Cerebral perfusion in patients with unilateral internal carotid artery occlusion by dual post-labeling delays arterial spin labeling imaging

BACKGROUND Global and regional cerebral blood flow(CBF)changes in patients with unilateral internal carotid artery occlusion(ICAO)are unclear when the dual post-labeling delays(PLD)arterial spin labeling(ASL)magnetic resonance imaging(MRI)technique is used.Manual delineation of regions of interest for CBF measurement is time-consuming and laborious.AIM To assess global and regional CBF changes in patients with unilateral ICAO with the ASL-MRI perfusion technique.METHODS Twenty hospitalized patients with ICAO and sex-and age-matched controls were included in the study.Regional CBF was measured by Dr.Brain's ASL software.The present study evaluated differences in global,middle cerebral artery(MCA)territory,anterior cerebral artery territory,and Alberta Stroke Program Early Computed Tomography Score(ASPECTS)regions(including the caudate nucleus,lentiform nucleus,insula ribbon,internal capsule,and M1-M6)and brain lobes(including frontal,parietal,temporal,and insular lobes)between ICAO patients and controls at PLD 1.5 s and PLD 2.5 s.RESULTS When comparing CBF between ICAO patients and controls,the global CBF in ICAO patients was lower at both PLD 1.5 s and PLD 2.5 s;the CBF on the occluded side was lower in 15 brain regions at PLD 1.5 s,and it was lower in 9 brain regions at PLD 2.5 s;the CBF in the contralateral hemisphere was lower in the caudate nucleus and internal capsule at PLD 1.5 s and in M6 at PLD 2.5 s.The global CBF in ICAO patients was lower at PLD 1.5 s than at PLD 2.5 s.The ipsilateral CBF at PLD 1.5 s was lower than that at PLD 2.5 s in 15 regions,whereas the contralateral CBF was lower at PLD 1.5 s than at PLD 2.5 s in 12 regions.The ipsilateral CBF was lower than the contralateral CBF in 15 regions at PLD 1.5 s,and in M6 at PLD 2.5 s.CONCLUSION Unilateral ICAO results in hypoperfusion in the global and MCA territories,especially in the ASPECTS area.Dual PLD settings prove more suitable for accurate CBF quantification in ICAO.

Emergency internal iliac artery temporary occlusion after massive hemorrhage during surgery of cesarean scar pregnancy:A case report

BACKGROUND Cesarean scar pregnancy(CSP)is rare but may result in uterine rupture during pregnancy or massive hemorrhage during abortion procedures.Awareness of this condition is increasing,and most patients with CSP are now diagnosed early and can be managed safely.However,some atypical patients are misdiagnosed,and their surgical risks are underestimated,increasing the risk of fatal hemorrhage.CASE SUMMARY A 27-year-old Asian woman visited our institution because of abnormal pregnancy,and she was diagnosed with a hydatidiform mole through transvaginal ultrasound(TVS).Under hysteroscopy,a large amount of placental tissue was found in the scar of the lower uterine segment,and a sudden massive hemorrhage occurred during the removal process.The bilateral internal iliac arteries were temporarily blocked under laparoscopy,and scar resection and repair were rapidly performed.She was discharged in good condition 5 d after the operation.CONCLUSION Although TVS is widely used in the diagnosis of CSP,delays in the diagnosis of atypical CSP remain.Surgical treatment following internal iliac artery temporary occlusion may be an appropriate management method for unanticipated massive hemorrhage during CSP surgery.

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.

Imaging characteristics and treatment strategies for carotid artery occlusion caused by skull base fracture

The internal carotid artery occlusion caused by head and neck trauma,also known as traumatic intracranial artery occlusion,is relatively rare clinically.Traumatic skull base fracture is a common complication of traumatic brain injury.Traumatic skull base fracture is one of the causes of traumatic internal carotid artery occlusion.If not detected early and treated in time,the prognosis of patients is poor.This editorial makes a relevant analysis of this disease.

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.

Dissection-related carotid-cavernous fistula(CCF)following surgical revascularization of chronic internal carotid artery occlusion:a new subtype of CCF and proposed management

Background:The development of carotid-cavernous fistulas(CCFs)during surgical recanalization of chronic internal carotid artery occlusion(ICAO)may be secondary to severe ICA dissection rather than a focal tear of the cavernous ICA seen in typical traumatic CCFs.The purpose of this study is to investigate the causal relationship between the CCFs and severe ICA dissections and to characterize technical outcomes after treatment with stenting.Methods:Five patients underwent treatment with self-expanding stents due to intraprocedural CCF and ICA dissection following surgical removal of ICAO plaque.The stents were telescopically placed via true channel of the dissection.Safety of the procedure was evaluated with 30-day stroke and death rate.Procedural success was determined by the efficacy of CCF obliteration and ICAO recanalization with angiography.Results:All CCFs were associated with spiral and long segmental dissection from the cervical to cavernous ICA.After stenting,successful dissection reconstruction with TICI 3 was achieved in all patients,with complete(n=4)or partial CCF(n=1)obliteration.No patient had CCF syndrome,stroke,or death during follow-up of 6 to 37 months;but one patient had pulsatile tinnitus,which resolved 1 year later.Angiography at 6 to 24 months demonstrated CCF obliteration in all 5 patients and durable ICA patency in 4 patients.Conclusions:Intraprocedural CCFs with spiral and cervical-to-cavernous ICA dissection during ICAO surgery are dissection-related because of successful obliteration after stenting for dissection reconstruction.Self-expanding stenting through true channel of the dissection,serving as implanting stent-autograft,may be an optimal therapy for the atypical CCF complication from ICAO surgery.

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.

Research Progress of Chronic Internal Carotid Artery Occlusion

Chronic internal carotid artery occlusion(CICAO)is a chronic cerebrovascular disease which,from various causes,leads to progressive stenosis of the internal carotid artery lumen and finally to complete occlusion.With an aging society,the detection rate of CICAO is increasing year by year,with the highest incidence of CICAO in elderly men.The main clinical manifestations of CICAO are ischemic stroke and transient ischemic attack.Drug therapy is the first choice for asymptomatic CICAO,and surgical treatment is an optional means of improving prognosis for symptomatic CICAO that cannot be controlled by drugs.The selection of indications needs further study.This article reviews the latest research progress in the epidemiology,etiology,clinical features,imaging analysis,and treatment of CICAO in order to guide clinical diagnosis and treatment.

Balloon occlusion test and therapeutic occlusion ontrau m atic carotid cavernous fistulas

Objective: To evaluate the safety of the balloon occlusion test(BOT) and therapeutic occlusion of the internal carotid artery(ICA). Methods: The data of 43 patients hospitalized consecutively with traumatic intractable carotid cavernous fistulas (TICCF) were analyzed. Therapeutic occlusion of ICA was performed on 39 cases and BOT was only performed on the remaining 4 cases. Our assessment consisted of: (1) angiographic evaluation of collateral circulation with or without BOT of ICA, and (2) evaluation of clinical tolerance to therapeutic occlusion of ICA with hypotensive challenge for 30 minutes. Complications of BOT and therapeutic occlusion of ICA were also analyzed retrospectively. Results: Complications related to BOT occurred in 1 case (2.3%) without causing permanent deficits. Complications related to therapeutic occlusion of ICA occurred in 4 cases (10%), including 1 technical (2.5%), 2 temporary (5%) and 1 permanent (2.5%) deficit. There was no fistula recurrence or mortality. Conclusions: BOT of ICA is safe and economical. The reliability of the results is almost the same compared with that of other more complicated methods of assessing therapeutic occlusion of ICA. And it is easy to treat TICCF with therapeutic occlusion of ICA.