Imaging characteristics and treatment strategies for carotid artery occlusion caused by skull base fracture:Three case reports

BACKGROUND Traumatic internal carotid artery(ICA)occlusion is a rare complication of skull base fractures,characterized by high mortality and disability rates,and poor prognosis.Therefore,timely discovery and correct management are crucial for saving the lives of such patients and improving their prognosis.This article retrospectively analyzed the imaging and clinical data of three patients,to explore the imaging characteristics and treatment strategies for carotid artery occlusion,combined with severe skull base fractures.CASE SUMMARY This case included three patients,all male,aged 21,63,and 16 years.They underwent plain film skull computed tomography(CT)examination at the onset of their illnesses,which revealed fractures at the bases of their skulls.Ultimately,these cases were definitively diagnosed through CT angiography(CTA)examinations.The first patient did not receive surgical treatment,only anticoagulation therapy,and recovered smoothly with no residual limb dysfunction(Case 1).The other two patients both developed intracranial hypertension and underwent decompressive craniectomy.One of these patients had high intracranial pressure and significant brain swelling postoperatively,leading the family to choose to take him home(Case 2).The other patient also underwent decompressive craniectomy and recovered well postoperatively with only mild limb motor dysfunction(Case 3).We retrieved literature from PubMed on skull base fractures causing ICA occlusion to determine the imaging characteristics and treatment strategies for this type of disease.CONCLUSION For patients with cranial trauma combined with skull base fractures,it is essential to complete a CTA examination as soon as possible,to screen for blunt cerebrovascular injury.

Endovascular Therapy of Internal Carotid Artery Tandem Occlusions and Literature Review

Acute large vessel occlusion is a common cause of acute ischemic stroke (AIS), with high rates of disability and lethality. The incidence of tandem occlusion of the internal carotid artery accounts for about 20% of patients with large vessel occlusion of the anterior circulation in acute ischemic stroke. The low rate of recanalization by intravenous thrombolysis in AIS due to internal carotid artery tandem occlusion, the poor establishment of collateral circulation within a short time, and the complex pathogenesis often suggest a poor prognosis for patients. Mechanical thrombectomy (MT) is beneficial for the opening of intracranial large vessel occlusion with internal carotid artery tandem occlusion, there are many problems regarding the emergency management of carotid artery occlusion or stenosis after mechanical thrombectomy, and there are currently no standardized treatment recommendations;The sequential approach to the management of carotid tandem occlusion, the timing of carotid stenting, and the use of antiplatelet agents remain controversial. The current state of research on carotid tandem occlusion is analyzed in the literature to promote clinical understanding of endovascular treatment for patients with acute ischemic stroke due to carotid tandem occlusion.

Hybrid surgery for symptomatic chronic complete occlusion of the internal carotid artery: A case report

Currently,there are antiplatelet drugs,extracranial-intracranial(EC-IC)vascular bypass,carotid endarterectomy(CEA),endovascular intervention(EI),and other revascularization procedures for symptomatic chronic internal carotid artery occlusion(CICAO).In consulting the literature,we found that existing techniques for single treatments cannot achieve satisfactory results when there is a long segment occlusion with plaque attached to the intracranial segment and a short stump at the initial segment.We reported the case of a 50-year-old male patient with blurred vision,headache,and weakness in the right upper limb.After the exclusion of other neurological diseases,he was diagnosed with symptomatic CICAO;the occlusion segment was long and the stump was too short.We performed a novel hybrid surgery for the patient—a carotid endarterectomy combined with internal carotid artery stenting.After 6 months of follow-up,computed tomography angiography(CTA)confirmed that the left internal carotid artery was unobstructed,and the symptoms were relieved.A brief review of the literature is presented in addition to this report.

Bilateral cerebral infarction in diabetic ketoacidosis and bilateral internal carotid artery occlusion:A case report and review of literature

BACKGROUND Diabetic ketoacidosis(DKA)is a serious complication of type 1 diabetes mellitus(T1DM).Very rarely does DKA lead to cerebral edema,and it is even rarer for it to result in cerebral infarction.Bilateral internal carotid artery occlusion(BICAO)is also rare and can cause fatal stroke.Moreover,case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce.In this study,we present a patient with BICAO,T1DM,hypertension,and hyperlipidemia,who had a catastrophic bilateral cerebral infarction after a DKA episode.We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction.CASE SUMMARY A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata,bilateral frontal lobe,and parietal lobe with right hemiplegia and Broca’s aphasia.She had a history of hypertension for 5 years,hyperlipidemia for 4 years,hyperthyroidism for 3 years,and T1DM for 31 years.The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion.She was admitted to our ward for rehabilitation due to prior stroke sequalae.DKA took place on hospital day 2.On hospital day 6,she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory.After weeks of aggressive treatment,she remained in a coma and on mechanical ventilation due to respiratory failure.After discussion with her family,compassionate extubation was performed on hospital day 29 and she died.CONCLUSION DKA can lead to cerebral infarction due to several mechanisms.In people with existing BICAO and several stroke risk factors such as hypertension, T1DM,hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.

Tissue plasminogen activator via cross-collateralization for tandem internal carotid and middle cerebral artery occlusion

Tandem internal carotid and middle cerebral artery occlusion after carotid dissection predicts poor outcome after systemic thrombolysis. Current treatments include the use of endovascular carotid stenting, which carries with it a high risk of propagating further embolic events and worsening the dissection. New strategies for avoiding the aforementioned side-effects include recanalization using cross-collaterals for delivery of intra-lesional tissue plasminogen activator(t PA). We present two cases that provide further support for this novel approach. Both patients presented with a National Institute of Health Stroke Scale of 20, received intra-arterial t PA via cross-collateralization, and made full recoveries without the need for stenting.

Central retinal artery occlusion after endovascular coil embolization for internal carotid artery aneurysm

Dear Editor,We are writing this letter to report an unexpected rare caseofcentralretinalarteryocclusion(CRAO)happened after stent-assisted coiling for internal carotid artery(ICA)aneurysm in a female patient.CRAO is a devastating ocular emergency with poor visual prognosis and no universal acceptedtreatmentatpresent.CRAOisusuallyassociated witharterialhypertension,diabetesmellitus,renaldisease.

Primary balloon angioplasty for chronic occlusion of intracranial internal carotid artery: A case report

Chronic occlusion of large intracranial arteries is the main cause of ischemic stroke in China.Patients with symptomatic intracranial artery occlusion and hemodynamic impairment are at high risk of recurrent stroke.Chronic occlusion of the intracranial segment of the internal carotid artery is a common type of intracranial artery occlusion.Medical management is regarded as the standard treatment for this disease.With the development of endovascular treatment,some patients with chronic cerebral artery occlusion have achieved satisfactory results with endovascular therapy.We reported a patient with symptomatic chronic occlusion of the ophthalmic segment of the internal carotid artery.Simple balloon angioplasty was performed,and the occluded ophthalmic segment of the internal carotid artery was successfully recanalized without perioperative complications.At 4 months followup,the internal carotid artery remained patent and perfusion of the right cerebral hemisphere improved dramatically.In addition,we briefly reviewed the relevant literature.

Clinical characteristics and treatment strategies of acute ischemic stroke with internal carotid artery occlusion: a case report

Acute ischemic stroke has the characteristics of high disability,lethality and recurrence rate,which seriously threatens the health of middle-aged and elderly people.This article describes the acute ischemic stroke with internal carotid artery occlusion as the main clinical feature and discusses its treatment strategy.Treatment remedies:clinical diagnosis was carried out based on the present medical history,physical examination and craniocerebral CT(computed tomography).Neurological function was improved by intravenous thrombolysis,cerebrovascular angiography was used to clarify cerebrovascular occlusion,cerebral blood supply was identified by CT perfusion,and neurological function recovery was followed up.After intravenous thrombolysis,the patient’s consciousness turned clear and the right limb muscle strength recovery was not obvious,but the patient did not receive bridging therapy.Cerebral angiography showed about 90%stenosis at the beginning of the left internal carotid artery,and the blood flow terminated at the C7 segment.Cerebral CT perfusion imaging showed decreased perfusion in the left cerebral hemisphere,but the patient did not receive carotid endarterectomy and vascular bypass treatment.Post treatment evaluating:follow-up showed that NIHSS(National Institute of Health stroke scale)score was significantly decreased and limb function was significantly restored.Conclusion:early intravenous thrombolytic therapy can help reduce the area of ischemic penumbra and improve long-term prognosis.Severe vascular stenosis can stimulate vascular compensation,significantly reduce the range of ischemia when thrombus occurs,and effectively reduce the disability rate without bridging therapy.Whether vascular stenosis and occlusion are treated by vascular bypass,etc.,individualized plans should be made according to vascular compensation.

Effect of cold weather on carotid artery stenosis and occlusion:A retrospective observational study

Objective:To investigate the effect of cold weather on carotid artery stenosis and occlusion.Methods:We conducted a retrospective observational study,in which 145 patients with carotid artery stenosis and occlusion were enrolled[115 men and 30 women;the mean age was 61.08 years(95%CI 59.27-62.88)].Patients were divided into the low-temperature group(n=98)(≤12℃)and the non-low temperature group(n=47)(>12℃).Clinical characteristics,blood pressure,National Institutes of Health Stroke Scale(NIHSS),blood fat,and blood viscositys were compared between the two groups.Correlation between NIHSS and mean daily temperature was analyzed.Results:There was no significant difference in the systolic and diastolic blood pressure between the two groups(P>0.05).The NIHSS score was slightly higher in the non-low temperature group compared to that of the low-temperature group(U=2984,P<0.01).Glycemia,cholesterol level,prothrombin time,fibrinogen,and International Normalized Ratio did not show any significant difference(P>0.05).Correlation analysis showed a very low positive and statistically significant correlation between ambient temperature and NIHSS score(r=0.18,P=0.029).Conclusion:Cold weather does not impact blood pressure,blood cholesterol,and coagulation factors of patients with carotid artery stenosis and occlusion.The neurological deficit is more severe in the non-low ambient temperature group.A potential relationship exists between ambient temperature and the level of neurological impairment.

CAS and CEA in the Treatment of Severe Internal Carotid Artery Stenosis

Objective:To explore the clinical value of carotid artery stent implantation(CAS)and carotid endarterectomy(CEA)in the treatment of patients with severe internal carotid artery stenosis.Methods:88 patients with severe carotid artery stenosis who underwent CAS and CEA in the First People's Hospital of Changde City(hereafter referred as "our hospital")from January 2018 to December 2020 were selected as the research objects and divided into CAS group(n=43)and CEA group(n=45).To understand the clinical application value and feasibility of the two surgical schemes by comparing the general situation,cerebral blood flow,MMSE scale,MOCA scale score and serum miR-145,IGF1R levels of the two surgical schemes.Conclusions:CAS and CEA in the treatment of patients with severe internal carotid artery stenosis,have good curative effect,can effectively improve the patient's cerebral blood flow,regulate serum miR-145,IGF 1R levels,promote the recovery of cognitive function,but relatively speaking,the incidence of stroke and hypotension after CAS is higher,and the incidence of hypertension after CEA is higher.

A Comprehensive Analysis of a Case of Internal Carotid Artery Stenting

With the development of science and technology and the continuous progress of interventional equipment,internal carotid artery stenting has become increasingly popular among patients in view of its advantages,which include high efficiency,minimally invasive,and fast postoperative recovery.It has grown importance as a surgical method for the treatment of severe internal carotid artery stenosis.This paper discusses a rare case of severe internal carotid artery stenosis and its management,where various types of pre-dilatation balloons were not able to be positioned in the stenting process.Relevant solutions have also been proposed in hope to provide a more theoretical and practical basis for clinical work.

从血管旁路移植术治疗症状性颈内动脉和大脑中动脉闭塞研究(CMOSS)看围手术期管理及血管旁路移植术的未来

血管旁路移植术治疗症状性颈内动脉或大脑中动脉血管闭塞的疗效一直备受争议。由中国发起的血管旁路移植术治疗症状性颈内动脉和大脑中动脉闭塞研究(CMOSS)最终取得阴性结果,但这并不能否定血管旁路移植术对症状性血管闭塞患者的治疗价值,而是预示着其临床应用需进一步地深入研究。该文对CMOSS结果进行了分析,对该类患者的围手术期管理进行了总结,介绍了下一步开展的CMOSS2,并探讨了血管旁路移植术的未来,以期为血管旁路移植术临床研究和实践提供参考。

复合技术治疗颈动脉次全闭塞伴远端完全塌陷的疗效分析

目的探讨复合技术治疗颈动脉次全闭塞(carotid artery near-occlusion,CNO)伴远端完全塌陷的疗效。方法回顾性收集中日友好医院2016年1月至2021年1月接受复合技术治疗的45例CNO伴远端完全塌陷患者临床资料,分析其临床特点、影像学检查、治疗及预后情况。结果技术成功率100%。患者术中均未使用转流管,32例使用人工血管补片,2例使用颈外静脉补片,11例未使用补片。29例患者内膜剥脱后颈动脉血运重建满意,未行进一步治疗;16例行普通球囊扩张;均未行支架植入。患者围手术期的主要终点事件发生率为6.66%(3例),包括1例心肌梗死,2例同侧脑卒中,术后高灌注综合征发生率8.88%,无严重颅神经损伤发生。患者术后1年的主要终点事件发生率13.2%(6例),2例发生急性心肌梗死,其中1例死亡;1例术后6个月发生同侧颈内动脉重度狭窄。结论复合技术治疗CNO伴远端完全塌陷可以取得较好的近期疗效。

Cardioembolic occlusion of the internal carotid artery presented with infarction in the posterior cerebral artery territory

Posterior circulation stroke may rarely be associated with occlusive disease in the anterior circulation, such as in the context of a direct （fetal） origin of the posterior cerebral artery （PCA） from the internal carotid artery （ICA）, or in the presence of a persistent trigeminal artery （PTA） or persistent hypoglossal artery （PHA）. Usually, they happened as infarction involving both ipsilateral carotid and posterior cerebral artery territories with carotid atherosclerosis etiology.3 Here, we reported a rare case with cadioembolic occlusion of the ICA presented with infarction mainly in the PCA territory.

The comparison of STA-MCA bypass and BMT for symptomatic internal carotid artery occlusion disease:a systematic review and meta-analysis of long-term outcome

Background:Superficial temporal artery(STA)-middle cerebral artery(MCA)bypass surgery is now being widely used in moyamoya disease,and its therapeutic value in SICAO remains divergent.Methods:A systematic search was performed in PubMed,EMBASE,and Cochrane Databases in Feb.2020 and updated in Jun.2019.We have strict inclusion and exclusion criteria.Cochrane Bias Risk Assessment Tool was used to assess the quality of included RCTs.Review Manager 5.3 was used for analysis results in terms of comparing the STA-MCA bypass and BMT.For dichotomous variable outcomes,risk ratios(RRs)and 95%confidence intervals(95%CIs)were calculated for the assessment.Results:The total patient cohort consisted of 2419 patients,of whom 1188(49.1%)patients had been grouped in STA-MCA bypass and 1231(50.9%)patients had been divided into the BMT group.Mean follow-up of included patients was 29 months.The RR of the seven studies was 1.01,and the 95%confidence interval was.89–1.15,with statistical significance,Z=.13,P=.89,sustaining that STA-MCA bypass was not superior to BMT in symptomatic carotid artery occlusion disease.Conclusions:STA-MCA bypass and BMT were associated with similar rates of a composite of long-term stroke.And the risk of long-term overall stroke was mildly higher with BMT.At present,each patient should receive more precise treatment,by reasonably assessing the individual differences of each patient to reduce the recurrence rate of stroke.

基于CTA数据后处理对颈内动脉狭窄处血流动力学特点的研究

目的 基于头颈部CTA影像数据建立计算流体力学(CF)仿真模型,研究颈内动脉狭窄处的血流动力学特点。方法 回顾性分析蚌埠医学院第二附属医院2021-05—2023-03符合纳入标准的30例患者,运用脑血管三维重建技术对颈动脉及颈内动脉进行3D模型重建,并进行血流动力学参数分析测量及统计,测得颈内动脉狭窄处的壁面剪切应力(WSS)、时间平均壁面剪切应力(TAWSS)、震荡剪切指数(OSI)、相对滞留时间(RRT)并分析各项参数之间的相关性及差异性。结果 颈内动脉狭窄区域的WSS、TAWSS、OSI、RRT分别为58.669 3(43.882 0,65.979 2)、18.695 8(14.973 8,25.534 6)、0.074 6(0.063 3,0.085 4)、0.092 3(0.082 2,0.109 6),正常侧WSS、TAWSS、OSI、RRT分别为15.215 3(9.039 7,25.117 2)、5.138 2(3.373 4,6.139 9)、0.122 7(0.099 7,0.151 2)、0.712 3(0.519 0,0.821 7)。颈内动脉狭窄处的血流速度及血流量分别为1.925 9±0.125 5、4.374 1±0.277 9,正常侧的血流速度及血流量分别为0.992 6±0.074 7、6.190 7±0.260 9。狭窄区域的WSS、TAWSS明显增大,OSI和RRT相对较小,血流速度明显增大,同时伴随较小的血流量,差异均有统计学意义(P<0.05)。结论 颈内动脉狭窄处的血流动力学因素较正常侧发生明显变化,可通过CFD仿真模拟分析方法评估血流动力学因素变化程度,帮助分析颈内动脉狭窄患者的危险程度,辅助临床诊断、治疗及预后评估。

颈动脉支架植入术联合规范脑血管病二级预防对颈内动脉颅外段重度狭窄患者的效果观察

目的探究颈动脉支架植入术联合规范脑血管病二级预防对颈内动脉颅外段重度狭窄患者认知功能影响的效果。方法选取2021年9月至2023年3月期间在济南市第三人民医院收治的68例颈内动脉颅外段重度狭窄患者,根据治疗方式不同将其分为对照组和观察组各34例。基础疾病治疗基础上,对照组采取规范的脑血管病二级预防,观察组完成颈动脉支架植入术,并坚持规范的脑血管病二级预防,比较两组精神状态、认知功能、不良情绪、日常生活活动能力及神经功能缺损评分情况。结果治疗后,两组患者的简易精神状态量表(MMSE)、蒙特利尔认知评估量表(MoCA)评分均有所提高,且观察组高于对照组,差异有统计学意义(P<0.05)。治疗后,两组患者的汉密尔顿焦虑量表(HAMA)和汉密尔顿抑郁量表(HAMD)评分均有所下降,且观察组低于对照组,差异有统计学意义(P<0.05)。治疗后,两组患者的日常生活能力评定量表(ADL)评分均有所提高,且观察组高于对照组,差异有统计学意义(P<0.05)。治疗后,两组患者的神经功能缺损(NIHSS)评分均有所降低,观察组低于对照组,差异有统计学意义(P<0.05)。结论颈动脉支架植入术联合规范脑血管病二级预防能够显著改善颈内动脉颅外段重度狭窄患者的精神状态、认知功能、不良情绪、日常生活活动能力和神经功能缺损。这一治疗策略有助于提升患者的生活质量和康复效果。

远端塌陷型颈内动脉假性闭塞腔内治疗的中远期疗效

目的探讨颈动脉支架植入术(carotid artery stenting,CAS)应用于远端塌陷型颈内动脉假性闭塞患者的中远期疗效。方法回顾性分析2018年1月至2019年12月复旦大学附属中山医院43例用CAS治疗的远端塌陷型颈内动脉假性闭塞患者临床资料,观察CAS的技术成功率、围手术期并发症发生率、5年支架内再狭窄率和免于同侧脑梗/死亡/心梗率。结果手术技术成功率100%。围手术期1例患者出现高灌注综合征,并发症发生率2.3%。患者术后随访36.5~68.1个月,中位随访时间为63.0个月,3例发生支架内再狭窄,同侧脑梗死复发5例,死亡2例,无心肌梗死。随访5年免于支架内再狭窄率为91.2%。5年免于死亡/心梗/同侧脑梗率为82.7%。结论CAS应用于颈动脉远端塌陷型假性闭塞患者的技术成功率和中远期疗效均满意。

非急性症状性颈内动脉闭塞患者血管内再通治疗失败的影响因素分析

目的探讨非急性症状性颈内动脉闭塞(Internal Carotid Artery Occlusion,ICAO)患者血管内再通治疗失败的影响因素。方法方便选择2017年1月—2023年8月广西医科大学附属武鸣医院收治的54例非急性症状性ICAO患者作为研究对象,对患者进行血管内再通治疗,根据手术结果分为成功组(n=48)和未成功组(n=6),收集患者临床资料,分析患者血管内再通成功率、颈内动脉闭塞开通失败影响因素。结果非急性症状性颈内动脉闭塞患者血管内再通治疗成功率为88.89%,成功组高血压、冠心病、高脂血症比例低于未成功组,差异有统计学意义(P均<0.05),两组患者其余各项指标比较,差异无统计学意义(P均>0.05);Lo⁃gistic多因素回归分析显示:高血压、冠心病、高脂血症为颈内动脉闭塞开通失败独立危险因素(OR=1.328、1.521、1.234,P均<0.05)。结论血管内再通治疗非急性症状性ICAO,血管内再通成功率高,但高血压、冠心病、高脂血症因素也会对患者预后状况产生不良影响。因此,仍需进行长期随访,进一步观察血管内再通治疗的可行性和安全性。

颈内动脉闭塞患者预后相关因素研究

目的探讨影响颈内动脉闭塞(ICAO)患者预后的相关因素,为临床改善ICAO患者预后提供理论依据。方法回顾性分析2017—2022年广西医科大学附属武鸣医院因ICAO入住神经内科的131例患者,根据ICAO发病时间分为急性颈内动脉闭塞(AICAO)和慢性颈内动脉闭塞(CICAO),根据预后的不同,分为预后良好和预后不良组,比较两组的基本信息(性别、年龄等)、既往病史(包括高血压、糖尿病、冠心病等)、发病时神经功能损害程度(美国国立卫生研究院卒中神经功能缺损评分NIHSS评分)、侧支循环代偿评分、介入手术开通治疗、出血转化之间的差异,分析影响患者预后的相关因素。结果CICAO患者总体预后良好,AICAO预后良好组患者发病时NIHSS评分<6分、侧支循环代偿良好比例高于预后不良组,而出血转化率低于预后不良组,组间比较差异均有统计学意义(P<0.05)。二分类Logistic回归分析显示,发病时NIHSS评分、侧支循环代偿评分、介入手术开通治疗、出血转化、次全闭塞对AICAO预后影响有统计学意义(P<0.05)。两组间的基本信息、既往病史、介入手术开通治疗等比较差异无统计学意义(P>0.05)。结论CIACO较AICAO总体预后良好,发病时NIHSS评分<6分、侧支循环代偿良好、无出血转化是IACO预后良好的相关因素。发病时NIHSS评分高、侧支循环代偿不良、出血转化是ACAO预后不良的危险因素。