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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]

Endovascular repair of traumatic internal carotid artery pseudoaneurysm (TICAP) with covered stents represents a safe treatment with few complications. However, the presence of foreign material used to treat TICAP and blood clots in the excluded pseudoaneurysms can trigger an acute systemic inflammatory response syndrome called postimplantation syndrome (PIS). To the best of our knowledge, PIS is described only after abdominal aortic endovascular aneurysm repair. Here, we report the case of PIS in a young, healthy, polytraumatized female patient with TICAP treated with endovascular covered stent. [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]

Few reports have been made on the presentation and treatment of schwannomas originating in the sphenoid sinus due to their rarity. We report the case of a 60-year-old woman who presented with a cyst-like mass in the right sphenoid sinus on magnetic resonance imaging. Computed tomography showed a bone defect in the internal carotid artery (ICA) and enlargement of the round foramen on the affected side. A histopathological diagnosis of schwannoma was made, and endoscopic sinus surgery was performed. The anterior part of the tumor could be easily removed by aspiration; however, its adhesion to the ICA was remarkable, and its boundaries were unclear. Although partial paralysis of the maxillary nerve remained, no recurrence occurred for over 10 years. Careful evaluation should be performed to check for bone defects in the nerve to differentially diagnose schwannoma from cystic masses of the sphenoid sinus. Additionally, excision of masses similar to the presented case may expectedly be difficult because of unclear excisional margins and strong capsule adherence to important organs such as the ICA. Moreover, correct imaging, histopathological diagnosis, and appropriate informed consent are essential before surgery.

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.

High energy trauma has been considered a risk factor for blunt cerebrovascular injuries (BCVI). The purpose of this study was to determine the incidence and risk factors for BCVI specifically in patients with maxillofacial fractures in an urban level I trauma center. A retrospective cohort study of patients aged ≥ 18 years, admitted to Massachusetts General Hospital (MGH) between 2007 and 2017, was implemented. There were 23,394 patients treated and entered into the MGH Trauma Registry: 22,287 sustained blunt trauma. Of the total blunt trauma patients, 68 (0.3%) had BCVI. There were 2421 patients with CMF fractures from blunt trauma (mean ± standard deviation age, 53 ± 22 years; 29.9% female included as study subjects, of whom 24 (1.0%) had BCVI). In a multivariate model, all mandible fracture (odds ratio (OR) 4.3, 95% confidence interval (CI) 1.6–11.6, P = 0.004), crush injury, defined as blunt compression injury (OR 11.1, 95% CI 2.1–58.1, P = 0.004), and cervical spine injury (OR 10.1, 95 CI 3.7–27.5, P < 0.001) were independent risk factors for BCVI. Mortality was 4.3 times higher in craniomaxillofacial fracture patients with BCVI versus those without BCVI; complications of BCVI (stroke) contributed to the majority of deaths. Appropriate screening and treatment of BCVI in patients with maxillofacial fractures is important. [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]

Background The potential role of the gut microbiome in cardiovascular diseases is increasingly evident. Arterial restenosis attributable to neointimal hyperplasia after cardiovascular procedures such as balloon angioplasty, stenting, and bypass surgery is a common cause of treatment failure, yet whether gut microbiota participate in the development of neointimal hyperplasia remains largely unknown. Methods and Results We performed fecal microbial transplantation from conventionally raised male C57BL/6 mice to age-, sex-, and strain-matched germ-free mice. Five weeks after inoculation, all mice underwent unilateral carotid ligation. Neointimal hyperplasia development was quantified after 4 weeks. Conventionally raised and germ-free cohorts served as comparison groups. Conclusions Germ-free mice have significantly attenuated neointimal hyperplasia development compared with conventionally raised mice. The arterial remodeling response is restored by fecal transplantation. Our results describe a causative role of gut microbiota in contributing to the pathogenesis of neointimal hyperplasia.

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.

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]

Endovascular thrombectomy in acute ischaemic stroke commonly uses aspiration catheters, either alone or in combination with stent retrievers. The Penumbra Aspiration System (Penumbra, Alameda, California, USA) was first approved by the US Food and Drug Administration in 2007, with low reported device-related complications. We present a case of a previously unreported complication related to malfunction of a Penumbra aspiration catheter during stroke thrombectomy resulting in a carotid-cavernous fistula. [ABSTRACT FROM AUTHOR]

Objective: Iatrogenic injuries of internal maxillary artery (IMA) and external carotid artery (ECA) during temporomandibular and retromandibular region surgeries are serious surgical complications with high mortality and morbidity. In order to avoid this complication, it is important for surgeons to know these vascular structures' course and their relationship with the mandibular condyle and ramus. The aim of this study was to reveal the relationship of the IMA and ECA with the mandible by head and neck computed tomography (CT) angiography. Materials and methods: Bilateral head and neck CT angiography data in 26 patients (52 region) were evaluated retrospectively. The spatial distance of IMA and ECA to the mandible was calculated in all three planes (IMAx, ECAx, IMAy, ECAy, IMAz, ECAz planes). The presence of vascular tortuosity and contact were also evaluated. Results: We have found that the nearest distance to the ramus of the ECA before giving a branch to IMA was 32.5±7.7 mm above the line drawn tangent to the lower border of corpus mandible. The internal maxillary artery was measured to be in contact with the medial cortical surface of the mandibular condyle in 39 of the 52 angiographies. This contact point was found to be 1.74 mm in front of the posterior margin of the ramus. Conclusion: In this study, we radiologically confirmed that the internal maxillary artery is in close association with the mandibular condyle. It is important for surgeons to be aware of this neighborhood in order to prevent intraoperative vascular injuries. [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]

Introduction: Percutaneous revascularization is one of the interventions through which results are obtained quite quickly among the current treatment of blockage artery diseases. In fact, the success achieved is lower than expected due to stenosis formation and spontaneous thrombosis. Vascular endothelial damage after endovascular interventions causes it to become a sticky surface for leukocytes and platelets, the distortion of the normally smooth surface through which the blood moves nonstop causes an increase in adhesion and procoagulant activities and permeability. While many cytokines, vasoactive molecules, and growth factors are released intermittently, if the inflammatory response is not suppressed in some way, the accumulation of extracellular matrix occurs with smooth muscle cell migration and proliferation in the vascular wall. This process, known as neointimal hyperplasia, has become a nightmare for many surgeons. As the known physiopathological mechanism of restenosis began to be understood, many pharmacological agents, mechanical agents were developed to prevent this process and tested with animal and human clinical trials. In our study, we aimed to show the inhibitive effect of cilostazol on neointimal hyperplasia by giving the experimental animal model an oral way. Methods: Intimal damage was created in the control and experiment group using the rat carotid artery balloon damage model. A group of animals was reserved as a Sham group. Preparations obtained from rat common carotid after oral cilostazol treatment for 2 weeks were evaluated histopathologically. Their statistical significance was observed. Results: In within-group analyses, while no difference was observed among themselves, in cross-group analyses, in terms of intimal thickening, a significant difference was found between Group 1 (Sham) and Group 2 (Control), Group 2 and Group 3 (Experiment), however, between Group 1 and Group 3, no statistically significant difference was detected. In light of these results, we reached the conclusion that cilostazol has an inhibitive effect on intimal hyperplasia when taken through the oral path. On the other hand, when comparing intimal and medial thickness rates, that the low artery intima/media ratio was found only in the experimental group, shows that the endothelial damage created in the intima was limited by cilostazol and decreased neointimal hyperplasia unrelated to the media layer. Discussion and Conclusion: This drug whose systemic and topical effectiveness has been detected previously, would yield positive results not only in patients with peripheral artery disease, but also in peripheral artery patients with symptoms of claudicatio intermittence because of the fact that it shows the most effective and direct impact when administered orally, it is easy to use and its absorption is quite high. [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 de-differentiation and proliferation of smooth muscle cells (SMCs) are widely accepted as the major contributor to vascular remodeling. However, recent studies indicate that vascular stem cells (VSCs) also play an important role, but their relative contribution remains to be elucidated. In this study, we used genetic lineage tracing approach to further investigate the contribution of SMCs and VSCs to neointimal thickening in response to endothelium denudation injury or artery ligation. In vitro and in vivo analysis of MYH11-cre/Rosa-loxP-RFP mouse artery showed that SMCs proliferated at a much slower rate than non-SMCs. Upon denudation or ligation injury, two distinct types of neointima were identified: Type-I neointimal cells mainly involved SMCs, while Type II mainly involved non-SMCs. Using Sox10-cre/Rosa-loxP-LacZ mice, we found that Sox10+ cells were one of the cell sources in neointima. In addition, lineage tracing using Tie2-cre/Rosa-LoxP-RFP showed that endothelial cells also contributed to the neointimal formation, but rarely transdifferentiated into mesenchymal lineages. These results provide a novel insight into the contribution of vascular cells to neointima formation, and have significant impact on the development of more effective therapies that target specific vascular cell types.

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.

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]

Background Pseudoaneurysms of the carotid artery are rare and can be both a cause and consequence of carotid blowout syndrome (CBS) in patients with head and neck cancer. Surgical or endovascular treatment approaches may be useful for managing this condition. Case Report A 55-year-old man presented with a pulsatile mass surrounding the carotid bifurcation in the neck. He reported a history of CBS that occurred as a surgical complication while removing a benign neck cyst. Additionally, he reported a history of laryngeal cancer that underwent complete remission after surgery and radiotherapy. The mass was diagnosed as a pseudoaneurysm. Surgical treatment proved challenging owing to the patient’s history of neck surgery and radiotherapy; therefore, stent-graft deployment was performed and the absence of pulsations was checked through the neck mass. Conclusion Endovascular treatment may be a useful therapeutic strategy in cases of post-CBS pseudoaneurysm in patients undergoing surgery and/or radiotherapy for head and neck cancer.

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]

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.

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]

RationaleIn atherosclerotic lesions, synthetic smooth muscle cells (sSMCs) induce aberrant microRNA (miR) profiles in endothelial cells (ECs) under flow stagnation. Increase in shear stress induces favorable miR modulation to mitigate sSMC-induced inflammation.ObjectiveTo address the role of miRs in sSMC-induced EC inflammation and its inhibition by shear stress.Methods and resultsCoculturing ECs with sSMCs under static condition causes initial increases of 4 anti-inflammatory miRs (146a/708/451/98) in ECs followed by decreases below basal levels at 7 days; the increases for miR-146a/708 peaked at 24 hours and those for miR-451/98 lasted for only 6 to 12 hours. Shear stress (12 dynes/cm(2)) to cocultured ECs for 24 hours augments these 4 miR expressions. In vivo, these 4 miRs are highly expressed in neointimal ECs in injured arteries under physiological levels of flow, but not expressed under flow stagnation. MiR-146a, miR-708, miR-451, and miR-98 target interleukin-1 receptor-associated kinase, inhibitor of nuclear factor-κB kinase subunit-γ, interleukin-6 receptor, and conserved helix-loop-helix ubiquitous kinase, respectively, to inhibit nuclear factor-κB signaling, which exerts negative feedback control on the biogenesis of these miRs. Nuclear factor-E2-related factor (Nrf)-2 is critical for shear-induction of miR-146a in cocultured ECs. Silencing either Nrf-2 or miR-146a led to increased neointima formation of injured rat carotid artery under physiological levels of flow. Overexpressing miR-146a inhibits neointima formation of rat or mouse carotid artery induced by injury or flow cessation.ConclusionsNrf-2-mediated miR-146a expression is augmented by atheroprotective shear stress in ECs adjacent to sSMCs to inhibit neointima formation of injured arteries.

Carotid Blow-Out Syndrome (CBS) is a life-threatening complication of head and neck cancer. We report the case of a patient who suffered a fatal haemorrhage whilst driving, review the law and role of healthcare professionals in preventing such events.

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]

We developed a neck central line insertion guidance system that renders 3D ultrasound (US) surface reconstructions of the carotid artery (CA) and internal jugular vein (IJV), a tracked model of the needle, and needle trajectory on a 2D monitor. Twenty clinicians evaluated this system compared to US-only guidance on a phantom using time and insertion accuracy metrics. The 3D system had a 100% success rate compared to 70% for the US-only system. The average distance from the centre line of the US reconstructed IJV was 1.8 ± 0.9 mm under 3 D guidance compared to 4.2 ± 2.9 mm for US-only. Our system significantly improved needle insertion success rates and targeting accuracy compared to the US-only approach through a radiation-free surface reconstruction of the neck vascular structures. This work has the potential to provide a mobile 3D imaging and visualisation system for needle-based vascular interventions. [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 and purposeEndovascular navigation under MR imaging guidance can be facilitated by a catheter with steerable microcoils on the tip. Not only do microcoils create visible artifacts allowing catheter tracking, but also they create a small magnetic moment permitting remote-controlled catheter tip deflection. A side product of catheter tip electrical currents, however, is the heat that might damage blood vessels. We sought to determine the upper boundary of electrical currents safely usable at 1.5T in a coil-tipped microcatheter system.Materials and methodsAlumina tubes with solenoid copper coils were attached to neurovascular microcatheters with heat shrink-wrap. Catheters were tested in carotid arteries of 8 pigs. The catheters were advanced under x-ray fluoroscopy and MR imaging. Currents from 0 mA to 700 mA were applied to test heating and potential vascular damage. Postmortem histologic analysis was the primary endpoint.ResultsSeveral heat-mitigation strategies demonstrated negligible vascular damage compared with control arteries. Coil currents ≤300 mA resulted in no damage (0/58 samples) compared with 9 (25%) of 36 samples for > 300-mA activations (P = .0001). Tip coil activation ≤1 minute and a proximal carotid guide catheter saline drip > 2 mL/minute also had a nonsignificantly lower likelihood of vascular damage. For catheter tip coil activations ≤300 mA for ≤1 minute in normal carotid flow, 0 of 43 samples had tissue damage.ConclusionsActivations of copper coils at the tip of microcatheters at low currents in 1.5T MR scanners can be achieved without significant damage to blood vessel walls in a controlled experimental setting. Further optimization of catheter design and procedure protocols is necessary for safe remote control magnetic catheter guidance.

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]