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Background: Carotid artery stenting (CAS) is associated with a higher risk of periprocedural stroke than carotid endarterectomy. For better patient selection, more accurate risk factors should be identified. The aim of this study was to determine whether expansive arterial remodeling can predict ischemic complications in patients undergoing CAS. Methods: This retrospective study included 82 patients with carotid stenosis treated by CAS. The plaque component was evaluated using MR plaque imaging before the procedure. Following the procedure, lesion assessment was performed using MRI diffusion-weighted imaging (DWI), and patients were classified as DWI positive or negative for comparison between groups. Results: Fifteen patients were classified as DWI positive and 67 patients as DWI negative. The mean expansive remodeling rate was 1.76 ± 0.21 in the DWI-positive group and 1.35 ± 0.18 in the DWI-negative group ( P < 0.001). Receiver-operating characteristic analysis revealed that the threshold for the expansive remodeling rate separating the two groups was 1.52 (area under the curve = 0.933). The positive predictive value of postoperative new DWI lesions in the high-intensity plaque associated with a high expansive remodeling rate was 64.3%, and the negative predictive value of the isointensity plaque associated with a low expansive remodeling rate was 97.8%. These values were higher than those of the plaque component alone (32.1% and 81.7%, respectively). Conclusions: This study revealed that expansive arterial remodeling is a strong risk predictor of ischemic complication in CAS. Expansive remodeling rate measurements are very simple and provide useful information for determining treatment strategies for patients with carotid stenosis. [ABSTRACT FROM AUTHOR]

Background: Blood pressure (BP) was reported to decrease significantly after carotid endarterectomy (CEA) or carotid stenting (CAS) up to the 1-year follow-up. We evaluated changes in BP for 3 years after treating hypertensive patients with symptomatic carotid artery stenosis by either CEA or CAS and determined predisposing factors for normotensive BP at the 3-year follow-up. Methods: A total of 123 hypertensive patients with at least 3 years of clinical and radiographic follow-up after treatment were included in this study and placed in the CEA ( n = 65) or CAS group ( n = 58). BP changes for 3 years, the number of patients with a normotensive BP (≤120/80 mmHg), and the percentage decrease in BP were evaluated and compared between groups. Results: Compared to pretreatment BP, the CEA group had significantly decreased BP at the 1- and 2-year follow-up ( p < 0.05), but not the 3-year follow-up. The CAS group had significantly decreased BP at the 1-, 2-, and 3-year follow-up ( p < 0.05). Stenosis location (body lesions over apical lesions; OR = 1.526, 95 % CI, 1.341 to 6.224; p = 0.034) was an independent predisposing factor for normotensive BP at the 3-year follow-up. Conclusions: For hypertensive patients with symptomatic carotid artery stenosis, BP was lowered at 3 years after both CEA and CAS compared to pretreatment BP. CAS might lower BP better over the long term than did CEA, and hypertensive patients with stenosis at body lesions might be normotensive at 3 years after CEA or CAS. [ABSTRACT FROM AUTHOR]

Background: We analysed the results of internal carotid artery (ICA) stenosis treatment at our institution over the last 10 years according to treatment modalities (carotid endarterectomy [CEA] vs carotid artery stenting [CAS]). Furthermore, we compared our results of treatment prior to the EVA-3S study being implemented into our practice (2003-2007) and after that (2008-2012). Method: During the years 2003-2012, a total of 1,471 procedures were performed for ICA stenosis. CEA was done in 815 cases and CAS in 656 cases. The primary outcome was disabling stroke (mRS > 2) or myocardial infarction (MI) within 30 days after treatment. Secondary outcomes were frequency of transient ischaemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living [ADL]) and any other significant complication. Comparisons of the results before and after 2008 were performed. Results: Major mortality and morbidity were divided according to treatment groups; reached 1.0 % in the CEA group and 3.0 % in the CAS group, p = 0.004. Minor stroke was recorded at 1.8 % and 2.7 % in the CEA and CAS, p = 0.245. TIAs in 1.0 % (CEA) and 4.7 % (CAS), p < 0.001. Any complication in 11.9 % (CEA) and 13.3 % (CAS), p = 0.401. In the overall results (i.e. CEA and CAS together), we found in 2008-2012 a decrease of incidence of TIAs (from 30/840 to 9/631, p = 0.011) and any complications (from 120/840 to 64/631, p = 0.017). Conclusions: CEA performed in a high-volume centre is a safe procedure in properly indicated patients. In all subgroup analyses, CEA fared better than or at least of equal benefit as CAS. Since 2008, the frequency of TIAs and other complications decreased significantly. This study supports an idea of CEA being the first choice of treatment and CAS being reserved for strictly selected cases, such as re-stenosis after a previous carotid procedure, carotid dissection, ICA stenosis after radiotherapy, previous major neck surgery, contralateral cranial nerve palsy or tandem stenosis. [ABSTRACT FROM AUTHOR]

Objective: Carotid artery stenting (CAS) is a well-accepted treatment for atherosclerotic stenosis of carotid arteries. Since the occurrence of distal embolization with CAS is still a major concern embolus protection devices (EPD) are usually employed during the procedure. We examined two types of embolus protection filters (Angioguard XP (AG); Filterwire EZ (FW)) and evaluated the function. Thus, the filter was examined postoperatively and the cause of intraoperative flow impairment was evaluated. Materials and methods: CAS was performed for 54 patients with carotid artery stenosis (55 lesions: 25 AG; 27 FW; 3 others). After completing CAS the filter membrane was stained with hematoxylin-eosin (HE) solution and removed from the filter strut. Once mounted on a glass slide the filter was evaluated under a microscope. The area occupied with debris was measured and the relationship to intraoperative flow impairment was evaluated. Furthermore, the relationship between perioperative ischemic complications and intraoperative flow impairment was statistically analyzed. Results: Microscopic observation of the slide revealed the pore density of the FW was 1.5 times higher than that of the AG and the filter area of the FW was 2.5 times wider than than the AG. HE staining facilitated characterization of the debris composition. The area occupied with debris was significantly more in the AG (0.241 ±0.13 cm) than in the FW (0.129 ±0.093 cm). Thus, fibrin was significantly more precipitated in the AG. Flow impairment occurred in 6 AG cases (24.0 %) and 4 FW cases (14.8 %). It was induced by filter obstruction in the AG and by vasospasms in the FW. Three cases treated with AG (12.0 %) were complicated with cerebral infarction and all of them were related to flow impairment. One FW case (3.7 %) was complicated with cerebral infarction in presence of preserved flow throughout the intervention. Conclusion: Filter function is different according to each design. The cause of flow impairment was attributable to filter obstruction in the AG group and to vasospasms in the FW group. Filter obstruction tends to result in cerebral infarction. [ABSTRACT FROM AUTHOR]

Background: Surgeons undertaking transsphenoidal surgery in patients with acromegaly confront multiple unique challenges secondary to the anatomic alterations caused by growth hormone-secreting tumors. The senior author has noted a fusiform dilatation of the cavernous carotid artery in many acromegalic patients. The authors aim to quantify this dilatation and correlate it with potential contributing factors. Methods: Clinical and radiographic data were retrospectively assessed in acromegalic patients undergoing transsphenoidal surgery from 2000 through 2011. Randomly selected patients with nonsecreting pituitary adenomas were used as the control cohort. Demographic information, comorbidities, and preoperative growth hormone and insulin-like growth factor-1 levels were recorded. Magnetic resonance (MR) imaging variables included tumor size, diameters of the petrous, cavernous, and supraclinoid segments of the carotid artery, and extent and location of cavernous sinus invasion. Independent correlations between acromegaly and each variable were assessed with multivariate regression analysis. Results: Forty randomly selected patients with growth hormone-secreting adenomas who underwent surgery and had MR imaging with thin coronal slices of the pituitary region were enlisted in our study cohort. The mean age was 45.7 years. Forty-two males (52.5 %) were included in the study. Mean carotid artery diameter measurements for acromegalic and control patients, respectively, were 4.2 vs. 3.8 mm (petrous carotid), 5.0 vs. 4.0 mm (cavernous carotid), and 3.3 vs. 2.9 mm (supraclinoid carotid). Multivariate analysis showed only age and cavernous carotid diameter were statistically significant independent variables ( p = 0.02, p < 0.001, respectively). Age, tumor size, growth-hormone or insulin-like growth factor-1 levels, and cavernous sinus invasion did not correlate with cavernous carotid artery diameter. Conclusions: In patients with acromegaly, there is a fusiform dilatation of the cavernous carotid artery that must be considered when planning transsphenoidal surgery. [ABSTRACT FROM AUTHOR]

The article presents a case study on the efficacy of emergent carotid artery stenting (CAS) for acute atherosclerotic occlusion of the cervical internal carotid artery (ICA) using a flow reversal system. It discusses the three cases of patients who were treated using the surgical procedure. Results reveal the efficacy and safety of the emergent CAS using a flow reversal technique which prevents embolic stroke during lesion crossing.

Background: Intraoperative fluorescence angiography with indocyanine green (ICG) as a tracer has recently been introduced as a novel technique for neurosurgery. We evaluated the feasibility and efficacy of near-infrared (NIR) indocyanine green (ICG) videoangiography for patients undergoing carotid endarterectomy (CEA). Methods: Sixty patients (7 females, 53 males; mean age, 71.8 years) undergoing CEA for severe stenosis of the internal carotid artery (ICA) were included. During CEA, microscope-integrated intraoperative NIR videoangiographic recording was performed before and after the excision of the plaque and closure of the ICA. Results: During the 60 CEA procedures, 60 consecutive ICG videoangiographic examinations were performed. All patients tolerated the intravenous injection of ICG well with no adverse effects. The videoangiographic study showed the blood stream of the ICA in all cases and the position of plaque in some cases. Conclusion: Microscope-based ICG videoangiography is simple, and provides reliable and rapid intraoperative assessment of CEA. [ABSTRACT FROM AUTHOR]

Constructive endovascular techniques remain the mainstay for the treatment of cavernous carotid aneurysms due to their efficacy. However, they do harbor risks of complications, such as thromboembolic events, arterial injuries, and vessel occlusions. A 58-year-old lady presented with delayed caroticocavernous fistula (CCF) 1 month after stent-assisted coil embolization of a cavernous carotid aneurysm (CCA). Following this, her caroticocavernous fistula resolved spontaneously with no further intervention. Our case demonstrates a unique presentation of a CCF as a delayed complication of stent-assisted coil embolization of CCA and the spontaneous resolution of the CCF. Symptomatic CCFs are commonly treated as an emergency in many institutions and the question arises as to whether we should adopt a conservative policy in the light of this case report. [ABSTRACT FROM AUTHOR]

A major stroke after carotid endareterectomy (CEA) is an event that should be managed according to a planned strategy. Literature data on this issue are not definitive. We reviewed our series in the attempt to define an algorithm of treatment if this complication occurs. A consecutive series of 413 CEAs in 390 patients was considered. All operations were performed under general anaesthesia and EEG monitoring. An indwelling shunt was inserted only according to EEG changes. Direct closure of the arteriotomy was performed in all cases. Intraoperative ultrasound was not routinely employed before 2004. Patients who suffered from the new onset of an ischaemic hemispheric deficit or the worsening of a pre-existing deficit within 72 h after surgery were included in the present study. Sixteen patients (3.9%) suffered from perioperative stroke. Seven patients presented neurological deficits that rapidly and spontaneously resolved. In nine cases (2.2%) a major stroke occurred. Acute occlusion of the internal carotid artery (ICA), with or without embolic blocking of the omolateral M1 segment, occurred in eight cases; in one case a patent ICA was associated with the occlusion of two frontal branches of the omolateral middle cerebral artery. Seven cases were reoperated on. The ICA was reopened in all these cases except one. Among these seven cases, three (42%) had a good outcome. A major stroke after CEA is caused, in most of cases, by the acute ICA occlusion with or without intracerebral embolic occlusion. Reopening of the occluded ICA gives good results when intracerebral vessels are patent and when the occluded ICA is satisfactorily reopened. An algorithm of planned reactions in case of perioperative stroke is finally proposed. [ABSTRACT FROM AUTHOR]

This article describes a new surgical technique consisting of the combined use of a fascial radial fore arm free flap (RFFF) as vascular graft for extra-intracranial bypass and as dura mater plasty for reconstruction of the antero-lateral skull base. This new technique is illustrated by a case of a complex intracranial meningioma with extracranial extension necessitating resection of internal carotid artery. The technical issues of antero-lateral skull base reconstruction and extra-intracranial bypass are discussed and the literature is reviewed. [ABSTRACT FROM AUTHOR]

Carotid and vertebral artery dissections from blunt cervical trauma are uncommon injuries that in recent years are becoming increasingly recognized as a result of angiographic screening protocols in trauma patients. Traumatic carotid cavernous fistulas are even less common events, but represent the most common intracranial vascular anomaly after head injury. The present report details the unique case of a woman with no history of collagen vascular disease who developed dissections of both carotid and both vertebral arteries, as well as a direct carotid cavernous fistula, after a motor vehicle collision. Her vascular injuries resolved without need for surgical or endovascular intervention. [ABSTRACT FROM AUTHOR]

Background.The generally accepted indications for carotid endarterectomy are the clinical picture and degree of per cent stenosis of the carotid artery. Despite the fact that stenosis measurement is defined, the methods vary considerably. The correlation of particular methods, especially angiography and duplex sonography, has been repeatedly demonstrated. However, the correlation between any technique and true anatomical stenosis, as evaluated on the surgical specimen, has been only anecdotally reported.Method.During carotid endarterectomy, the atherosclerotic plaque was removed in one piece and subsequently stored and histologically processed. The histological slides were evaluated under an optical microscope, scanned and the slide with maximum stenosis was determined using a planimetric program. Both the minimal lumen area and the area of the whole plaque were measured. The stenosis was calculated using the planimetric method. On the maximum stenosis slice, the minimal diameter and the diameter of the whole plaque were also measured. Angiographic images were scanned and the per cent stenoses were remeasured, according to the NASCET and ECST criteria. In total, of 147 cases, all above-mentioned parameters were obtained. Student’s t tests for paired samples were used to evaluate the results.Findings.The t-tests indicated significant differences between the per cent stenosis as measured on the anatomical specimen and on the angiogram (p<0.05). The results indicate that the angiographic measurement underestimates the degree of in-situ anatomical stenosis. The underestimation was more marked the less the degree of stenosis.Conclusions.Our study finds that per cent stenosis measurement obtained by angiography with NASCET or ECST methods does not reliably reflect the anatomical degree of per cent stenosis, which makes questionable the rigorous following of percentage stenosis using angiography as the sole indicator for carotid endarterectomy in all cases. [ABSTRACT FROM AUTHOR]

Background.Surgical treatment of patients with suspected internal carotid artery (ICA) pseudo-occlusion and reduced cerebrovascular reactivity (CVR) is still uncertain regarding the diagnostic procedures, the risks and the optimal timing as well as performance of revascularization.Method. From 1983-2001, 781 patients with symptomatic ICA stenosis were treated surgically. In 53 patients, a final diagnosis of extracranial ICA pseudo-occlusion was established by repeating Digital Subtraction Angiography (DSA). Angiographical findings were anterograde “string-like” filling of ICA beyond the carotid bifurcation or retrograde filling of the proximal, so called “occluded” extracranial ICA, extending up to the skull base. The CVR was reduced. All patients underwent direct surgery of extracranial carotid artery. Diagnostic parameters, peri-operative risks and postoperative course of these patients were evaluated.Findings. In 40 patients (75.5%) a successful revascularization of ICA was possible. ICA pseudo-occlusion was in all cases of atheromatous origin, moreover in 8 patients combined with a floating thrombus, distal to the stenosis. Thrombectomy was done by means of Fogarty catheter. In 13 patients (24.5%), a surgical re-opening of the ICA lumen was not possible. Five of these patients showed in DSA an anterograde “string sign”, eight presented retrograde filling of ICA reaching the skull base. Peri-operative mortality was 1.9%, peri-operative morbidity was 7.5%. After a 4 years (mean) follow-up, 95% of the reopened ICA remained patent.Conclusion.In patients with explicit carotid artery occlusion signs, careful selective DSA should be compulsory with a late series to detect ICA pseudo-occlusion. There is a chance for extracranial reopening ICA, even with compromised CVR, if anterograde “string like” or retrograde filling of proximal so called “occluded” ICA as far as the skull base is angiographically identified. [ABSTRACT FROM AUTHOR]

Summary. Background: To evaluate the effect of carotid endarterectomy on ophthalmic artery flow direction and peak systolic flow velocity, the authors examined the ophthalmic artery on 32 patients who had undergone carotid endarterectomy. Methods: The 32 patients had more than 70% stenosis of the internal carotid artery at its origin on angiography. The ophthalmic artery ipsilateral to the carotid endarterectomy was evaluated by the ophthalmic artery color Doppler flow imaging before surgery and then at one week, one month, and three months after surgery. Findings: (1) Before carotid endarterectomy: eight patients showed reversed ophthalmic artery direction. In the other 24 patients with antegrade ophthalmic artery flow direction, the average peak systolic flow velocity was 0.17±0.10 m/sec. (2) At one week after carotid endarterectomy: The reversed ophthalmic artery flow direction was resolved in each patient. The average peak systolic flow velocity in the patients with preoperative antegrade flow rose significantly to 0.28±0.10 m/sec (p<0.05). (3) At one month and three months after carotid endarterectomy: All patients showed the antegrade ophthalmic artery flow direction. The average peak systolic flow velocities showed no significant change compared to the value at one week after carotid endarterectomy. (4) During the followed up period, there was no patient showing worsening or recurrence of clinical symptoms including the visual symptoms. Interpretation: Carotid endarterectomy brought about the correction of the reversed flow and an increase in the peak systolic flow velocity of the ipsilateral ophthalmic artery immediately after surgery. [ABSTRACT FROM AUTHOR]

Summary. Background: Percutaneous transluminal angioplasty (PTA) and stenting seems to be, at present, the treatment of choice for early restenosis after endarterectomy and for atherosclerotic stenoses of supra-aortic trunks near or at the ostium. In contrast, the role of PTA and stenting for treatment of symptomatic and asymptomatic atherosclerotic stenosis of carotid bifurcation is still debated. Methods: The present study comprises 27 consecutive cases of atherosclerotic lesions of the carotid bifurcation treated with PTA and stenting. All patients were symptomatic, except for 2 suffering from asymptomatic stenosis with contralateral carotid occlusion. There were 23 stenoses occluding 70% or more of the lumen according to the NASCET criteria and 4 mild stenoses (50–60% of the lumen) with large type C ulcers. Criteria for exclusion from surgery in these cases were aged >79 years, previous neck surgery for laryngeal cancer, carotid bifurcation at C2, association with intracranial aneurysms, occlusion of the contralateral carotid artery, and heart, lung and kidney diseases. All procedures were performed under local anaesthesia associated with mild sedation in a few cases. In all cases, self-expandable stents (Wallstent) were used. Follow-up ranged from 6 to 37 months. Findings: Transient neurological deficit occurred in 3 cases (11%). One case (3.7%) experienced a minor stroke at three months. Asymptomatic tight restenosis due to intimal hyperplasia occurred in one case (3.7%). In 8 cases (40%) of complex stenosis involving common and internal carotid arteries there was some loss of contact of the stent with the wall of the common carotid artery in the late follow-up. One case (3.7%) experienced severe and prolonged hypotension and bradycardia during the release of the stent. Interpretation: From literature data and our results it emerges that periprocedural catastrophic embolism is unlikely to occur. The best results are undoubtedly obtained when treating stenosis limited to the internal carotid artery. Nevertheless, the ideal stent to treat vessels of different calibre, as occurs at the carotid bifurcation, is not yet available. The problem of periprocedural cerebral protection has not been resolved. Reported series are heterogeneous and retrospective, and an adequate follow-up of cases is still lacking. [ABSTRACT FROM AUTHOR]

Summary Background. Carotid endarterectomy has been reported to increase the time free from cerebral ischemic events in both symptomatic and asymptomatic patients with a high grade of stenosis of the internal carotid artery. In cases in whom the compensatory circulation during the carotid clamp time is not sufficient, the use of intraluminal shunts has been proposed. However, the use of intraluminal shunts present several problems, such as the tecnical difficulties in positioning the shunt, the variability of time requested for the placement, the inconstancy of the blood flow during surgery, and the need to clamp off the carotid to introduce and remove the shunt. For these reasons, most operators prefer not to employ intraluminal shunts, while others do use them only in selected cases. The purpose of this work is to present, for the first time, a new type of temporary extraluminal shunt, connecting the femoral to the internal carotid artery with the interposition of a roller pump to regulate the blood flow. This method allows one to perform carotid endarterectomy without interrupting the blood flow to the brain. Methods. 407 consecutive patients, who underwent carotid endarterectomy between August 1992 and April 2000, were considered. 35 patients presented an absolutely insufficient collateral circulation, demonstrated by important modifications of the electroencephalographic monitoring during the carotid clamp time. In these patients the endorterectomy was performed using a new femoral-carotid extraluminal shunt. Findings. In all the cases in whom the femoral-carotid extraluminal shunt was positioned, the normalisation of electroencephalographic monitoring was achieved by regulating the blood flow with the interposed roller pump. The use and the placement of the shunt was simple and easy. None of the patients showed postoperative complications, except for one who had a stroke two days after surgery. Interpretation. The results obtained, although to be confirmed by further studies, seem to demonstrate the effectiveness of our femoral-carotid extraluminal shunt, which was simple to use and safe. [ABSTRACT FROM AUTHOR]

The authors describe a 25-year old patient with blunt trauma-induced bilateral, distal segment internal carotid artery (ICA) lacerations, resulting in a left-sided direct carotid-cavernous sinus fistula (CCF) and presenting with massive oronasal bleeding. The combination of severe oronasal bleeding, with air in the carotid canal should alarm the treating physician to the presence of a distal internal carotid artery laceration. [ABSTRACT FROM AUTHOR]

Presents a case report of common carotid-internal carotid interposition vein graft bypass for carotid restenosis after repeated percutaneous transluminal angioplasty (PTA) in a 57-year-old male with diabetes. Examination of histological change of the restenosed carotid artery after repeated PTA; Demonstration of cerebral infarction in magnetic resonance imaging; Role of carotid artery stenosis in the development of transient ischemic attacks and stroke.

Describes a case of pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery. Advantages of endovascular techniques over direct surgical approach; Suitability for the management of pituitary adenomas.

Discusses the duplication of the middle cerebral artery associated with an unruptured aneurysm. Defect of the vessel arising from the internal carotid artery; Avoidance of damage to the artery during surgery to maintain normal cerebral blood supply; Requirement for radical treatment in case of risk of rupture of the aneurysm.