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Background and Purpose: Despite the findings reported in the COSS (Carotid Occlusion Surgery Study), patients with atherosclerotic cerebrovascular disease continue to be referred for superficial temporal artery to middle cerebral artery bypass surgery. Here, we determined how today’s patients differ from the population reported in COSS. Methods: We retrospectively analyzed all patients that were referred to our Department for superficial temporal artery to middle cerebral artery bypass surgery of atherosclerotic cerebrovascular disease following the publication of COSS. Results: Between 2012 and 2019, 179 patients were referred for 186 bypass surgeries. Ninety-one (51%) patients suffered atherosclerotic, unilateral internal carotid occlusion and 88 (49%) atherosclerotic multivessel disease. All patients had received intensive medical management. A single transitory ischemic attack or ischemic stroke within the last 120 days according to the inclusion criteria of COSS occurred in only 36 out of 179 (20%) patients, whereas 27 out of 179 (15%) suffered >1 transitory ischemic attack within 120 days, 109 out of 179 (61%) had recurrent minor ischemic stroke, and 7 out of 179 (4%) were hemodynamically unstable and required blood pressure maintenance. The distribution of symptoms did not differ between atherosclerotic unilateral internal carotid artery occlusion and atherosclerotic multivessel disease ( P =0.376) but hemodynamic impairment was significantly greater in atherosclerotic multivessel disease ( P Conclusions: Patients referred for flow augmentation surgery today appear to suffer more severe symptoms and vessel occlusion patterns than patients reported in COSS. A new, carefully designed randomized controlled trial appears warranted, considering the still poor prognosis of severe atherosclerotic cerebrovascular disease.

The presence of contralateral carotid occlusion (CCO) has been controversial throughout the history of carotid intervention. Some studies cite a higher stroke risk in the setting of CCO, whereas other studies document no difference in stroke risk. We investigated the risk of stroke after intervention in the setting of CCO in a large, national, validated dataset.Data were obtained from the 2011-2014 American College of Surgeons National Surgical Quality Initiative Project files using targeted carotid endarterectomy (CEA), carotid angioplasty, and carotid artery stenting (CAS) data. Patient and procedural characteristics, and 30-day postoperative outcomes were compared using Pearson χDuring the study period, 11,948 CEA and 422 CAS procedures were available for study, with significantly fewer CEA (4.73% of all CEA) than CAS (9.95%; P .0001) occurring in the setting of CCO. CAS was associated with more severe degree of stenosis than CEA (P = .045). Multivariable logistic regression showed that stroke after procedures was higher in patients with CCO than without CCO (odds ratio, 1.73; 95% confidence interval, 1.08-2.76; P = .02), but specific procedure (CEA vs CAS) was not associated with stroke while controlling for confounders. However, when evaluating our secondary composite outcome, CCO was not associated with the outcome while controlling for confounders.There is currently a bias that CCO confers a higher risk on patients undergoing carotid procedures and this notion is manifest in the proportion of CEA and CAS procedures done in the setting of CCO. Our study observes that CCO provides only a minor influence on periprocedural stroke risk and that other factors are more closely tied to outcomes of CEA and CAS.

Objective To describe the first cases of carotid occlusions identified by the Portuguese neurologist Egas Moniz while performing the cerebral angiography he invented. Methods We reviewed the publications of Egas Moniz on the subject of cerebral angiography and ischemic stroke. Results We identified the first description of carotid occlusion a situation unknown until then. Also, some of the carotid occlusions he described were suggestive of dissection an unknown situation. Nevertheless, he admitted the role of trauma in such cases by lesioning the intimal layer and he also described the characteristic post-bulbar ”bezel-like“ image of dissection. Conclusions In 1936 Egas Moniz described, for the first time, one case of carotid occlusion a situation unknown until then. He also described some of the characteristic aspects of carotid dissections. Carotid occlusions were only thoroughly described in English literature more than a decade later with the well-known work of Miller Fisher, in 1951.

BackgroundThe optimal treatment and prognosis for stroke patients with tandem cervical carotid occlusion are unclear. We analyzed outcomes and treatment strategies of tandem occlusion patients in the ESCAPE-NA1 trial.MethodsESCAPE-NA1 was a multicenter international randomized trial of nerinetide versus placebo in 1105 patients with acute ischemic stroke who underwent endovascular treatment. We defined tandem occlusions as complete occlusion of the cervical internal carotid artery (ICA) on catheter angiography, in addition to a proximal ipsilateral intracranial large vessel occlusion. Baseline characteristics and outcome parameters were compared between patients with tandem occlusions versus those without, and between patients with tandem occlusion who underwent ICA stenting versus those who did not. The influence of tandem occlusions on functional outcome was analyzed using multivariable regression modeling.ResultsAmong 115/1105 patients (10.4%) with tandem occlusions, 62 (53.9%) received stenting for the cervical ICA occlusion. Of these, 46 (74.2%) were stented after and 16 (25.8%) before the intracranial thrombectomy. A modified Rankin Score (mRS) of 0–2 at 90 days was achieved in 82/115 patients (71.3%) with tandem occlusions compared with 579/981 (59.5%) patients without tandem occlusions. Tandem occlusion did not impact functional outcome in the adjusted analysis (OR 1.5, 95% CI 0.95 to 2.4). Among the subgroup of patients with tandem occlusion, cervical carotid stenting was not associated with different outcomes compared with no stenting (mRS 0–2: 75.8% vs 66.0%, adjusted OR 2.0, 95% CI 0.8 to 5.1).ConclusionsTandem cervical carotid occlusion in patients with acute large vessel stroke did not lower the odds of good functional outcome in our study. Functional outcomes were similar irrespective of the management of the cervical ICA occlusion (stenting vs not stenting).

This study sought to analyze the incidence of contralateral microembolic infarctions (MIs) on diffusion-weighted imaging (DWI) following protected carotid artery stenting (CAS) and compared the difference of risk factors between ipsilateral and contralateral lesions. From April 2010 to March 2017, 147 CASs in 140 patients were performed. All the patients underwent DWI within 1 week before and 24 hrs after the procedures. CAS was successfully completed in 145 (98.6%) of the 147 procedures. Forty-nine (33.8%) patients with new MIs revealed on postprocedural DWI were enrolled. They were divided into ipsilateral and contralateral groups based on the side of the CAS and MIs. The ipsilateral group indicates patients with MIs exclusively on the side of CAS. The contralateral group includes patients with MIs on the opposite side of the CAS or both sides. Patients with MIs at vertebrobasilar territory were excluded. Patient characteristics, morphology of the carotid artery and aortic arch, and procedural data were retrospectively assessed and compared between the two groups. Twenty-two (15.2%) and 14 (9.7%) patients were assigned to the ipsilateral and contralateral groups, respectively. Advanced age, left-sided stenosis, severe aortic arch calcification (AAC) on chest X-ray and contralateral carotid occlusion significantly increased the occurrence of contralateral MIs. On multivariable logistic regression analysis, severe AAC was statistically more frequent in the contralateral group. In the present study, the incidences of contralateral MIs after CAS is relatively not low. Advanced aortic atherosclerosis is statistically predictive for contralateral MIs. AAC on chest X-ray is a useful finding for estimating aortic atherosclerosis in candidates for CAS.

Background: Craniotomy and surgical clipping is the standard modality of treatment in patients of cerebral aneurysms. However, the surgical clipping of aneurysm may pose serious difficulties in the case of a bilateral carotid artery occlusion. The endovascular treatment has shown promising results in this disease. Methods: A retrospective study of all patients of posterior circulation aneurysms in the background of carotid occlusive disease at our department was performed. The aim of this study was to describe the clinical, radiological characteristics, and the treatment of this rare entity. Results: Four patients were treated from January 2009 to October 2015. The mean age of our patients was 34 years with ages that ranged from 17 to 45 without any gender predominance. The mean period between onset of symptoms and diagnosis was 6 weeks. Angiographic localization of the disease was observed in all patients. All patients were treated by endovascular techniques. The postoperative course has been satisfactory with a complete neurological recovery in all patients. Conclusions: Rupture of posterior circulation aneurysms in the setting of bilateral internal carotid artery occlusion is extremely rare. Treatment is exclusively endovascular intervention. The functional outcome of ruptured posterior circulation aneurysms in setting of bilateral carotid occlusive disease is particularly favorable with good neurological recovery.

Acute carotid occlusion is a rare but important complication that can occur after a carotid endoacrterectomy (CEA) procedure. Standard intervention after a re-occlusion is usually surgical. We reported a case of a 78-year old patient with acute internal carotid occlusion after a CEA and sociated intracranial embolization to the posterior communicating artery. Surgical approach was therefore excluded because of the above-mentioned cerebral perfusion deficit. Endovascular treatment allowed to restore the proper ICA vessel caliber and the cerebral blood flow through a thromboaspiration catheter. Moreover, the procedure was performed using devices usually intended for other body district. Endovascular treatment could represent an alternative treatment in post-CEA acute occlusions, especially in patient with associated intracranial perfusion deficit, allowing the operator to resolve both issues and reduce the overall ischemic time.

This study aimed to report the clinical features and early and long-term outcomes of patients treated with carotid endarterectomy (CEA) combined with a routine shunt for carotid stenosis with the occlusion of the contralateral carotid artery (CCO), and to compare them with patients without contralateral occlusion (NO-CCO). A retrospective analysis included 301 patients who had carotid artery stenosis treated with CEA using a routine shunt. Of these patients, 35 patients and 266 patients were categorized into a CCO group and NO-CCO group, respectively. Demographics and short-term and long-term outcomes were documented and compared. The demographic characteristics were not significantly different between the two groups. The periprocedural mortality, stroke rate, and rate of periprocedural myocardial infarction were not significantly different between both groups. The mean follow-up period for long-term outcomes was 34.45 ± 22.99 months, and the Kaplan-Meier analysis showed no statistical difference between both groups regarding stroke, myocardial infarction, and mortality. CEA combined with the routine shunt is an effective and durable procedure for carotid artery stenosis patients with CCO.

To assess technical results and close functional outcomes of acute ischemic stroke (AIS) in patients treated with endovascular thrombecomy (ET) in regional vascular centers (RVC) of St-Petersburg.Retrospective analysis of 183 patients with AIS, including 143 patients with AIS due to a large intracranial vessel occlusion in anterior (AC) and 25 patients in posterior cerebral (PC) circulation, 15 with isolated extracranial carotid occlusion treated in 6 RVC in 2017 was performed. All patients underwent ET.Effective reperfusion (mTICI 2b-3) was achieved in 71.5% (71.3% AC, 72% PC). On discharge, 35,7% patients had good (mRs 0-2) functional outcome (37.1% AC, 28% PC). The incidence of symptomatic intracranial hemorrhage (according to ECASS II criteria) was 10.7% (9.1% AC, 20% PC), the mortality was 29.2% (22.4% AC, 68% PC).). The results of our study show the possibility of effective and safe application of ET in patients with AIS in the anterior and posterior cerebral circulation in regional vascular centers of St.-Petersburg.Цель исследования. Оценить технические результаты и ближайшие функциональные исходы у пациентов, подвергшихся внутрисосудистой тромбоэмболэктомии (ВСТЭ) при остром ишемическом инсульте (ИИ), в условиях региональных сосудистых центров Санкт-Петербурга. Материал и методы. Проведен ретроспективный анализ результатов лечения 183 больных в остром периоде ИИ в 6 региональных сосудистых центрах в 2017 г. У 143 пациентов имел место инсульт, вызванный окклюзией магистральной интракраниальной артерии в каротидной системе (1-я группа), у 25 - окклюзия в вертебрально-базилярной системе (2-я группа), у 15 - изолированное поражение внечерепного отдела внутренней сонной артерии. Всем пациентам выполнялась ВСТЭ. Результаты и заключение. Частота эффективной реперфузии (градация по mTICI 2b-3) составила 71,5% (71,3 и 72% в 1-й и 2-й группах соответственно). Хороший функциональный исход (0-2 балла по mRs) на момент выписки был достигнут у 35,7% пациентов (у 37,1 и 28%). Частота симптомных внутричерепных кровоизлияний (по критериям ECASS II) составила 10,7% (9,1 и 20%), летальность - 29,2% (22,4 и 68%). Таким образом, результаты исследования свидетельствуют о возможности эффективного и безопасного использования ВСТЭ у пациентов с ИИ в передних и задних отделах артериального круга большого мозга в условиях региональных сосудистых центрах мегаполиса.

Introduction/purpose Management of tandem carotid occlusions is not yet well-defined. Though several authors have proposed acute carotid stenting followed and intracranial mechanical thrombectomy, the subsequent need for immediate antiplatelet therapy comes with an associated risk of potentially devastating hemorrhage. We sought to demonstrate that carotid stenting can be safely delayed in tandem carotid occlusions with good clinical outcomes. Materials and methods Between July 2015 and July 2016, we report our first ten consecutive patients with tandem carotid occlusions to our university comprehensive stroke center. Demographics, technical variations, recanalization rates and times, and clinical follow-up are reported. The abstract will be updated with additional consecutive cases of tandem occlusion through June 2018. Results A total cohort of our first ten consecutive patients (avg NIHSS=17) included seven carotid occlusions and three 95%–99% carotid bulb stenosis. Tandem intracranial occlusions included three at M2, four at M1, and three ‘T’ lesions at the ICA terminus. All patients were initially wire re-canalized, followed by prolonged PTA and mechanical thrombectomy. Nine patients received IV tPA (avg DTN 31 min) and five were drip-n-ship. The average tPA to groin puncture time was 104 min, and the average groin puncture to recanalization time was 50 min. TICI 2b/3 recanalization was obtained in nine of ten patients with only one patient 2a/2b. Nine patients had delayed carotid stenting between days 7–14 post-stroke. One patient had silently re-occluded the carotid bulb on the day of planned stenting, one patient had a small reperfusion hemorrhage prior to antiplatelet therapy (90 d MRS=0), and one patient had a small ICH after stent placement (90 d MRS=3). All patients had a 90 d MRS=/ Conclusion It appears that tandem carotid occlusions can be treated with emergent prolonged PTA of the extra-cranial carotid occlusion followed by intra-cranial mechanical thrombectomy. Delayed carotid stenting appears to be safe and may lead to good clinical outcomes. Further studies are needed to confirm the findings in this small cohort. Disclosures C. Green: None. B. Wiseman: None. A. Ferrell: None. P. Brown: None. P. Kvamme: None.

Background and purpose Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown. Methods Consecutive patients presenting at a single center with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) were retrospectively reviewed. Those treated with intravenous thrombolysis or intra-arterial thrombolysis/thrombectomy were excluded. Patients were divided into two groups based on whether they experienced recurrent in-hospital stroke. Results The selected study population (n = 33) represented a small (20.4%) proportion of all newly symptomatic carotid occlusions, who nevertheless had an elevated risk of recurrent stroke during admission (24.2%). Of the variables examined (age, gender, admission National Institutes of Health Stroke Scale score, vascular risk factors, atrial fibrillation, prior stroke/transient ischaemic attack and anticoagulation within 48 h of presentation), only anticoagulation was significantly associated with a lower risk of in-hospital recurrent stroke. Anticoagulated patients showed a decreased incidence of stroke recurrence within the first week (6.7% vs. 38.9%, P = 0.032) and fewer strokes or deaths at 1 month (13.3% vs. 47.1%, P = 0.040). Hemorrhagic transformation was not observed in any patient. On follow-up imaging, ICA recanalization was significantly more frequent in anticoagulated patients (46.2% vs. 9.1%, P = 0.047). Conclusion Patients with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) represent a small but high risk subgroup of patients with carotid occlusion. Early anticoagulation was associated with fewer recurrent strokes and increased ICA recanalization. Larger scale prospective studies may be justified.

We report an 8-year-old female who developed left abducens nerve palsy and progressively enlarging left internal carotid aneurysm in the setting of sphenoid sinusitis. Despite conservative management with antibiotics and antiplatelet agent, she developed enlargement of the aneurysm with embolic stroke. For that reason, she underwent occlusion of her left internal carotid artery with coiling, after confirmation of good collateral circulation. The patient tolerated the procedure well, with improvement of her symptoms. To our knowledge, this is the first report documenting good neurological outcome after elective internal carotid occlusion. Due to lack of guidelines, management of aneurysms secondary to infection should be individualized, based on collateral circulation and risk of intervention.

Introduction/Purpose There are, at present, no standardized clinical practice guidelines addressing the endovascular management of acute ischemic stroke attributable to tandem occlusive disease (cervical carotid occlusion with intracranial large vessel occlusion). We conducted a systematic review of available literature, as well as reviewed cases from our own institution, in order to identify current practice variants, and highlight neurointerventional approaches that are most frequently utilized. Materials and Methods We conducted a retrospective review of patients with acute ischemic stroke secondary to a tandem occlusion (intracranial occlusion with concomitant extracranial steno-occlusive carotid disease) that were treated with emergent thrombectomy from July 1, 2011 to December 31, 2015 at the University of Kentucky. Clinical (age, gender, stroke risk factors, NIHSS at admission), radiographic (distribution of intracranial occlusion), and interventional (recanalization technique for extra- and intracranial steno-occlusive disease, peri- and post-operative anti-coagulation/anti-platelet, and time to recanalization) data were collected. Using the PubMed database, we conducted a review of available literature from ?January 1, 2011 through February 28, 2017 on the endovascular treatment of tandem occlusions, extracting the same clinical, radiographic, and interventional data when available. Results 29 studies (Mean age: 65.2; Mean NIHSS on admission: 15.7) were included. 28 (97%) carried out acute stent-assisted recanalization of the cervical ICA, with 25 (89%) using adjunctive angioplasty. 18 (64%) of these favored the proximal-to-distal approach. 13 (45%) utilized systemic heparinization. 7 (24%) utilized general anesthesia for all cases, 6 for majority (21%), and 3 (10%) for some (no distribution given). Loading doses (LD) of aspirin and clopidogrel were given before stenting in 7 (24%) and post-procedure in 2 (7%). Aspirin alone before stenting was used in 3 (10%) and after in 6 (21%), with 5 of these 9 giving clopidogrel LD post-procedure. 5 (17%) reported peri-procedural GPIIb/IIIa inhibitors. 19 (68%) addressed maintenance antiplatelet regimens, all using aspirin and clopidogrel. For our institution, 10 patients (Mean age: 60, Mean NIHSS at admission: 16.3) were included. 4 underwent acute stenting (50% proximal-to-distal approach); 2 underwent angioplasty alone, 2 underwent thromboaspiration alone, and 2 underwent IA tPA alone. 1 case used systemic heparinization. General anesthesia was used in 5 patients. 2 received aspirin LD and 1 aspirin and clopidogrel LD post-procedure. 3 discharged on aspirin and clopidogrel, 2 on aspirin alone. Conclusion For tandem occlusions with cervical ICA involvement, acute stenting with adjunctive angioplasty, is a current prevailing practice for recanalization of the extracranial ICA. There is considerable variability in antiplatelet protocols, with a slight favoring of the administration of loading doses of aspirin and clopidogrel before stent deployment. Variability is also present for anesthesia, with general anesthesia having a significant role. Disclosures S. Coffman: None. S. Trott: None. A. Alhajeri: None. J. Fraser: None.

We read with interest the recent study of Grossberg et al1 on cervical carotid pseudo-occlusion (PO) showing that PO is relatively common in patients with isolated intracranial internal carotid artery occlusion. We are writing to further highlight the clinical relevance of this poorly recognized entity and the need for an alternative noninvasive diagnostic modality for early detection. Misdiagnoses of PO as true occlusions may affect acute clinical decision making in the era of endovascular clot retrieval. When a chronic carotid occlusion is incorrectly suspected, or when a technically challenging procedure too prolonged for timely …

We present a patient with Takayasu arteritis and severe aortic valve regurgitation and bilateral carotid artery occlusions, who underwent aortic valve replacement and aorto-bicarotid bypass. The management of the cardiovascular manifestations of Takayasu arteritis is reviewed.

Extracranial–intracranial bypass procedures are performed either for purposes of flow augmentation in the setting of cerebrovascular occlusive disease, or for flow replacement in the setting of planned vessel sacrifice. Flow replacement bypass is typically performed for the treatment of complex aneurysms, and its role is well accepted, although infrequently required. Extracranial–intracranial bypass for flow augmentation is a well-established treatment in moyamoya disease, but has a limited role for atherosclerotic occlusive disease treatment due to evidence failing to support its role in routine management in this setting. In this chapter, we briefly discuss the indications for extracranial–intracranial bypass, patient selection, and different types of bypasses, which can be offered for flow augmentation and flow replacement.

The Circle of Willis is linked to the vertebra-basilar system by an important posterior communicating artery (PCoA), and in case of internal carotid occlusion it acts as the sole source of blood supply to the cerebral hemispheres. External diameters have been used to determine hypo plasticity of these arteries with the normal diameter being above 0.5 mm. Hypo plasticity of the PCoA is a risk factor for ischemic infarctions in cases of internal carotid artery occlusion. In this article we present a rare case of hypo plastic bilateral posterior communicating arteries in a female cadaver. Hypo plasticity of the PCoA is an attributable factor to ischemic infarctions in cases of the internal carotid occlusion. Even when neurosurgery is a possibility, access is limited by the micro size of these arteries.

Cerebral hyperperfusion syndrome represents a clinical spectrum characterized by severe unilateral headache, acute changes in mental status, vomiting, seizures, focal neurologic deficits, and, in its most severe form, intracranial hemorrhage. With the exception of one early case report, reperfusion injury to the brain following carotid endarterectomy has been reported only ipsilateral to the side of surgery. We report the unique case of a patient with symptomatic severe right internal carotid artery stenosis and contralateral carotid occlusion who underwent carotid endarterectomy complicated by cerebral hyperperfusion syndrome and associated bilateral intracranial hemorrhage.

Introduction Definitive treatment of symptomatic atheromatous internal carotid artery occlusion remains controversial, as far as in rare cases, late spontaneous recanalization has been seen. Methods We consecutively studied 182 patients (January 2003 to August 2012) with an ischemic stroke in the internal carotid artery territory and diagnosis of atheromatous internal carotid artery occlusion during hospitalization. Findings Seven patients presented a late spontaneous recanalization (>3 months) of the internal carotid artery. We described therapeutic attitude according to usual care in these patients. Conclusions The authors attempt to highlight the unusual condition of recanalization after a symptomatic atheromatous chronic internal carotid artery occlusion. If these patients can be treated similar to patients with asymptomatic carotid pathology, then this needs to be clarified. However, due to the risk of ipsi- and contralateral ischemic strokes, revascularization techniques should be considered in certain cases. More studies are needed to establish the most appropriate therapeutical approach in order to avoid arbitrary treatment of these patients.

PURPOSE:To evaluate the treatment outcome of severe peritonitis in rats submitted to permanent bilateral carotid occlusion (PBCO).METHODS:Sixteen Wistar rats (mean age of 8.5 months) with PBCO underwent autogenously fecal peritonitis, and were treated with moxifloxacin combined with dexamethasone, and followed-up for 45 days. Ten rats (mean age five months) without PBCO were used as a control group. The variables were expressed by their mean and standard error of the mean (SEM). p

Objective/background The influence of contralateral carotid occlusion (CCO) on the outcome of carotid endarterectomy (CEA) and stenting (CAS) is debated. This study aims to evaluate CEA and CAS results in patients with CCO. Methods All carotid revascularizations from 2005 to 2011 were analyzed, focusing on the role of CCO on 30-day cerebral events and death (CED). A meta-analysis was performed to evaluate the results of the literature by random effect. Results Of the 1,218 carotid revascularizations performed in our institution, 706 (57.9%) were CEA and 512 (42.1%) were CAS. CED occurred in 3.6% of the CEAs and 8.2% of the CASs ( p = .001). CCO was present in 37 (5.2%) CEAs and 38 (7.4%) CASs. In CEA, CCO patients had a higher CED compared with the non-CCO patients (16.2% vs. 2.9%, p = .001), as confirmed by multiple regression analysis (OR [odds ratio]: 5.1[1.7–14.5]). In CAS, CED was not significantly different in the CCO and non-CCO patients (2.6% vs. 8.7%, p = 0.23). The comparative analysis of the CCO patients showed a higher CED in CEA compared with that in CAS (16.2% vs. 2.6%, p = 0.04). Meta-analysis of 33 papers (27 on CEA and 6 on CAS) revealed that CCO was associated with a higher CED in CEA, but not in CAS (OR: 1.82 [1.57–2.11]; OR: 1.22 [0.60–2.49], respectively). Conclusion CCO can be considered as a risk factor for CED in CEA, but not in CAS. CAS appears to be associated with lower CED than CEA in CCO patients.

The Fogarty catheter represents a major advancement for the effective removal of distal thrombi during vascular surgery, including carotid endarterectomy (CEA). One complication related to its use is injury to the cavernous carotid artery with development of a carotid cavernous fistula (CCF). Including a recent case at our institution, 21 patients with a Fogarty-related CCF have been reported since 1967. We performed a detailed review of all Fogarty-related CCFs during the treatment of carotid occlusive disease. We suggest a management algorithm for post-CEA acute carotid occlusion.

Complete long segment carotid occlusion presents a treatment challenge. These patients cannot be managed adequately by endarterectomy or stenting. Despite best medical management, many continue to develop recurrent strokes. In this select group of patients, there may be role for flow augmentation techniques like superficial temporal-middle cerebral artery bypass. We report a patient who was thus successfully treated and remains asymptomatic. The relevant literature is reviewed.

Introduction: Pituitary adenoma producing symptomatic carotid compression of the internal carotid artery without any apoplexy sign would be extremely rare and there was only one report regarding to this condition. Case Presentation: In this case report we have described a 57-year-old woman with a nonfunctional pituitary macro adenoma which has resulted to symptomatic internal carotid occlusion. Magnetic resonance imaging (MRI) revealed a large pituitary adenoma caused tight stenosis of right internal carotid. The patient has also experienced the transient ischemic attack which has confirmed to be the cause of internal carotid artery occlusion by this macro adenoma tumor. There was not any sign of apoplexy at the time of admission and the patient has not shown a history of pituitary adenoma. The patient then has undergone an endonasal transsphenoidal resection because of this nonfunctional pituitary adenoma. Conclusions: Pituitary macro adenoma producing symptomatic internal carotid occlusion might develop to several serious conditions including transient ischemic attack. Urgent surgical procedure might be the best approach to prevent further severe complications in such patients.

Background Limb-shaking transient ischemic attack (TIA) is a well-recognized, but rare observation in contralateral carotid steno-occlusive disease. Consequently, most clinicians have not had the chance to witness an attack. Case presentation We present the story of a 64-year old gentleman with exercise-induced weakness associated with tremor in his right arm. His left internal carotid artery was occluded at the bifurcation. Administration of statin and antiplatelet did not relieve his symptoms, and his stereotypic, exercise-induced “limb-shaking” episodes persisted. He underwent successful extracranial to intracranial (EC-IC) bypass, which stopped his symptoms. The patient, however, returned to our department and reported that he was able to recreate his original symptoms by compressing the bypass graft manually. Conclusion To our knowledge, this is the first case with video documentation of the clinical appearance of a limb-shaking TIA. We hope this case report will increase the physicians’ understanding of the clinical nature of limb-shaking TIAs. Electronic supplementary material The online version of this article (doi:10.1186/s12883-016-0601-8) contains supplementary material, which is available to authorized users.

Surgery on paraclinoid carotid aneurysms is technically demanding and entails considerable risks, especially to visual function. The aim of this study was to evaluate the clinical and visual outcome after surgery in 66 patients with paraclinoid carotid aneurysms (30 ruptured and 36 unruptured) treated between 1990 and 2014. Thirty-six aneurysms were of standard size, and 30 were large (16–20 mm) or giant (>20 mm); the Barami classification was used in every case. During surgery, multiple clips were needed in 25 % of patients with standard, and in 80 % of patients with large-giant aneurysms; temporary carotid occlusion was performed on 11 % of patients with standard and 63 % with large-giant aneurysms. Postoperatively, a cerebrospinal fluid fistula was repaired surgically in two patients. At the 3-month follow-up, the modified Rankin Score (mRS) was favorable (0–2) in 63 % of patients with ruptured and in 97 % with unruptured aneurysms; four patients presenting with large hematomas died. Postoperative visual impairment (worsening or newly developing deficit) was noted in 25 % of cases with standard and 14 % of cases with large-giant ruptured aneurysms, and, respectively, in 10 % with standard and 31 % with large-giant unruptured aneurysms. It has been concluded that surgery remains a reasonable choice in the management of patients with paraclinoid carotid aneurysms.

In a challenging case of carotid occlusion with slowly evolving stroke, we used brain imaging to facilitate endovascular revascularization resulting in the relief of the patient's symptoms. Patients with carotid occlusion and continued neurological worsening or fluctuations present enormous treatment challenges. These patients may present “slow” strokes with subacute infarcts that present significant challenges and risks during attempts at revascularization of the occluded artery. We present such a case in which we used multimodal imaging techniques, including MR-perfusion, to facilitate endovascular revascularization. Our approach of delayed but cautious intra-arterial thrombolytic therapy, guided by brain imaging, and followed by stent placement across the residual stenosis, enabled revascularization of the occluded artery without overt in-hospital complications.

Spontaneous bilateral internal carotid artery dissection has frequently been described in the literature as a cause of stroke. In more than half of the patients with internal carotid artery dissection, recanalization occurs early after the event and is unusual later than 6 months after onset of the dissection. We describe a patient with ischemic stroke due to left internal carotid artery occlusion in the extracranial segment. The patient was treated with anticoagulants and early vessel recanalization did not occur. Ten months later, he developed contralateral internal carotid occlusion in the intracranial tract, which was followed by early complete recanalization. Anticoagulation therapy was continued and, 16 months after the initial event, the left internal carotid artery unexpectedly also reopened. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound, 2011

Therapeutic parent artery occlusion has been routinely utilized for management of some intracranial aneurysms. One possible long-term complication of this procedure is “de novo” formation of aneurysms. The purpose of this paper is to estimate the incidence of de novo aneurysm formation, the time period between occlusion and formation, and the most common sites of formation. A PubMed search was performed for all articles between 1970 and 2008 reporting cases of both therapeutic carotid occlusion and de novo cerebral aneurysms. The 20 papers reviewed reported 187 patients having undergone therapeutic carotid occlusion. Of the 163 patients reported in complete-case series, seven developed new aneurysms (4.3%). Thirty-six total new aneurysms were reported, ranging from 1 to 5 per patient. The average time period between occlusion and detection of de novo aneurysm was 9.1 years (range: 2 to 20 years). These aneurysms occurred mostly in the anterior circulation, predominately the anterior communicating artery and posterior communicating artery, and frequently occurred contralateral to the site of occlusion. Therapeutic parent artery occlusion is a likely risk factor for de novo aneurysm formation. Noninvasive follow-up studies should be performed, especially between 2 and 10 years after occlusion.

The challenge in acute stroke is still to reperfuse as early as possible the ischemic territory. Since fibrinolytic therapies have a limited window with potential risk of bleeding, having a nonpharmacologic mean to recruit vessels in area surrounding necrosis might be useful. We propose here to use antigravity suit inflated at “venous” pressure levels to shift blood towards thoracic and brain territories. We report two cases of spectacular clinical recovery after acute carotid occlusion.

Tissue plasminogen activator (tPA) is the only approved thrombolytic therapy for acute ischemic stroke, yet many patients do not recanalize. Enhancing thrombolytic efficacy of tPA is a major focus of stroke research. Traditionally, a “rat dose” of 10 mg/kg has been used in rodent models. Recent studies suggested that the clinical “human” dose (0.9 mg/kg) may better mimic clinical recanalization. These studies only compared the rat and clinical doses and so we aimed to test recanalization efficacy of multiple tPA doses ranging from 0.9 to 10 mg/kg in a model of endothelial injury and vessel stenosis. The common carotid artery of rats was crushed and stenosed to allow in-situ occlusive thrombus formation (Folt’s model of ‘physiological’ thrombus). Intravenous tPA was administered 60 minutes post-occlusion (n = 6-7/group). Sustained recanalization rates were 0%, 17%, 67% and 71%, for 0.9, 1.8, 4.5 and 10 mg/kg, respectively. Median time to sustained recanalization onset decreased with increasing dosage. We conclude that 10 mg/kg of tPA is too effective, whereas 0.9 mg/kg is ineffective for lysis of occlusive thrombi formed in situ. Neither dose mimics clinical tPA responses. A dose of 2x the clinical dose is a more appropriate mimic of clinical tPA recanalization in this model.

We report an 80-year-old patient with internal carotid artery (ICA) occlusion and smoothly progressive worsening of neurological and neuropsychological dysfunction over 3 weeks despite intravenous heparin anticoagulation. At autopsy, there were multiple small [nonvisible on computed tomography (CT)] and large (seen on CT) infarcts distal to the occluded ICA. They corresponded to multiple embolic arterial occlusions throughout the hemisphere. These findings show that smoothly progressing stroke associated with ipsilateral ICA occlusion may be due to relentless, iterative artery-to-artery embolism rather than to hemodynamic compromise. They also cast doubts on the potential usefulness of anticoagulation in this situation.

Mycotic cerebral aneurysms can present unique neurosurgical challenges. We report a patient with left carotid occlusions, a ruptured left middle cerebral artery mycotic aneurysm, and a rapidly appearing unruptured left anterior cerebral artery/anterior communicating artery (ACA/ACom) mycotic aneurysm in the setting of mitral valve endocarditis with a perivalvular leak and evolving congestive heart failure. Following medical stabilization and antibiotic administration, a combined endovascular (with contralateral access via the ACom) and open surgical approach was used to selectively secure both aneurysms with preservation of distal flow, allowing lifesaving cardiac valve replacement. This case illustrates the therapeutic complexity of mycotic cerebral aneurysms, which we discuss in the context of an increasing reliance on endovascular approaches.

A 29-year-old woman is diagnosed with a large broad-base right ophthalmic artery aneurysm. Despite an intact visual field, she complained of mild right visual blurriness. Between endovascular and surgical treatments, surgery was favored due to her young age. It was decided to perform the surgery with simultaneous endovascular temporary carotid balloon occlusion. A right pterional craniotomy and intradural anterior clinoidectomy were performed, the balloon was positioned in the petrous carotid, and the distal durai ring was opened exposing the proximal neck. Under temporary proximal carotid balloon occlusion and distal carotid clip occlusion, the aneurysm was fully dissected and clipped. Intraoperative angiogram confirmed complete aneurysm occlusion and patency of the ophthalmic artery. The patient's neurological exam remained unchanged.The video can be found here: http://youtu.be/BIQKTl9bDqA.

The 2-year risk of ipsilateral ischemic stroke following internal carotid artery occlusion (ICAO) in a patient undergoing maximal medical therapy is 5–8 % per year. While medical therapy may reduce the risk of stroke, it does not completely eliminate it. Since the 1985 extracranial-intracranial (EC-IC) bypass study, additional trials have been conducted to further investigate the usefulness of EC-IC bypass surgery in more selected patients with cerebral ischemia and impaired hemodynamic reserve. These important studies will be briefly reviewed in this article, as well as a discussion regarding the utility of bypass surgery for ICAO in current clinical practice. In addition, a short discussion regarding the pathophysiology of carotid occlusion will be presented. We will also highlight our own institutional patient selection criteria based on the latest methods for hemodynamic assessment, as well as our intraoperative flow assisted surgical techniques (FAST), and post-operative patient follow-up.

Carotid and vertebral rete mirabile is an unusual segmental regression of both the cavernous carotid artery and transdural vertebral arteries with a network of collateral vessels seen rarely in human beings. We present a 57-year-old woman with carotid and vertebral rete mirabile who presented with an acute intraparenchymal hemorrhage. The majority of patients present with subarachnoid hemorrhage or ischemic stroke. This is the first case of a non-Asian patient presenting with an intraparenchymal hemorrhage. In this case report, we describe the clinical and angiographic features of this unusual entity.

Emergency revascularization of acute carotid artery occlusion is still controversial. We treated 15 patients (13 men and two women, mean age of 67.3 years) with acute atherosclerotic carotid occlusion by endovascular procedures and evaluated the usefulness of this treatment. All of the patients were evaluated with emergency MRI and MRA before treatment. Intracranial tandem arterial occlusion due to distal embolism was observed in nine patients, and contralateral carotid stenosis (>70%) was observed in seven. The mean NIHSS score of the patients was 15.4±7.4 (mean±SD) before treatment. Treatment modality included local intraarterial fibrinolysis (LIF), percutaneous transluminal angioplasty (PTA), and carotid artery stenting (CAS). A protective balloon was successfully placed in the distal carotid artery through the plaque before recanalization in seven patients. Three patients were treated with LIF+PTA, five with PTA+CAS, six with LIF+PTA+CAS, and one with PTA only. Successful recanalization of the carotid artery was obtained in 14 of the 15 patients, and distal tandem middle cerebral artery occlusion was also successfully recanalized in eight of the nine patients. GOS was four or five in eight patients (good outcome group) and 1–3 in seven patients (poor outcome group). Mean NIHSS score of the 15 patients was (6.9 ± 7.4) after treatment. Preoperative NIHSS score (10.3 ± 7.4) in the good outcome group was significantly lower than that (21.3 ± 5.4) in the poor outcome group. The protective balloon technique, PTA with stenting, seems to be useful for acute revascularization of urgent carotid occlusion. Simultaneous treatment of the intracranial tandem occlusive lesion is essential to achieve good clini-cal results. Patients with acute carotid occlusion with NIHSS scores of less than 16 could be good candidates for this advanced treatment.