CT Angiography Manual Multiplanar Vessel Diameter Measurement vs. Semiautomated Perpendicular Area Minimal Caliber Computation of Internal Carotid Artery Stenosis

Objective: To determine the diagnostic agreement of CT angiography (CTA) manual multiplanar reformatting (MPR) stenosis diameter measurement and semiautomated perpendicular stenosis area minimal caliber computation of extracranial internal carotid artery (ICA) stenosis.Methods: We analyzed acute cerebral ischemia CTA at our tertiary stroke center in a 12-month period. Prospective NASCET-type stenosis grading for each ICA was independently performed using (1) MPR to manually determine diameters and (2) perpendicular stenosis area with minimal caliber semiautomated computation to grade luminal constriction. Corresponding to clinically relevant NASCET strata, results were grouped into severity ranges: normal, 1–49%, 50–69%, and 70–99%, and occlusion.Results: We included 647 ICA pairs from 330 patients (median age of 74 [66–80, IQR]; 38–92 years; 58% men; median NIHSS 4 [1–9, IQR]). MPR diameter and semiautomated caliber measurements resulted in stenosis grades of 0–49% in 143 vs. 93, 50–69% in 29 vs. 27, 70–99% in 6 vs. 14, and occlusion in 34 vs. 34 ICAs (p = 0.003), respectively. We found excellent reliability between repeated manual CTA assessments of one expert reader (ICC = 0.997; 95% CI, 0.993–0.999) and assessments of two expert readers (ICC = 0.972; 95% CI, 0.936–0.988). For the semiautomated vessel analysis software, both intrarater reliability and interrater reliability were similarly strong (ICC = 0.981; 95% CI, 0.952–0.992 and ICC = 0.745; 95% CI, 0.486–0.883, respectively). However, Bland–Altman analysis revealed a mean difference of 1.6% between the methods within disease range with wide 95% limits of agreement (−16.7–19.8%). This interval even increased with exclusively considered vessel pairs of stenosis ≥1% (mean 5.3%; −24.1–34.7%) or symptomatic stenosis ≥50% (mean 0.1%; −25.7–26.0%).Conclusion: Our findings suggest that MPR-based diameter measurement and the semiautomated perpendicular area minimal caliber computation methods cannot be used interchangeably for the quantification of ICA steno-occlusive disease.

Carotid Artery Stenosis and ischemic Strokes in Patients with Giant Cell Arteritis A characteristic Pattern - Literature Review and Case Report

Purpose: Ischemic stroke is a relatively rare complication of giant cell arteritis often accompanied by vessel stenosis. Our purpose was to compare the location of internal carotid artery stenosis in GCA patients by performing a literature review suggesting a specific and characteristic pattern. Methods: We performed a Pubmed research including all articles and cited articles reporting cases and case series about giant cell arteritis patients with internal carotid artery stenosis and ischemic strokes. Results: In this case series 39 cases were included. We found a clear tendency of giant cell arteritis related stenosis to be in the intracranial segments (35/39 (89,7 %)). Only in 8/39 (20,5 %) patients there was further involvement of extracranial segments. Many cases (27/39 (69,2 %)) showed a bilateral involvement. Discussion: This literature review reveals a specific pattern of internal carotid artery involvement in patients with giant cell arteritis and ischemic strokes. To our knowledge this pattern has not been reported as a sign strongly pointing towards giant cell arteritis before. We have not found case reports mentioning other common types of vasculitis reporting this involvement pattern. Conclusion: Internal carotid artery stenosis and ischemic stroke is a rare complication in patients with giant cell arteritis. Considering the characteristic features of bilateral distal internal carotid artery stenosis giant cell arteritis should be suspected which potentially leads to an early diagnosis and immunotherapy.

Seizures 3 Months After Endarterectomy

A 57-year-old woman had development of acute-onset, right-sided weakness and sensory change (face, arm, and leg) when at a casino. She was brought to the emergency department, and her symptoms had essentially resolved upon her arrival. Brain magnetic resonance imaging showed no acute stroke, and a transient ischemic attack was diagnosed. She was transferred to an academic medical center. Investigations showed high-grade left internal carotid artery stenosis; the same day, a stent was placed via endovascular procedure by an interventional neuroradiologist. Magnetic resonance imaging of the head showed an enhancing lesion with surrounding edema in the left frontal and parietal lobes at the cortex, also involving the nearby leptomeninges. Electroencephalography showed potentially epileptogenic discharges over the left central head region. Brain biopsy was performed, which showed abundant CD68+ macrophages, granulomatous inflammation, and necrosis associated with foreign material. The associated lymphocytic infiltrates were predominantly composed of CD3+ T cells and only sparse CD20+ B cells. The foreign material seen was lamellated, amorphous, nonpolarizable, and nonrefractile, typical of hydrophilic polymers commonly used in intravascular medical devices. The patient was diagnosed with seizures caused by multifocal, intracranial, foreign-body, granulomatous reaction to polymers that had embolized to brain parenchyma during the prior endovascular procedure. To suppress this inflammatory reaction, corticosteroids were initiated—intravenous methylprednisolone, followed by an oral prednisone course, with a plan to gradually taper. Antiseizure medication was continued at the same doses. The patient’s seizures remitted initially but relapsed upon corticosteroid dose reduction despite a very slow prednisone taper. At that point, 18 months after the initial onset of seizures, the patient had cushingoid features, depression, and chronic insomnia. During the next year, 2 steroid-sparing strategies were employed sequentially. In patients who have received neurovascular medical device therapy and have subsequent development of seizures, focal neurologic deficit, headache, or encephalopathy, central nervous system inflammation triggered by retained foreign-body material should be considered as a potential cause.

Skull shape abnormalities in ischemic cerebrovascular and mental diseases in adults

Morphological changes in the child skull due to mechanical and metabolic stimulation and synostosis of the suture are well known. On the other hand, few studies have focused on clinical conditions relevant for adult skull deformity. We retrospectively reviewed computed tomography (CT) findings obtained from 365 cases that were treated for head injuries, moyamoya disease, cervical internal carotid artery stenosis, and mental diseases, and investigated the morphological changes in the skull associated with these diseases. The findings from head injuries were used not only for control subjects, but also for the analysis of generational changes in skull shape based on birth year. Head shape had a brachiocephalic tendency with occipital flattening in people born from the 1950s onwards. Cases of moyamoya disease, cervical internal carotid artery stenosis, and mental diseases showed significantly thicker frontal and occipital bone than those of control subjects. The skull thickening was especially noticeable in the frontal bone in moyamoya disease. Plagiocephaly was significantly frequent in moyamoya disease. These uncommon skull shapes are useful CT findings in screening subjects for early evidence of mental diseases and intracranial ischemic diseases with arterial stenosis.

Stepwise improvement in limb shaking achieved by staged angioplasty for severe carotid stenosis

Cerebral hyperperfusion syndrome is a rare but severe complication of carotid artery stenting or carotid endarterectomy. Staged angioplasty is reportedly an effective strategy to avoid cerebral hyperperfusion syndrome. We encountered a case of internal carotid artery stenosis with a rare clinical presentation of limb shaking that was successfully improved by staged angioplasty. To our knowledge, there are no reported cases of limb shaking treated with staged angioplasty. A 76-year-old woman presented with continuous chorea in her left lower limb and shoulder. Medical examination revealed a tiny cerebral infarction in the right corona radiata and severe right internal carotid artery stenosis. Angiography showed near occlusion of the right internal carotid artery. Staged angioplasty was performed to avoid the risk of cerebral hyperperfusion syndrome. The first angioplasty resulted in an expanded diameter of 2.5 mm and was followed by definitive carotid artery stenting using a closed-cell stent 3.5 weeks later. Limb shaking improved in a stepwise manner along with an improvement in internal carotid artery stenosis and distal flow state with no signs of cerebral hyperperfusion syndrome. Patients with internal carotid artery stenosis or occlusion presenting with limb shaking have been suggested to have impaired cerebrovascular reactivity, which is also thought to be a risk factor for cerebral hyperperfusion syndrome. The stepwise improvement in limb shaking observed in this case supports the idea that the pathophysiology of limb shaking is related to cerebral haemodynamic impairment. Measures to prevent cerebral hyperperfusion syndrome, including staged angioplasty, should be actively considered in patients with limb shaking because the symptoms themselves suggest severe hypoperfusion.