injuries. [ABSTRACT FROM AUTHOR]

This report demonstrates the successful treatment of a carotid artery pseudoaneurysm using percutaneous thrombin injection. The patient, a 62-year-old woman with multiple comorbidities, experienced a pseudoaneurysm following an unintentional carotid artery puncture during a failed attempt to place a triple lumen catheter in the right jugular vein. Percutaneous thrombin injection was chosen as the treatment method, with Doppler ultrasound monitoring. Follow-up examinations showed no signs of recurrence, and the patient was discharged after nine days without complications. [ABSTRACT FROM AUTHOR]

Traumatic internal carotid artery injuries can produce direct carotid-cavernous fistulas as well as giant internal carotid artery pseudoaneurysms. Clinical sequelae can include headaches, cranial nerves palsies, proptosis, chemosis and optic neuropathy with visual loss as the most dangerous complication. Herein, we present a case of one of the largest reported internal carotid artery pseudoaneurysms associated with a direct carotid cavernous fistula. We describe the techniques and pitfalls of treatment with parent vessel occlusion. [ABSTRACT FROM AUTHOR]

Young adults who present to the ED with neck pain following non‐penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport‐related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front‐line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi‐disciplinary team management of this condition. In general, guideline‐based recommendation for the management of neck artery dissection involving an intimal flap is by anti‐platelet therapy while treatment of neck artery dissection that results in a pseudo‐aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke. [ABSTRACT FROM AUTHOR]

Introduction. Carotid artery pseudoaneurysms can refer to pseudoaneurysms involving any segment of the carotid arteries. Posttraumatic internal carotid artery pseudoaneurysm dilatation due to intimal transection is extremely rare entity that requires detailed clinical examination and multiple diagnostic modalities to confirm the diagnosis. The aim of the study is to present rare entity of posttraumatic extracranial internal carotid artery pseudoaneurysm dilatation due to intimal transection, diagnostic algorithm and diagnostic findings. Case Report. The patient was a 30-year-old, previously healthy, female who came to see a cardiologist due to intermittent tachycardia, which first appeared a week before the examination. Duplex ultrasound was performed, and aneurysm of extracranial segment of internal carotid artery was found. The patient had severe neck trauma due to bicycle accident in childhood, which was treated at home, without medical examination. Further computed tomography angiography and magnetic resonance angiography were performed. All imaging findings were in favor of chronic arterial wall small pseudoaneurysmal dilatation, with intimal transection, without signs of acute trauma. Based on the above, a decision was made to continue conservative treatment in accordance with the recommendations of current guidelines. Periodic clinical diagnostic follow-up was performed. After the applied therapy, the complaints in terms of intermittent tachycardia disappeared completely. Conclusion. Formation of extracranial internal carotid artery pseudoaneurysm due to intimal transection is a rare entity, and requires multiple imaging findings in order to evaluate if the trauma is acute or chronic. In most cases, chronic pseudoaneurysm does not require surgical intervention. It requires conservative medical treatment and diagnostic follow-up. [ABSTRACT FROM AUTHOR]

In Eagle syndrome, elongated styloid processes may provoke internal carotid dissection and pseudoaneurysm causing stroke and data regarding possible complications or long-term results of pseudoaneurysm treatment using a flow diverter are limited. We report a case of a dissection-related pseudoaneurysm in the left cervical carotid artery treated by implantation of a flow diverter. Follow-up imaging of the flow diverter showed fracture of a continuous radiopaque marker at 3 months and fracture of a second continuous radiopaque marker at 7 months, while contrasting of the vessel was preserved. At the time of angiographic control (8 months after implantation), the flow diverter and the extracranial left internal carotid artery were occluded, and the patient did not experience any symptoms throughout the period. [ABSTRACT FROM AUTHOR]

Penetrating injuries of the neck involving major vessels are associated with high morbidity and mortality. A traumatic arteriovenous (AV) fistula can provide a protective effect by decompressing the injured arterial structure and prevent massive blood loss and airway compression. We present a novel description of CCA (common carotid artery) transection with associated protective AV fistula. Protective AV fistulae have been uncommonly described, and to our knowledge, this is the first case involving carotid transection with associated protective AV fistula ultimately allowing lifesaving operative repair. [ABSTRACT FROM AUTHOR]

Common carotid artery (CCA) rupture during parathyroid cancer surgery is extremely rare and is generally life-threatening. We present a case of successful management of a ruptured CCA following the emergency placement of stent-graft in a 59-year-old male diagnosed with recurrent parathyroid cancer. During recurrent parathyroid cancer surgery, his right CCA ruptured unexpectedly, and his vital signs deteriorated rapidly despite surgical management. After stent replacement, his unstable vital signs improved and, thereafter, he was discharged without any complications. [ABSTRACT FROM AUTHOR]

Background: Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported peri-operative mortality rate of 10%. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have been described as useful strategies for managing ICA bleeds. The objective of this study was to develop a formalized management protocol for intra-operative ICA injury through engagement with a multi-disciplinary panel. Methods: A modified Delphi method including literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional neuroradiologists, anesthesiologists, and operating room nursing staff. Results: After three rounds of stakeholder engagement with the expert panel, consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: Alert, Control, and Transfer. 'Alert' focusses on early communication with anesthesia and nursing staff. 'Control' focusses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, 'Transfer' describes the process of contacting neuro-interventional radiology and safely transferring the patient. A one-page handout of the protocol was developed for placement in operating theatres. Conclusion: Due to the life-threatening nature of ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic internal carotid artery (ICA) injuries are an uncommon complication of petrous temporal bone (PTB) fractures that can have devastating consequences of stroke, haemorrhage and death. Current guidelines suggest that all PTB fractures should be screened for blunt cerebrovascular injury, however clinical practice varies. The purpose of this study was to identify features associated with PTB fractures that increase the likelihood of ICA injury.Methods: A retrospective cohort study was performed on all patients with PTB fractures who were investigated with computed-tomography angiography (CTA) scan admitted to a Level One Trauma Service in Melbourne, Australia from 2015-2020. Patient demographic and injury data were obtained from The Royal Melbourne Hospital Trauma Registry and medical records. Multivariate binomial logistic regression was performed to identify features associated with ICA injury.Results: Out of 377 patients with 419 PTB fractures, 205 received a CTA scan and were included, identifying 22 ICA injuries (9.4%). The median age of ICA injuries was 33 (IQR 23-61), median Abbreviated Injury Scale (AIS) score for the head region was 5 (IQR 5-5) and the in-hospital mortality rate was 45.5%, mainly due to unsurvivable brain injury. Five patients (22.7%) developed ICA-specific complications of stroke or carotid-cavernous fistula. We identified five factors that were significantly associated with ICA injury. These included PTB fractures involving the carotid canal (OR 6.7, 95% CI 1.9-23.9, p=0.003), presenting with an initial GCS less than nine (OR 5.7, 95% CI 1.2-26.5, p=0.025) and increasing head AIS (OR 2.4, 95% CI 1.2-4.6, p=0.009). Mechanisms of injury that were associated with ICA injury were motor vehicle crash (OR 4.4, 95% CI 1.4-14.2, p=0.012) and motorbike crash (OR 4.6, 95% CI 1.2-18, p=0.029).Conclusion: Patients with PTB fractures and an additional feature of carotid canal involvement, presenting GCS less than nine, increasing head AIS indicative of severe head trauma or mechanism of injury by motor vehicle or motorbike crash, are at an increased risk of ICA injury and should be screened with a CTA scan. [ABSTRACT FROM AUTHOR]

Accidental carotid artery injury is an uncommon but serious central venous catheter insertion complication. Hemostasis might not be readily achieved by manual compression; therefore, surgery or endovascular treatment remains the mainstay for accidental carotid artery injury. However, not all patients are suitable candidates for surgery. Vascular closure devices are widely used in femoral arteries to achieve hemostasis and early ambulation. The use of vascular closure devices is occasionally reported in other vascular beds. Here we present a case of an iatrogenic left common carotid artery injury treated by vascular closure device, which is of help in the future management of this complication. [ABSTRACT FROM AUTHOR]

The abnormal change of vascular smooth muscle cell (VSMC) behavior is an important cellular event leading to neointimal hyperplasia in atherosclerosis and restenosis. Plantamajoside (PMS), a phenylethanoid glycoside compound of the Plantago asiatica, has been reported to have anti-inflammatory, antioxidative, and anticancer activities. In this study, the protective effects of PMS against intimal hyperplasia and the mechanisms underlying the regulation of VSMC behavior were investigated. MTT and BrdU assays were performed to evaluate the cytotoxicity and cell proliferative activity of PMS, respectively. Rat aortic VSMC migrations after treatment with the determined concentration of PMS (50 and 150 μM) were evaluated using wound healing and Boyden chamber assays. The inhibitory effects of PMS on intimal hyperplasia were evaluated in balloon-injured (BI) rat carotid artery. PMS suppressed the proliferation in platelet-derived growth factor-BB-induced VSMC, as confirmed from the decrease in cyclin-dependent kinase (CDK)-2, CDK-4, cyclin D1, and proliferating cell nuclear antigen levels. PMS also inhibited VSMC migration, consistent with the downregulated expression and zymolytic activities of matrix metalloproteinase (MMP)2, MMP9, and MMP13. PMS specifically regulated MMP expression through p38 mitogen-activated protein kinase and focal adhesion kinase pathways. Tissue inhibitor of metalloproteinase (TIMP)1 and TIMP2 levels were upregulated via Smad1. TIMPs inhibited the conversion of pro-MMPs to active MMPs. PMS significantly inhibited neointimal formation in BI rat carotid arteries. In conclusion, PMS inhibits VSMC proliferation and migration by upregulating TIMP1 and TIMP2 expression. Therefore, PMS could be a potential therapeutic agent for vascular atherosclerosis and restenosis treatment. [ABSTRACT FROM AUTHOR]

Introduction: The presence of an aberrant internal carotid artery (ICA) in the middle ear is rare. Patients may be asymptomatic or complain of conductive hearing loss, otalgia, pulsatile tinnitus, or aural fullness. Otoscopic exam findings can include a pulsating erythematous lesion on the tympanic membrane (TM). It may be misdiagnosed as a glomus tumor, hemangioma, or serous otitis media, or go unrecognized until surgical exploration. Early recognition is important as intraoperative discovery carries risk of iatrogenic injury, hemorrhage and subsequent neurologic sequelae. Prevention requires adequate preoperative suspicion and can be confirmed with radiologic examination via computed tomography (CT) scan or magnetic resonance angiography (MRA). Management of iatrogenic injury of an aberrant ICA can include packing, vessel embolization and/or surgical ligation. Patient case: We report the case of an aberrant ICA injury in a pediatric patient undergoing a myringotomy with tube placement, who sustained neurologic deficits that eventually resolved following treatment with packing and coil embolization. Discussion and conclusions: An aberrant ICA can cause life-threatening complications without prior diagnosis in a routine myringotomy. Suspicious exam findings should prompt temporal bone CT to rule out aberrant ICA or other vascular pathology of the middle ear prior to surgery. In the case of iatrogenic injury of an aberrant ICA, there is no consensus in existing literature on optimal management. We reviewed 37 studies to compare therapeutic options and subsequent outcomes. Though complications are rare regardless of management, cases in which solely packing was utilized demonstrated an increased incidence of hemiparesis, aphasia, hearing loss, re-bleeding, and delayed pseudoaneurysm, as compared to an approach coupling packing with embolization or ligation, both of which have comparable outcomes. [ABSTRACT FROM AUTHOR]

A carotid cavernous fistula is an abnormal connection between the carotid artery and cavernous sinus which is a rare and sight threatening complication of craniofacial trauma. We report a case of a 36-year-old man with history of road traffic accident, flail chest, on mechanical ventilation who developed redness and progressive swelling of right eye. On evaluation, he was found to have right-sided conjunctival chemosis, pulsatile proptosis, and loud bruit on auscultation over right eyeball. Non-contrast computed tomography revealed multiple skull bone fractures with prominence of right-sided cavernous sinus and superior ophthalmic vein. Contrast enhanced magnetic resonance imaging with angiography revealed bulky cavernous sinus with tortuous right superior ophthalmic vein suggestive of right carotid cavernous fistula. Carotid cavernous fistula should be considered as a differential diagnosis for a critically ill patient with history of trauma developing swollen red eyes as the typical signs and symptoms cannot be assessed in patients on mechanical ventilation. The timely diagnosis and prompt treatment can save vision and can improve the outcome. [ABSTRACT FROM AUTHOR]

Objective: Current EAST guidelines recommend against routine carotid intervention for patients with blunt carotid artery injury (BCI), but offer limited information on its role for BCI patients presenting with neurological deficit. Our goal was to describe the contemporary management and outcomes of patients presenting with BCI and neurological deficit unrelated to head injury.Methods: We identified all adults who sustained a BCI between 2010 and 2017 in the American College of Surgeons Trauma Quality Improvement Program. We extracted patient demographics, injury characteristics (carotid and non-carotid), as well as the frequency, timing and approach of carotid intervention. Presence of neurological deficit unrelated to head injury at presentation was determined using Abbreviated Injury Scale codes. The main outcomes were in-hospital mortality and home discharge. Patients with and without neurological deficit at presentation were compared through multivariable logistic regression modeling. Among those with neurological deficit at presentation, the associations between carotid intervention (open or endovascular) and the outcomes were also assessed through multivariable logistic regression.Results: We identified 5,788 patients with BCI of whom 383 (7%) presented with neurological deficit unrelated to head injury. Among the 296 patients (5%) who underwent carotid intervention, 36 (12%) had presented with neurological deficit unrelated to head injury. Interventions were most often endovascular (68% [200/296]) and within a median time of 32 h (IQR 5-203). In-hospital mortality was 16% (918/5,788), and in-hospital stroke prevalence was 6% (336/5,788). When comparing patients with and without neurological deficit at presentation, those with deficits were more frequently managed with an intervention. After adjustment, the likelihood of mortality was higher (OR [95% CI] = 2.16 [1.63-2.85]) and the likelihood of home discharge lower (OR [95% CI] = 0.29 [0.21-0.40]) among patients presenting with neurological deficit. Among those with neurological deficit, carotid intervention was positively associated with home discharge (OR [95% CI] = 2.96 [1.21-7.23]), but not with in-hospital mortality (OR [95% CI] = 0.87 [0.36-2.10]). Results were similar in the subgroup of patients with isolated BCI (2,971/5,788).Conclusions: Intervention in BCI patients presenting with neurological deficit may contribute to a greater likelihood of home discharge but not reduced in-hospital mortality. [ABSTRACT FROM AUTHOR]

Paradoxical intravascular bullet embolism involving the aortic arch (AA) is a rare and highly lethal condition. We describe an unusual case of a civilian gunshot injury to the neck. A bullet entered in the neck, injured the internal jugular vein (IJV), and then continued into the lumen of the common carotid artery (CCA). The bullet traveled under its own momentum and against the flow of blood, along the carotid and brachiocephalic vessels, finally lodging in the wall of the lesser curvature of the AA. The injury tract resulted in an arterial-venous fistula between IJV and CCA and a pseudoaneurysm of the AA. Open surgical repair of the neck and AA was complicated by secondary distal embolization of the bullet, requiring an embolectomy. [ABSTRACT FROM AUTHOR]

Purpose: Atherosclerosis and its related clinical complications are the leading cause of death. MicroRNA (miR)-92a in the inflammatory endothelial dysfunction leads to atherosclerosis. Krüppel-like factor 2 (KLF2) is required for vascular integrity and endothelial function maintenance. Flavonoids possess many biological properties. This study investigated the vascular protective effects of chrysin in balloon-injured carotid arteries. Materials and methods: Exosomes were extracted from human coronary artery endothelial cell (HCAEC) culture media. Herb flavonoids and chrysin were the treatments in these atheroprotective models. Western blotting and real-time PCRs were performed. In situ hybridization, immunohistochemistry, and immunofluorescence analyses were employed. Results: MiR-92a increased after balloon injury and was present in HCAEC culture media. Chrysin was treated, and significantly attenuated the miR-92a levels after balloon injury, and similar results were obtained in HCAEC cultures in vitro. Balloon injury-induced miR-92a expression, and attenuated KLF2 expression. Chrysin increased the KLF2 but reduced exosomal miR-92a secretion. The addition of chrysin and antagomir-92a, neointimal formation was reduced by 44.8 and 49.0% compared with balloon injury after 14 days, respectively. Conclusion: Chrysin upregulated KLF2 expression in atheroprotection and attenuated endothelial cell-derived miR-92a-containing exosomes. The suppressive effect of miR-92a suggests that chrysin plays an atheroprotective role. Proposed pathway for human coronary artery endothelial cell (HCAEC)-derived exosomes induced by chrysin to suppress microRNA (miR)-92a expression and counteract the inhibitory effect of miR-92a on KLF2 expression in HCAECs. This provides an outline of the critical role of the herbal flavonoid chrysin, which may serve as a valuable therapeutic supplement for atheroprotection. [ABSTRACT FROM AUTHOR]

This case study examines the management of a trauma patient brought emergently to the operating room following a motor vehicle collision with concomitant oropharyngeal and carotid artery injuries caused by tree branches. The patient stated that he had used cannabis and synthetic cannabinoids a short time before the accident, and his behavior was dangerously erratic at the scene as well as upon arrival to the emergency room. Understanding the pharmacologic and physiologic effects of these illicit substances is key to managing any patient undergoing anesthesia, particularly when requiring emergent vascular repair. [ABSTRACT FROM AUTHOR]

Patient: Male, 16-year-old Final Diagnosis: The bilateral maxillary pseudoaneurysms Symptoms: Pain • paresis • swelling Medication: -- Clinical Procedure: Embolization Specialty: Dentistry • otolaryngology Objective: Rare disease Background: Pseudoaneurysms of the head and neck region are relatively rare and consequently there are few reports in the literature. The main causes of pseudoaneurysms in the head and neck area are associated with blunt or penetrating injuries in this area or are iatrogenic, originating during surgical procedures. Case Report: The authors illustrate a case of a 16-year-old boy who had an accident on a scooter. A maxillary artery hemorrhage occurred after multiple craniofacial trauma including bilateral fracture of the condylar processes and treatment with intravascular embolization. Due to the anatomical location of the injury and deep location of the maxillary artery, it was impossible to control the bleeding by direct pressure; the only option was vessel embolization using interventional radiology or surgical intervention. The authors describe symptoms of pseudoaneurysm: pain in the area of the temporomandibular joint on the left side, persistent bilateral swelling of the cheeks and parotideomasseteric region with a greater asymmetry on the left side, as well as peripheral paresis of the facial nerve on the left side. The diagnosis was based on magnetic resonance imaging, ultrasound, and angio-CT. A reduction in the clotted pseudoaneurysm size on the left side was confirmed after 6 and 10 months through monitoring ultrasound examination of the neck vessels. Conclusions: No similar case of a patient has been reported in the available literature. The development of bilateral pseudoaneurysms after injury is very rare. However, doctors should be alert to this possibility in the case of massive post-traumatic or postoperative bleeding. [ABSTRACT FROM AUTHOR]

Balloon angioplasty-induced neointimal hyperplasia remains a clinical problem that must be resolved. The bioactivities of the Crossostephium chinense extract (CCE) have demonstrated potential in preventing the progression of restenosis. The present study evaluated whether CCE can suppress balloon angioplasty-induced neointima formation and elucidated its possible pharmacological mechanisms. A rat model of carotid arterial balloon angioplasty was established to evaluate the inhibitory effect of CCEs on neointimal hyperplasia. Two cell lines, A10 vascular smooth muscle cells (VSMCs) and RAW264.7 macrophages, were used to investigate the potential regulatory activities and pharmacological mechanisms of CCEs in cell proliferation and migration and in inflammation. Our in vitro results indicated that CCE3, the ethanolic extract of C. chinense, exerted the strongest growth inhibitory and antimigratory effects on VSMCs. CCE3 blocked the activation of focal adhesion kinase, platelet-derived growth factor receptor-β (PDGFRB), and its downstream molecules (AKT and mTOR) and reduced the expression of matrix metalloproteinase-2. In addition, our findings revealed that CCE3 significantly increased the expression of miRNA-132, an inhibitory regulator of inflammation and restenosis, and suppressed the expression of inflammation-related molecules (inducible nitric oxide synthase, cyclooxygenase-2, interleukin- (IL-) 1β, and IL-6). Our in vivo study results indicated that balloon injury-induced neointimal hyperplasia was inhibited by CCE3. CCE3 could reduce neointima formation in balloon-injured arteries, and this effect may be partially attributed to the CCE3-induced suppression of PDGFRB-mediated downstream pathways and inflammation-related molecules. [ABSTRACT FROM AUTHOR]

Craniopharyngiomas are benign tumors of the sellar and parasellar region for which surgical resection remains the treatment of choice. There are many publications on the most frequent postoperative complications, but few reports on subclinical lesions affecting the arteries of the circle of Willis, despite their high morbidity and mortality rate. Trauma-induced aneurysms are infrequent, representing less than 1% of intracranial aneurysms. Iatrogenic intracranial pseudoaneurysms are a subtype of surgically induced aneurysms developed as a result of direct injury to the arterial wall or after dissection of tumors adherent to the vessel adventitia. The natural history of these lesions is not well known because their incidence is extremely low. We report two cases of postoperative aneurysms of the internal carotid artery after craniopharyngioma resection and a brief review on the management of such lesions. [ABSTRACT FROM AUTHOR]

Background: Internal carotid artery (ICA) injuries represent a rare, potentially fatal complication of endoscopic endonasal skull base surgery (EESBS). The use of adenosine to induce transient hypotension and facilitate management of high-flow, high-pressure arterial lesions has been well-documented in neuro-endovascular literature. A similar setting in which adenosine-induced hypotension may prove beneficial is during the management of major vascular injury encountered during EESBS. Methods: A case of ICA injury and subsequent repair during EESBS is presented. Results: A 74-year-old female underwent endoscopic transsphenoidal resection for a recurrent pituitary adenoma. During suprasellar resection, the right cavernous ICA was inadvertently injured resulting in brisk bleeding. Immediate vascular tamponade was applied, and a crushed muscle graft was obtained. Two intravenous doses of adenosine were administered in quick succession to produce transient hypotension and facilitate repair of the injury with the graft. Neurovascular imaging revealed a small pseudoaneurysm which remained stable throughout the postoperative course. The patient underwent definitive stent embolization of the pseudoaneurysm 1 month following discharge. Conclusion: Prompt repair of ICA injury during EESBS is crucial, but often limited by poor visualization. Adenosine-induced hypotension has demonstrated great efficacy as an adjuvant in neurovascular clipping of intracranial aneurysms and remains a valuable tool for the endoscopic skull-base surgeon as well. In cases with high risk for ICA injury, adenosine should be readily available. [ABSTRACT FROM AUTHOR]

Cervical carotid and vertebral artery traumatic injuries can have a devastating natural history. This article reviews the epidemiology, mechanisms of injury, clinical presentation, and classification systems pertinent to consideration of endovascular treatment. The growing role of modern endovascular techniques for the treatment of these diseases is presented to equip endovascular surgeons with a framework for critically assessing patients presenting with traumatic cervical cerebrovascular injury. [ABSTRACT FROM AUTHOR]

Background: Posttraumatic carotid artery dissection (PTCAD) is a common injury in motor vehicle accidents and other extension and rotation injuries, but rarely developed from being shaken vigorously. Case Description: A 7-day-old infant presented to our facility after being attacked by a large dog. Initial examination revealed multiple puncture wounds and lacerations with visible dura. Head CT demonstrated subarachnoid, intraparenchymal, and epidural hemorrhages as well as left hemispheric loss of gray-white differentiation. Thus, the patient presented similarly to shaken baby syndrome (SBS). The patient was taken emergently to the operating room for hematoma evacuation and dural repair. Postoperatively, worsened left hemispheric ischemia was noted and an MRA demonstrated a Grade IV left ICA dissection. No intervention, including anticoagulation, was sought as the stroke was determined to be complete with irreversible damage. Hospital course was complicated by worsening exam, seizures, and a retinal hemorrhage. At 2 years follow-up, the patient still has notable delays but is progressing slowly through milestones. Conclusion: Large animal attacks are a rare cause of PTCAD but may be due to the mechanism of shaking during the attack. We propose either CTA or MRA be considered as part of the initial workup in cases where an infant is attacked by a dog or other large animals, preventing delay of treatment. [ABSTRACT FROM AUTHOR]

Background: Penetrating Carotid artery injuries are rarely encountered even in busy in urban Trauma Centers. Repair is preferred over ligation for Internal (IC) and Common Carotid (CC) arteries. To date, the use of temporary shunts correlated to neurological outcomes has not been reported.Objectives Are To Specifically Address the Question: In patients with penetrating IC or CC injury requiring repair, does use of temporary shunts decrease mortality and/or improve neurologic outcomes? We hypothesized that the use of temporary shunts during revascularization might produce improvements in both areas.Methods: A literature search was performed through Medline Complete-PubMed, Cochrane, Ovid, and Embase for the period of 1900-2019. PRISMA guidelines were utilized. Thirty-two articles met inclusion criteria, ranging from 1960-2018. These were analyzed to determine whether surgical repair was performed with or without the use of temporary shunts. External Carotid artery injuries were excluded. Pre- and postoperative neurological outcomes and overall outcomes were analyzed. Non-parametric data were analyzed with Fisher's Exact or Chi-square tests as applicable. Statistical significance was set to a p-value < 0.05.Results: There were a total of 973 patients with penetrating IC and CC injuries; 136 (14%) patients underwent ligation and were excluded. Our study population consisted of 837 patients; 126 (15.1%) with shunts (WS), 711 (84.9%) without shunts (WOS). Mortality stratified to patients repaired WS versus WOS was 5.6% versus 11.1% (p=0.058). Neurological improvement was noted to be similar for patients undergoing repair WS - 14.2% versus WOS - 13.7% (p=0.8). Worsening neurological status for patients shunted WS - 3.4%, versus WOS - 9.0% (p=0.038). Data were analyzed for outcome variables including neurological deficits with or without mortality. Patients shunted had an improved and/or unchanged neurological outcome compared to patients not shunted during repair - 91.3% versus 80.9% (p=0.0047).Conclusions: Patients sustaining penetrating Internal and Common Carotid injuries repaired with temporary shunts have a slightly lower mortality rate and similar or unchanged neurological outcomes versus those repaired without shunts. Based on this evidence, we recommend thoughtful interoperative consideration for the use of temporary shunts for patients requiring complex repairs of these injuries. [ABSTRACT FROM AUTHOR]

Objective: To highlight the importance of imaging in reducing an accidental injury to the anomalous brachiocephalic trunk and its branches during tracheal surgery. Case report: This paper reports two cases of accidental injury to the great vessels in the neck during tracheal surgery. The first incident occurred during a repeat tracheostomy, when the right common carotid artery was injured. On reviewing the computed tomography images, the bifurcation of the brachiocephalic artery was seen to the left of the midline, and the right common carotid artery was adherent just below the tracheostomy site. The second incident happened during surgery for tracheal stenosis, when there was an inadvertent injury to the main brachiocephalic trunk, which was adherent to the trachea in the lower neck region. Conclusion: For airway surgeons, radiological assessment of vascular structures in relation to the trachea prior to surgery is as important as the endoluminal airway assessment for the best outcome. [ABSTRACT FROM AUTHOR]

Objective : Covered stenting is an optional strategy for traumatic carotid pseudoaneurysm, especially in malignant conditions of potential rupture, but the long-term outcomes are not clear. Our aim was to determine if covered stenting is an effective option for traumatic carotid pseudoaneurysm with promising long-term outcomes. Methods : Self-expanding Viabahn and balloon-expandable Willis covered stents were separately implanted for extra- and intracranial traumatic carotid pseudoaneurysm. The covered stent was placed across the distal and proximal pseudoaneurysm leakage under roadmap guidance. Procedural success was defined as technical success (complete exclusion of the pseudoaneurysm and patency of the parent artery) without a primary end point (any stroke or death within 30 days after the procedure). Longterm outcomes were evaluated as ischemic stroke in the territory of the qualifying artery by clinical follow-up through outpatient or telephone consultation and as the exclusion of the pseudoaneurysm and patency of the parent artery by imaging follow-up through angiography. Results : Five patients with traumatic carotid pseudoaneurysm who underwent covered stenting were enrolled. The procedural success rate was 100%. No ischemic stroke in the territory of the qualifying artery was recorded in any of the five patients during a mean clinical follow-up of 44±16 months. Complete exclusion of the pseudoaneurysm and patency of the parent artery were maintained in all five patients during a mean imaging follow-up of 39±16 months. Conclusion : Satisfactory procedural and long-term outcomes were obtained, suggesting that covered stenting is an effective option for traumatic carotid pseudoaneurysm. [ABSTRACT FROM AUTHOR]

Objective: Challenging differential diagnosis Background: The complications of fine-needle aspiration cytology (FNAC) are rare but can be challenging for performing physicians to diagnose and manage. This type of procedure is perceived as routine and devoid of substantial risks, but uncommon complications can occur and need to be addressed with careful workup. Case Report: A FNAC procedure for a young female patient with multiple thyroid nodules was requested by her general practitioner. After the FNAC thyroid procedure, a carotid wall hematoma was suspected and could not be excluded with ultrasound (US) alone. Thus, the patient underwent a computed tomography angiogram (CTA) that excluded blood extravasation from the carotid, confirming the suspicion of perivascular blood accumulation. As a precaution, the patient was hospitalized, with US follow-up; she was dismissed the day after her hospital admission with a diagnosis of a benign thyroid nodule in multinodular goiter according to SIAPEC-IAP classification. Conclusions: This case highlights how a routine-perceived procedure such as FNAC could present a challenge to the performing physicians, pathologist, and radiologist, raising the suspicion of a severe complication that needs to be addressed with a readily available emergency service that may be accessible only within a central hospital-level organization. This case reinforces the point that more careful adherence to clinic-radiological guidelines is needed to avoid potentially inappropriate and harmful procedures. A review of the literature concerning guidelines for FNAC procedure, diagnostic classifications, and reported complications is provided as part of this case report. [ABSTRACT FROM AUTHOR]

Carotid blowout syndrome (CBS) is a fatal complication of head and neck cancer. Endovascular treatment, particularly deconstructive embolization, is effective for CBS, but it might result in thromboembolic events. We report the case of a 57-year-old man with underlying recurrent head and neck cancer who had CBS. The patient received endovascular embolization of the right internal, external, and common carotid arteries. Right internal carotid artery to middle cerebral artery embolic occlusion was noted immediately after the procedure, and left-sided weakness and facial palsy were found. Ipsilateral suprabulbar cervical internal carotid artery puncture was performed under fluoroscopic guidance, and rescue suction thrombectomy was successful. The patient had no significant neurological sequela. Transcarotid intraarterial thrombectomy is a reasonable method for managing postembolization large vessel occlusion, even in the neck, after irradiation. [ABSTRACT FROM AUTHOR]

Background: Our previous studies observed that administration of exosomes from endothelial progenitor cells (EPC) facilitated vascular repair in the rat model of balloon injury. However, the molecular events underlying this process remain elusive. Here, we aim to interrogate the key miRNAs within EPC-derived exosomes (EPC-exosomes) responsible for the activation of endothelial cell (EC) repair. Methods: The efficacy of EPC-exosomes in re-endothelialization was examined by Evans Blue dye and histological examination in the rat model of balloon-induced carotid artery injury. The effects of EPC-exosomes on human vascular EC (HUVEC) were also studied by evaluating the effects on growth, migratory and tube formation. To dissect the underlying mechanism, RNA-sequencing assays were performed to determine miRNA abundance in exosomes and mRNA profiles in exosome-treated HUVECs. Meanwhile, in vitro loss of function assays identified an exo- somal miRNA and its target gene in EC, which engaged in EPC-exosomes-induced EC repair. Results: Administration of EPC-exosomes potentiated re-endothelialization in the early phase after endothelial damage in the rat carotid artery. The uptake of exogenous EPC-exosomes intensified HUVEC in proliferation rate, migration and tube-forming ability. Integrative analyses of miRNA-mRNA interactions revealed that miR-21-5p was highly enriched in EPC-exosomes and specifically suppressed the expression of an angiogen- esis inhibitor Thrombospondin-1 (THBS1) in the recipient EC. The following functional studies demonstrated a fundamental role of miR-21-5p in the pro-angiogenic activities of EPC-exosomes. Conclusions: The present work highlights a critical event for the regulation of EC behavior by EPC-exosomes, which EPC-exosomes may deliver miR-21-5p and inhibit THBS1 expression to promote EC repair. [ABSTRACT FROM AUTHOR]

Vascular smooth muscle cell (VSMC) proliferation and migration are crucial events in the pathological course of atherosclerosis and restenosis after percutaneous coronary intervention (PCI). Dioscin has been shown to exhibit powerful cardiovascular protective effects and potent therapeutic potential in cancer owing to the inhibition of cell proliferation and migration. However, its effects on arterial wall hypertrophy-related diseases caused by VSMC proliferation and migration remain unclear. In this study, we investigated the effects of dioscin on intimal hyperplasia after balloon injury in vivo , its effects on VSMC proliferation and migration in vitro , and the mechanisms underlying these effects. Results showed that dioscin treatment significantly inhibited VSMC proliferation and intimal thickening after balloon injury. In cultured VSMCs, treatment with dioscin significantly decreased fetal bovine serum or platelet-derived growth factor-induced cell proliferation and migration. Moreover, dioscin inhibited the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2) and expression of Forkhead box M1 (FoxM1) and its downstream target genes. FoxM1 knockdown with shRNA partially counteracted the inhibitory effects of dioscin on cell proliferation and migration. In conclusion, we demonstrated that dioscin attenuated neointima formation in response to balloon injury by suppressing VSMC proliferation and migration through MAPK-FoxM1 pathway. Our data suggested that dioscin might be a potential therapeutic agent for atherosclerosis and restenosis after PCI. [ABSTRACT FROM AUTHOR]

Abstract Vascular remodeling, resulting from proliferation and migration of vascular smooth muscle cells (VSMCs), is a major cause of atherosclerosis and restenosis. The lysophospholipid mediator sphingosine-1-phosphate (S1P) regulates proliferation and migration of VSMCs via S1P-specific G protein-coupled receptors, including S1P receptor 1 (S1PR1) to S1PR3. However, the role of S1PR1 in vascular remodeling is not well understood. Therefore, in this study, we aimed to investigate the effect of S1PR1 on neointimal hyperplasia in a carotid artery ligation mouse model using transgenic C57Bl/6 mice that overexpressed S1PR1 (Tg-S1PR1) under the control of α-smooth muscle actin promoter. We found that S1PR1 expression in carotid artery was upregulated after carotid artery ligation in non-transgenic (nTg) mice. Tg-S1PR1 mice showed enhanced ligation-induced neointimal hyperplasia with increased neointimal cell proliferation, compared with control nTg mice. VSMCs isolated from Tg-S1PR1 mice showed enhanced proliferation and migration in response to S1P stimulation. VSMCs from Tg-S1PR1 mice showed greater expression of interleukin-6 (IL-6) compared with nTg mouse-derived VSMCs, and administration of IL-6-neutralizing antibody into Tg-S1PR1 mice suppressed neointimal hyperplasia. These results suggest that S1P-S1PR1 signaling plays an important role in neointimal hyperplasia after vascular injury via IL-6 production. Highlights • Sphingosine-1-phosphate receptor 1 (S1PR1) expression in carotid artery was upregulated after carotid artery ligation. • Overexpression of S1PR1 (Tg-S1PR1) in vascular smooth muscle cells (VSMC) enhances ligation-induced neointimal hyperplasia. • VSMCs obtained from Tg-S1PR1 increases expression of interleukin-6 (IL-6). • Administration of IL-6 neutralizing antibody suppresses neointimal hyperplasia after ligation. [ABSTRACT FROM AUTHOR]

Abstract Background Exosomes released from endothelial progenitor cells (EPCs) play a protective role in various disease models. Both endothelial cell (EC) damage and smooth muscle cell (SMC) proliferation are involved in the pathological process of restenosis after angioplasty and stenting. Few studies have focused on the therapeutic role of exosomes in EC damage and SMC proliferation. In this study, we sought to investigate the effect of exosomes released by human fetal aorta-derived EPCs on the rat carotid artery balloon injury model in vivo. We also sought to determine the effect of exosomes on both ECs and SMCs in vitro. Methods Exosomes (Exo group) or saline (Con group) were injected in rat carotid balloon injury model animals. The rats were sacrificed after 2, 4, 14, and 28 d, and injured carotid specimens were collected for Evans blue staining, hematoxylin-eosin staining, and immunohistochemistry. Results When the Con group and the Exo group were compared, the reendothelialized areas were not significantly different after 2 or 4 d, as shown by Evans blue staining. The hematoxylin-eosin results showed that the intimal to medial area ratio was slightly but not significantly higher in the Exo group after 2 and 4 d. The immunohistochemistry results showed that the proliferation of SMCs was slightly higher in the Exo group after 2 and 4 d, but the difference was not significant. The reendothelialization area of the Con group was significantly smaller than that of the Exo group at day 14. Both the intimal to medial area ratio and SMC proliferation in the Exo group were significantly smaller than those of the Con group at 14 or 28 d. In the in vitro study, exosome treatment significantly enhanced the proliferation and migration of both ECs and SMCs. Conclusions Exosomes derived from EPCs could inhibit neointimal hyperplasia after carotid artery injury in rats. The protective effect of exosomes may manifest through the promotion of EC repair rather than direct suppression of proliferation and migration of smooth muscles cells. [ABSTRACT FROM AUTHOR]

Invasive pituitary adenomas can infiltrate the dura mater, sphenoid sinus, or cranial bone. Endoscopic transsphenoidal sinus surgery is considered the standard of care; however, several potential complications must be noted. These complications can include cerebrospinal fluid leaks, infection, bleeding, optic nerve damage, and endocrinological complications such as diabetes insipidus. We present a case of a 69-year-old female with multiple recurrent invasive pituitary adenomas who has previously undergone 5 transsphenoidal procedures. Intraoperatively, the patient suffered from a left-sided carotid artery injury that was repaired with a muscle graft. Management of carotid artery injury during transsphenoidal surgery is optimized in a step-by-step approach which includes early recognition of the injury, briefing the surgical team, immediate control using compression, use of additional tissue graft for wound repair, and postoperative care. Through the use of the approach mentioned above, we were able to control the complication successfully. [ABSTRACT FROM AUTHOR]

• We summarize Kato's paper (1941) on the pink teeth phenomenon in 203 rabbits. • Various findings on oral tissues after hanging or strangulation were obtained. • Pink teeth in fresh corpses may indicate asphyxia caused by cervical compression. • Enormous experimental data are expected to be used in other forensic studies. The effects on oral tissues of asphyxiation caused by cervical compression were investigated in 203 rabbits by Kiyotoshi Kato, who published four papers in classical Japanese in Kokubyo Gakkai Zasshi (now The Journal of the Stomatological Society, Japan) in 1941. The aim of this review is to summarize and disseminate the enormous amount of experimental data (reprint permission in English has been obtained from the journal). Based on the experimental models of hanging, strangulation with an external force equal to body weight, and strangulation with an external force equal to 1/10th body weight, the macroscopic and histological findings of the oral region immediately after death, including the respiratory condition until death and ocular conjunctival petechiae, were obtained and compared with 4 cases of human strangulation. Strangulation after each of four physical conditions (anesthesia, starvation, alcohol intake, and bleeding) was also investigated. Experiments were performed to investigate the effects of tracheal obstruction, cervical vein ligation, common carotid artery ligation, cervical nerve amputation, or combinations thereof. In the discussion focusing solely on tooth discoloration, it was suggested that the presence of pink teeth at a stage when putrefaction has little or no effect might be a finding indicative of death from asphyxiation caused by cervical compression. This review provides detailed data on the condition of oral tissues after asphyxiation caused by cervical compression and is expected to be used not only for elucidating the mechanism of the pink teeth phenomenon but also for conducting other forensic research. [ABSTRACT FROM AUTHOR]

The article presents a case of a 59-year-old man who has asymptomatic, left-sided oropharyngeal lesion six months after chemoradiotherapy for human papillomavirus-positive T2N2bM0 tonsillar cancer. Based on examination, he has a resectable recurrence without internal carotid artery (ICA) or retropharyngeal carotid abutment. He successfully underwent salvage transoral robotic surgery (TORS).

Introduction: Computed tomography angiography (CTA) is used to screen patients for cerebrovascular injury after blunt trauma, but risk factors are not clearly defined in children. This modality has inherent radiation exposure. We set out to better delineate the risk factors associated with blunt cervical vascular injury (BCVI) in children with attention to the predictive value of seatbelt sign of the neck. Methods: We collected demographic, clinical and radiographic data from the electronic medical record and a trauma registry for patients less than age 18 years who underwent CTA of the neck in their evaluation at a Level I trauma center from November 2002 to December 2014 (12 years). The primary outcome was BCVI. Results: We identified 11,446 pediatric blunt trauma patients of whom 375 (2.7%) underwent CTA imaging. Fifty-three patients (0.4%) were diagnosed with cerebrovascular injuries. The average age of patients was 12.6 years and included 66% males. Nearly half of the population was white (52%). Of those patients who received CTA, 53 (14%) were diagnosed with arterial injury of various grades (I-V). We created models to evaluate factors independently associated with BCVI. The independent predictors associated with BCVI were Injury Severity Score >/= 16 (odds ratio [OR] [2.35]; 95% confidence interval [CI] [1.11-4.99%]), infarct on head imaging (OR [3.85]; 95% CI [1.49-9.93%]), hanging mechanism (OR [8.71]; 95% CI [1.52-49.89%]), cervical spine fracture (OR [3.84]; 95% CI [1.94-7.61%]) and basilar skull fracture (OR [2.21]; 95% CI [1.13-4.36%]). The same independent predictors remained associated with BCVI when excluding hanging mechanism from the multivariate regression analysis. Seatbelt sign of the neck was not associated with BCVI (p=0.68). Conclusion: We have found independent predictors of BCVI in pediatric patients. These may help in identifying children that may benefit from screening with CTA of the neck. [ABSTRACT FROM AUTHOR]

Ginsenoside Re (GS-Re) is one of the main ingredients of ginseng, a widely known Chinese traditional medicine, and has a variety of beneficial effects, including vasorelaxation, antioxidative, anti-inflammatory, and anticancer properties. The aims of the present study were to observe the effect of GS-Re on balloon injury-induced neointimal hyperplasia in the arteries and to investigate the mechanisms underlying this effect. A rat vascular neointimal hyperplasia model was generated by rubbing the endothelium of the common carotid artery (CCA) with a balloon, and GS-Re (12.5, 25 or 50 mg/kg/d) were subsequently continuously administered to the rats by gavage for 14 days. After GS-Re treatment, the vessel lumen of injured vessels showed significant increases in the GS-Re 25.0 and 50.0 mg/kg/d (intermediate- and high-dose) groups according to H.E. staining. Additionally, a reduced percentage of proliferating cell nuclear antigen (PCNA)-positive cells and an increased number of SM α-actin-positive cells were detected, and the levels of NO, cyclic guanosine monophosphate (cGMP), and eNOS mRNA as well as the phos-eNOS ser1177 /eNOS protein ratio were obviously upregulated in the intermediate- and high-dose groups. Moreover, the promotive effects of GS-Re on NO and eNOS expression were blocked by L-NAME treatment to different degrees. These results suggested that GS-Re can suppress balloon injury-induced vascular neointimal hyperplasia by inhibiting VSMC proliferation, which is closely related to the activation of the eNOS/NO/cGMP pathway. [ABSTRACT FROM AUTHOR]

Objective: To share experience of presentation and management of carotid artery injuries in tertiary care Hospitals Rawalpindi, Lahore and Quetta. Study Design: Cross sectional descriptive study. Place and Duration of Study: Combined Military Hospital Rawalpindi Lahore and Quetta, from Jun 2005 to Jul 2014. Material and Methods: The data of demography, mode of presentation, associated injuries and surgical procedures performed in the patients with penetrating neck injuries were collected and analyzed descriptively. Results: All 32 patients were male. Age ranged from 18 to 52 years (mean: 30.7 ± 7.1 years). Time of presentation to vascular surgeon ranged from 1 to 52 hours (mean: 4.4 ± 2.3 hours). Sixteen cases (50%) resulted from shrapnel injuries. Thirteen patients (40.6%) had bullet injuries and in three (9.3%), stab wounds. In only 6 cases (18.7%) carotid injury was confirmed on angiography preoperatively. Common carotid artery (CCA) was the most frequently injured artery in 15 cases (46.8%). There were 6 cases (18.7%) of External carotid artery (ECA), 4 (12.5%) cases of internal carotid artery (ICA) and 1 case (3.1%) of injury to the carotid bifurcation. Two cases (6.2%) had both ICA and ECA injuries. Four patients (12.5%) had no carotid artery injury on surgical exploration. Conclusion: Surgical exploration of neck penetrating injuries on the basis of hard signs and platysmal penetration was found a safe procedure especially in patients who had history of hemodynamic instability. [ABSTRACT FROM AUTHOR]

Background: Asthma is associated with an increased cardiovascular disease (CVD) risk in adults, but the impact of asthma and atopic conditions on CVD risk in children is less well established. We hypothesized that children in the Childhood Origins of Asthma (COAST) Cohort with asthma and atopic conditions would have early carotid arterial injury. Methods: The COAST study is a longitudinal birth cohort of children at increased risk of developing asthma. Children underwent ultrasonography measuring far wall right carotid bifurcation (RCB) and common carotid artery (RCCA) intima-media thickness (IMT; a measure of arterial injury). Multivariable linear regression models adjusted for age, gender, race, blood pressure, and body-mass index were used to assess associations of asthma and markers of arterial injury. Results: The 89 participants were a mean (standard deviation) 15.3 (0.6) years old and 42% were female; 28 asthmatics had atopic disease, 34 asthmatics were without other atopic disease, and 15 non-asthmatics had atopic disease. This study population was compared to 12 controls (participants free of asthma or atopic disease). Compared to controls (589 μm), those with atopic disease (653 μm, p = 0.07), asthma (649 μm, p = 0.05), or both (677 μm, p = 0.005) had progressively higher RCB IMT values (ptrend = 0.011). In adjusted models, asthmatic and/or atopic participants had significantly higher RCB IMT than those without asthma or atopic disease (all p≤0.03). Similar relationships were found for RCCA IMT. Conclusion: Adolescents with asthma and other atopic diseases have an increased risk of subclinical arterial injury compared to children without asthma or other atopic disease. [ABSTRACT FROM AUTHOR]

Photodynamic therapy (PDT) has been used to inhibit intimal hyperplasia in injured arteries. Because of the limited tissue penetration of visible light, an endovascular light source with a guided wire is often required for effective treatment. Indocyanine green (ICG), a near-infrared (NIR) photosensitizer, has been used in PDT for cancers. An extracorporeal light source may be used for shallow tissue because of the better tissue penetration of NIR light. The aim of this study was to evaluate the effect of ICG-PDT using extracorporeal NIR light on the inhibition of intimal hyperplasia in balloon-injured carotid arteries. A balloon injury (BI) model was used to induce intimal hyperplasia of carotid artery. Sprague-Dawley rats were divided into control, BI, BI + 1 × PDT, and BI + 2 × PDT groups. The control group underwent a sham procedure. PDT was performed 7 days after BI. In the BI + 1 × PDT group, ICG was administered 1 h before light irradiation. External illumination with 780-nm light-emitting diode light at a fluence of 4 J/cm2 was applied. For the BI + 2 × PDT group, PDT was performed again at day 7, following the first PDT. Hematoxylin and eosin (H & E) staining was performed to assess vessel morphology. Arterial wall thickness was significantly larger in the BI group compared with the control group. ICG-PDT significantly reduced arterial wall thickness compared with the BI group. Repeated PDT further decreased arterial wall thickness to the level of the control group. These findings indicate a promising approach for the treatment of restenosis of carotid arteries. [ABSTRACT FROM AUTHOR]

Cardio-cerebrovascular disease is one of the three major causes of mortality in humans and constitutes a major socioeconomic burden. Carotid atherosclerosis (CAS) is a very common lesion of the arterial walls, which leads to narrowing of the arteries, in some cases occluding them entirely, increasing the risk of cardiovascular events. The aim of the present study was to evaluate a cynomolgus monkey model of carotid atherosclerosis (CAS) induced by puncturing and scratching combined with a high-fat diet. A total of 12 cynomolgus monkeys were randomly divided into four groups: A, puncturing and scratching carotid artery intimas + high-fat diet (n=3); B, puncturing and scratching carotid artery intimas + regular diet (n=3); C, high-fat diet only (n=3); and D, regular diet only (n=3). Blood was harvested at weeks 4, 6 and 8 and plasma lipid levels were assessed. At week 8, monkeys were sacrificed and carotid arteries were harvested for hematoxylin and eosin (H&E) staining to observe pathological changes. The results revealed that a high-fat diet led to increased plasma lipid levels and accelerated plaque formation. Carotid color Doppler ultrasonography was performed and, along with H&E staining, revealed plaque formation in group A. In summary, the results of the present study suggest that a cynomolgus monkey model of CAS model may be successfully constructed by puncturing and scratching of the carotid artery intimas in combination with a high-fat diet. [ABSTRACT FROM AUTHOR]

The article examines the Pennsylvania Supreme Court case Shinal v. Toms which shows the dangers of a narrow and rigid approach to consent. The case involves Dr. Steven Toms who performed a total resection of a recurrent craniopharyngioma on Megan Shinal, but he perforated her carotid artery. The majority decision in the case was based on Pennsylvania precedent holding that a hospital has no duty to obtain a patient's informed consent because it is the physician's duty to obtain consent.

Objectives This study aimed to review endoscopic skull base surgeon experience with internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) to provide an estimate of the incidence of ICA injury, the associated factors and identify the best training modalities for the management of this complication. Design Anonymous electronic survey of past participants at a well-established endoscopic skull base surgery course and a global online community of skull base surgeons. Main Outcome Measures Relative incidence of ICA injuries during EES, associated anatomic and intraoperative factors, and surgeon experience. Results At least 20% of surgeons in each surveyed population experienced a carotid artery injury. Reported carotid artery injuries were most common during tumor exposure and removal (48%). The parasellar carotid artery was the most commonly injured segment (39%). Carotid artery injuries were more common in high-volume surgeons, but only statistically significant in one of the two populations. Attendance at a skull base course or courses did not change the incidence of carotid artery injury in either surveyed population. In both surveys, respondents preferred live surgeries or active (not computer simulated) training models. Conclusions ICA injury is underreported and most common when manipulating the parasellar carotid artery for exposure and tumor dissection. Given the high morbidity and mortality associated with these injuries, vascular injurymanagement should be prioritized and taught in a graduated approach by modern endoscopic skull base courses. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective. Objective. The purpose of this project is to identify factors that predict vertebral artery injury (VAI) in an effort to assess risks and benefits of computed tomography angiography (CT-A) of the neck in the trauma setting. We seek to develop guidelines for practitioners to stratify patients at medium/high risk of VAI from those who are at low risk. Summary of Background Data. VAI and blunt carotid injury (BCI) together comprise blunt cerebrovascular injury (BCVI). More is known about risk factors for BCI than for VAI, but the neurovascular complications associated with VAI are similarly disastrous. With increasing frequency, trauma providers are using CT-A to screen for BCVI; this test carries risks that include radiation exposure and nephrotoxicity, in addition to higher cost of treatment and longer hospital stay. Methods. Trauma patients seen over 4 months at an urban, level 1 trauma were analyzed. BCVI screening was conducted in 144/1854 (7.77%) patients. Presence of VAI and several clinical characteristics were recorded. Univariate analysis and binomial logistic regression analysis were conducted at a 95% significance level. Results. VAI was diagnosed in 0.49% of the study population. Univariate analysis determined six factors associated with positive VAI screening. Regression analysis showed four factors that independently predicted VAI: female sex, decreased Glasgow Coma Scale, cervical spine (c-spine) fracture, and concurrent BCI. A positive c-spine physical examination trended toward predicting VAI without achieving significance. Conclusion. Several independent predictors of VAI were identified. This study highlights the importance of identifying patients at a higher risk for VAI and indicating CT-A of the neck versus those who are at low risk and can be evaluated without undergoing advanced imaging, as CT-A appears unnecessary for most trauma patients. [ABSTRACT FROM AUTHOR]

Background Nontraumatic carotid artery injury with active extravasation, or carotid blowout syndrome (CBS), is relatively rare and highly difficult to treat because it is difficult to approach the lesions owing to anatomic factors. It also involves quick progression and a risk of cerebral embolization caused by thrombi and carotid artery occlusion. Recently, covered stents were revealed to be effective for CBS. However, they have several disadvantages, such as their costs, rebleeding complications, or cerebral embolic risks. A firm selection method of CBS types that are appropriate for covered-stent therapy is expected. Case Description A 38-year-old man with esophageal cancer presented with massive hematemesis. Computed tomography revealed active extravasation from the left common carotid artery with medial projection. Initially, the open direct approach failed, which resulted in further bleeding and transient cardiopulmonary arrest. With tentative hemostasis using manual finger compression, emergency angiography was performed, and a covered stent, Fluency 8 mm × 60 mm, was placed at the rupture point. He was transferred to the rehabilitation hospital 36 days after admission with a modified Rankin score of 2 without major complications. Conclusion CBS cases having rupture points around the clavicle and having medial projection extravasation should be treated by covered stent placement under tentative hemostasis using manual finger pressure rather than conventional open surgical treatment. [ABSTRACT FROM AUTHOR]

Background Carotid injuries secondary to a penetrating mechanism of trauma can present immediately, weeks, or even years after the initial injury. Although uncommon, these injuries are associated with significant morbidity and mortality. We present two cases of delayed presentation of carotid injury after penetrating neck trauma, both of which were managed surgically. Case report A 57-year-old male presented with a symptomatic left facial artery pseudoaneurysm two weeks after sustaining a Zone III laceration at angle of mandible. He underwent successful left neck exploration and repair of pseudoaneurysm with complete resolution of his symptoms post-operatively. A 33-year-old female with a history of penetrating right neck trauma repaired primarily 10 years prior in Russia presented with new onset left upper extremity weakness and tingling. Outpatient diagnostic workup revealed a right common carotid aneurysm which was repaired with a polytetrafluoroethylene interposition graft. The patient was discharged without residual neurologic deficits. She represented several years later with neurologic symptoms and an occluded graft. She underwent successful ligation of her graft and was discharged with complete resolution of her symptoms. Conclusion Penetrating carotid injuries can manifest in an immediate or delayed fashion. Computerized tomographic angiography appears to be an appropriate diagnostic tool. Once diagnosed, either endovascular or surgical repair may be valid treatment options. [ABSTRACT FROM AUTHOR]

Background: The impact of carotid artery stent fractures on the incidence of adverse clinical events remains unclear. The objective of this study is to report the stent fracture rate and its association with in-stent restenosis and adverse outcomes in the ACT-1 trial (Carotid Angioplasty and Stenting Versus Endarterectomy in Asymptomatic Subjects Who Are at Standard Risk for Carotid Endarterectomy With Significant Extracranial Carotid Stenotic Disease).Methods: ACT-1 is a prospective multicenter trial of patients who have standard surgical risk with severe asymptomatic carotid artery stenosis randomly assigned to carotid artery stenting or carotid endarterectomy (Abbott Vascular). The primary end point was a composite of death, stroke, or myocardial infarction during the 30 days after the procedure or ipsilateral stroke during the 365 days after the procedure. After 771 patients were enrolled, successively randomly assigned patients were required to undergo annual radiographic (x-ray) analysis for stent fracture. Images were independently adjudicated by a core laboratory.Results: Of 1021 patients treated with carotid artery stenting during a mean follow-up of 3.1±1.6 years, 939 had at least 1 x-ray during the follow-up period. Stent fracture was reported in 51 (5.4%) patients. With a maximum follow-up period of 5 years, adverse clinical outcomes occurred in 39 patients with at least 1 x-ray during the follow-up. Of 826 (80.9%) subjects who underwent both duplex ultrasound and x-ray, 822 (99.5%) were interpretable. There was no association between stent fracture and the primary end point (P=0.86) or with restenosis (P=0.53).Conclusions: In this large, independently adjudicated, multicenter study, the stent fracture rate was low and not associated with major adverse clinical events or in-stent restenosis.Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00106938. [ABSTRACT FROM AUTHOR]