Carotid artery stenting (CAS) is now covered by health insurance and several different stents and embolic protection devices (EPD) exist. Currently available stents include open-cell design and closed-cell design, and available EPD include filter-type and balloon-type. By selecting the appropriate devices for each case, we are able to expand the applicability of CAS. Although CAS has certain limitations, including allergy to the contrast medium, difficulty in access route, cholesterin crystal embolization, allergy to antiplatelet drugs, caltification, and ischemic heart disease, these limitations can be overcome by means of modern technology.
Cranial nerve palsy occurring after carotid endarterectomy (CEA) is the most common recognized complication, along with others such as stroke and myocardial infarction (MI). We examined the incidence and follow-up of cranial nerve palsy and other periprocedural major adverse events in 216 consecutive CEAs performed between January 2006 and December 2012. Six cranial nerve palsies (2 dysphonia, 1 dysphagia, 1 tongue hemiparesis, and 2 first bite syndromes) were identified in 4 patients (1.9%). All symptoms were transient and the patients recovered within 3 months. The incidence of perioperative stroke, death, and MI was 0%. Diffusion-weighted imaging performed on the day after surgery revealed an asymptomatic single spotty lesion in only 2 patients (0.9%). An optimal and meticulously conducted surgery based on a thorough knowledge of surgical anatomy could enable surgeons to avoid cranial nerve palsy and other major complications associated with CEA.
Topics: Various issues regarding cervical carotid artery stenosis - Original Articles
Previous randomized clinical trials have reported the advantage of surgical treatment in reducing the risk of stroke compared with medical therapy alone in asymptomatic carotid artery stenosis. However, recent advances in medical treatment have resulted in a decline in the risk of stroke in patients with asymptomatic carotid artery stenosis treated medically. Therefore, we aimed to assess the surgical and long-term outcomes of patients with asymptomatic carotid artery stenosis in our hospital, and to identify high-risk patients. Between August 2006 and December 2013, 216 consecutive carotid artery revascularization procedures with carotid endarterectomy (CEA; 129 procedures) or carotid artery stenting (CAS; 87 procedures) for carotid artery stenosis were performed in our hospital. There were 123 patients with asymptomatic carotid artery stenosis (71 CEAs and 52 CASs) and 93 patients with symptomatic carotid artery stenosis (58 CEAs and 35 CASs). The main indications for surgical treatment of asymptomatic carotid artery stenosis were as follows: mobile plaque (4.1%), severe stenosis (≥80%) (41%), progression of stenosis (21%), restenosis (4.7%), need to lower the perioperative risk of another surgery (8.1%), and vulnerable plaques on carotid artery ultrasound or magnetic resonance imaging. Perioperative complication rate (any stroke or death within 30 days) was 1.6% in the asymptomatic group and 5.4% in the symptomatic group, which was not significantly different. The average annual estimated 5-year risk of perioperative events and ipsilateral stroke was 0.67%, and that of perioperative events and any stroke was 1.4% in asymptomatic stenosis, which were comparable to the best results of medical treatment. Our findings showed that aggressive surgical treatment for asymptomatic carotid artery stenosis in high-risk patients may reduce the risk of further stroke. Further studies are needed to clarify this point.
Background: Cerebral hyperperfusion after carotid endarterectomy (CEA) is an important target for perioperative care, as it can lead to postoperative intracerebral hemorrhage (ICH), a devastating complication. Previous reports have suggested that quantitative single-photon emission computed tomography (SPECT) is useful for detecting and predicting cerebral hyperperfusion. The purpose of this study was to examine retrospectively the validity and usefulness of quantitative SPECT for perioperative care in our department. Methods: Fifty-eight patients undergoing CEA were preoperatively assessed by SPECT for cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to acetazolamide. We defined hyperperfusion tendency as a > 100% increase compared with preoperative values or focal hyperperfusion with a right/left difference compared with contralateral values. We strictly controlled postoperative blood pressure in patients with preoperatively reduced CVR, acute major stroke, or postoperative hyperperfusion tendency. Results: Postoperative hyperperfusion tendency was found in eight patients (13.8%), but only one of these showed classic hyperperfusion, marked by a > 100% increase. No patient developed ICH, but two patients developed renal dysfunction and required temporary dialysis due to induced hypotension. As reported previously, we found that reduced preoperative CVR and a high degree of stenosis were significant risk factors for hyperperfusion tendency. The hyperperfusion tendency of patients with acute cerebral infarction tended to progress slowly. Conclusion: Selective blood pressure control based on pre- and postoperative quantitative SPECT analysis is useful. Postoperative management of patients with acute cerebral infarction and overestimation of the hyperperfusion tendency due to the variability in quantitative SPECT requires further attention.
Aging is a risk factor for atheromatous carotid artery stenosis and also for many cancers. The aim of this study was to explore the relationship between cancer and severe carotid stenosis requiring carotid endarterectomy (CEA). We retrospectively reviewed data obtained from 97 patients (92 men and 5 women; mean age: 76 years) who underwent CEA and were followed for more than six months at our institution. The follow-up period ranged from 6 months to 11 years (mean: 3.6 years). We divided the patients into four groups based on the timing between CEA and cancer: group 1 had a past history of cancer; group 2 underwent CEA during medical treatment for cancer; group 3 underwent CEA before surgery for cancer because severe carotid stenosis was detected by ultrasonography; and group 4 developed cancer after CEA. Five patients died during follow-up after CEA, and three of them died of cancer. Group 1 included 10 patients, among whom five received radiotherapy to the neck. CEA was performed safely in this group. Group 2 comprised two patients (one each with esophageal cancer and bilateral parotid cancer). Group 3 also included two patients, both of whom had colon cancer and severe carotid stenosis detected by ultrasonography before cancer surgery. They underwent laparoscopic tumor resection soon after CEA while off of antiplatelet medication. Group 4 had a total of eight patients. None of the patients developed ischemic stroke during surgery after stopping antiplatelet medication. In Japan, the population is aging rapidly, so the relationship between cancer and carotid stenosis will become more important over time. We identified the following points about the relationship between CEA and cancer from our experience: 1) CEA should be performed with the assumption that the patient will undergo cancer surgery in the future. 2) As ultrasonography becomes more common, detection of asymptomatic severe carotid stenosis may increase, necessitating decisions about the order of and method for treating both carotid stenosis and cancer. 3) CEA can be performed safely even after irradiation of the neck in our experience. 4) CEA was also performed safely in one patient with massive bilateral parotid tumors.
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Rendu-Weber disease, is an autosomal dominant disorder that results from multi-system vascular dysplasia. It is not a rare condition, but is under-recognized, and is characterized by the presence of mucocutaneous telangiectases and arteriovenous malformations (AVMs) of the brain, lung, liver, and spinal cord. Neurological manifestations may develop due to paradoxical embolisms from a pulmonary AVM or hemorrhage of AVMs of the brain and spinal cord. This article summarizes the clinical features of HHT as well as its treatment, and also emphasizes the need for a high index of suspicion for this disease in patients with characteristic clinical manifestations.
Vascular reconstruction is often essential for the treatment of complex intracranial saccular or dissecting aneurysms. We describe the use of a short interposed graft using the saphenous vein or radial artery to connect the proximal side of the superficial temporal artery (STA) and the recipient's intracranial artery (e.g., the M2 or M3 segment of the middle cerebral artery or the A3 segment of the anterior cerebral artery). In this procedure, the STA and the short interposed graft are anastomosed in side-to-end fashion so that the distal side of the STA is preserved. In this way, the blood flow of the scalp skin flap is not disturbed. Bypass surgery using a short interposed graft was performed between December 2007 and January 2014 in 7 patients with complex intracranial aneurysms requiring parent artery occlusion or trapping. All 7 patients demonstrated good recovery according to the Glasgow Outcome Scale. No newly developed neurological deficits related to bypass surgery were observed in any of the 7 patients, all of whom had good graft patency after surgery. No scalp skin problems were observed. Short interposed grafting from the proximal side of the STA to the recipient intracranial artery without occlusion of the distal side of the STA is effective after occlusion of the parent artery. This “moderate flow bypass” technique may be a effective alternative to high-flow bypass surgery.
Transient neurological deterioration is relatively common after superficial temporal artery-middle cerebral artery bypass surgery for the treatment of moyamoya disease. Evaluation of postoperative cerebral blood flow (CBF) indicated that these symptoms could be associated with hemodynamic alteration. To prevent permanent neurological damage, timely and adequate management of this status is required. However, there is currently no intraoperative evaluation system to predict transient neurological deterioration in the postoperative period. Therefore, in this preliminary study, we evaluated quantitative cortical blood flow using indocyanine green videoangiography, ultrasonic blood flowmeter, and a dedicated software in a case of moyamoya disease. As a result, substantial increase of focal cortical blood flow was calculated by the software. However, no postoperative neurological deterioration was observed, and the postoperative CBF evaluation showed no hyperemia or ischemic status. This system might be useful; however, further evaluation is essential.
Surgical treatment for recurrent aneurysms after clipping or coiling is generally more difficult than the initial treatment. Patients and Methods: This study included 14 patients (3 males and 11 females, mean age 58 years-old) who were surgically treated owing to a remnant aneurysm or recurrence of an aneurysm, after initial surgery or endovascular coil embolization. Patient characteristics and strategy for reoperation were retrospectively reviewed. Results: There were 8 ruptured and 6 unruptured aneurysms before the initial treatment with surgery (7 clipping cases and 1 wrapping case: surgical group) or coil embolization (6 cases: coil group). Presentation before the second surgery was rupture in 2 cases, and remnant or enlargement of the aneurysm in 12 cases. In the surgical cases, the most frequent aneurysm sites were the internal carotidposterior communicating artery, and middle cerebral artery; in the coiled patients, the sites varied. Intervals between the initial treatment and retreatment owing to aneurysmal growth or rupture were 13.5 and 1.5 years in the surgical and coil groups, respectively. In both the surgery and coil groups, incomplete occlusion of the aneurysm was considered to be a factor of regrowth. The second surgery was neck clipping in 10 cases (71%), and bypass followed by parent artery occlusion in 3 cases. Among 10 clipping cases, a previous clip or coil had to be removed in 6, and bypass was used to assist temporary proximal occlusion. In one case treated with bypass and parent artery occlusion, transient ischemic symptoms occurred, but improved after antiplatelet administration. The Glasgow outcome scale at discharge showed good recovery in all cases, except for one with moderate disability due to preexisting hemiparesis. Conclusion: Regrowth in both the surgery and coil groups was associated with incomplete occlusion and large size in the coil group. Surgical retreatment can be successfully accomplished with a strategy that includes careful dissection of the adhesive tissues, clip/coil removal, bypass to assist temporary proximal occlusion, and bypass with parent artery occlusion.
We describe 5 cases of non-sinus type parasagittal dural arteriovenous fistulas (d-AVF) that had shunts that were drained exclusively by cortical veins without any sinus interposition. Between August 2009 and August 2014, we treated 5 cases of non-sinus type parasagittal d-AVF (4 men and 1 woman; mean age, 64.8 years). All cases were classified as Cognard type IV. Two cases presented with intracerebral hemorrhage, whereas the condition was identified incidentally in 3 cases. All patients underwent radical treatment, including transarterial embolization (TAE) alone in 1 case, surgical interruption of the draining vein in 2 cases, and TAE and surgical interruption of the draining vein in 2 cases, without any complications. During surgery in 4 cases, it was found that the draining vein and shunt point were attached to the depths of the falx cerebri, which was most likely related to the falcine venous plexus. This finding appears to be a notable feature of non-sinus type parasagittal d-AVF. Hence, non-sinus type parasagittal d-AVF should be considered as a separate clinical entity from the general superior sagittal sinus d-AVF.
A 56-year-old woman presented with sudden-onset headache and nausea. She was transferred to our hospital from a local hospital after subarachnoid hemorrhage and unilateral moyamoya disease were diagnosed by computed tomography and magnetic resonance angiography. On admission, she showed no disturbance of consciousness or neurologic deficits. Cerebral angiography showed an anterior communicating artery aneurysm (3 mm in maximum diameter), stenosis at the end of the right internal carotid artery, and abundant ipsilateral moyamoya vessels. On the same day, endovascular embolization was performed using six coils, and the aneurysm was completely occluded with preservation of the parent artery. After embolization, neither symptomatic cerebral vasospasm nor hydrocephalus occurred. The patient was discharged without neurologic deficits. According to several reports, it is difficult to perform direct surgery for a ruptured aneurysm associated with moyamoya vessels because of technical difficulties attributable to the abundance of collateral vessels in the operative field and postoperative cerebral ischemia due to collateral vessel injury. Endovascular embolization for an anterior communicating artery aneurysm associated with unilateral moyamoya disease is a good option for cases in which direct surgery is difficult.
We report a case of external carotid artery (ECA) angioplasty and stenting followed by superficial temporal artery (STA) to middle cerebral artery (MCA) bypass for internal carotid artery occlusion with ipsilateral ECA stenosis. A 63-year-old patient presented with moderate left hemiparesis, and imaging studies revealed cerebral infarction at the right corona radiata and right cervical internal carotid artery (ICA) occlusion with severe ipsilateral ECA stenosis. Preventive angioplasty and stenting for ECA stenosis were initially performed to ensure sufficient blood flow to the STA. After 4 weeks, double STA-MCA anastomoses were performed to augment cerebral perfusion. The patient had no postoperative cerebrovascular complications. This therapeutic strategy is thus safe and effective for cerebral blood vessel reconstruction.