Abstract 1122‐000078: C‐Guard Stent for the Treatment of Cervical Internal Carotid Artery Aneurysms: Report of 2 Cases

Introduction : C‐Guard carotid stent is a self‐expandable open cell stent covered with a double‐layer mesh which was developed for the treatment of internal carotid artery disease. Lower procedural and complications rates, as well as lower post‐operative infarctions are some advantages of this device. Nevertheless, the use of C‐Guard in the treatment of cervical internal carotid artery (ICA) aneurysms is scarce. Therefore, we present two cases in which the C‐Guard stent achieved complete angiographic occlusion at follow‐up. Methods : We identified two cases in which the C‐Guard carotid stent was used to treat symptomatic cervical ICA aneurysms. Angiographic follow‐up was performed. Results : Case 1: 47‐yo female presented left‐sided motor deficit. CT showed ischemic areas in the right hemisphere and CTA demonstrated an unruptured aneurysm in the C1 segment of the right ICA. The patient started dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. A 6mm x 40 mm C‐Guard carotid stent was deployed without complications. One‐year follow‐up CTA showed complete obliteration of the aneurysm with reconstruction of the ICA. Case 2: 38‐yo male presented decreased left visual acuity. CTA and DSA showed an unruptured aneurysm in the C1 segment of the ICA. The patient started DAPT with aspirin and clopidogrel. A 7mm x 30 mm C‐Guard carotid stent was deployed without complications. Three‐month follow‐up DSA showed complete obliteration of the aneurysm with adequate filling of distal vessels. Conclusions : C‐Guard stent is a potential alternative to conventional carotid stents in the treatment of cervical ICA aneurysms with high obliteration rates at follow‐up.

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.

Endovascular therapy with or without intravenous thrombolysis in acute stroke with tandem occlusion

BackgroundEndovascular therapy (EVT) is effective and safe in patients with tandem occlusion. The benefit of intravenous thrombolysis (IVT) prior to EVT in acute tandem occlusion is debatable.ObjectiveTo compare EVT alone with EVT plus IVT in patients with acute ischemic stroke due to anterior circulation tandem occlusions.MethodsThis is an individual patient pooled analysis of the Thrombectomy In TANdem lesions (TITAN) and Endovascular Treatment in Ischemic Stroke (ETIS) Registries. Patients were divided into two groups based on prior IVT treatment: (1) IVT+ group, which included patients who received IVT prior to EVT, (2) IVT− group, which included patients who did not receive IVT prior to EVT. Propensity score (inverse probability of treatment weighting (IPTW)) was used to reduce baseline between-group differences. The primary outcome was favorable outcome—that is, modified Rankin Scale (mRS) score 0 to 2 at 90 days.ResultsOverall, 602 consecutive patients with an acute stroke with tandem occlusion were included (380 and 222 in the bridging therapy and EVT alone groups, respectively). Onset to imaging time was shorter in the IVT+ group (median 103 vs 140 min). In contrast, imaging to puncture time was longer in the IVT+ group (median 107 vs 91 min). In IPTW analysis, the IVT+ group had higher odds of favorable outcome, excellent outcome (90-day mRS score 0–1), and successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b/3 at the end of EVT). There was no difference in the risk of significant hemorrhagic complications between groups. In secondary analysis of patients treated with acute cervical internal carotid artery stenting, bridging therapy was associated with higher odds of favorable outcome and lower odds of mortality at 90 days.ConclusionsOur results suggest that bridging therapy in patients with acute ischemic stroke due to anterior tandem occlusion is safe and may improve functional outcome, even in the setting of acute cervical internal carotid artery stenting during EVT.

Emergent carotid artery stenting for cervical internal carotid artery injury during carotid endarterectomy: A case report

Background: Carotid endarterectomy (CEA) has been the standard preventive procedure for cerebral infarction due to cervical internal carotid artery stenosis, and internal shunt insertion during CEA is widely accepted. However, troubleshooting knowledge is essential because potentially life-threatening complications can occur. Herein, we report a case of cervical internal carotid artery injury caused by the insertion of a shunt device during CEA. Case Description: A 78-year-old man with a history of hypertension, diabetes, and hyperuricemia developed temporary left hemiplegia. A former physician had diagnosed the patient with a transient cerebral ischemic attack. The patient’s medical history was significant for the right internal carotid artery stenosis, which was severe due to a vulnerable plaque. We performed CEA to remove the plaque; however, there was active bleeding in the distal carotid artery of the cervical region after we removed the shunt tube. Hemostasis was achieved through compression using a cotton piece. Intraoperative digital subtraction angiography (DSA) revealed severe stenosis at the internal carotid artery distal to the injury site due to hematoma compression. The patient underwent urgent carotid artery stenting and had two carotid artery stents superimposed on the injury site. On DSA, extravascular pooling of contrast media decreased on postoperative day (POD) 1 and then disappeared on POD 14. The patient was discharged home without sequela on POD 21. Conclusion: In the case of cervical internal carotid artery injury during CEA, hemostasis can be achieved by superimposing a carotid artery stent on the injury site, which is considered an acceptable troubleshooting technique.

Abstract 41: Endovascular Treatment Alone versus Endovascular Treatment With Intravenous Thrombolysis in Patients With Tandem Occlusion: Analysis of the TITAN and ETIS Registries

Introduction: The benefit of intravenous thrombolysis (IVT) prior to endovascular treatment (EVT) in patients with acute ischemic stroke due to anterior circulation tandem occlusion is not well established. In this study, we aimed to investigate the effect of IVT on the outcome of EVT for anterior circulation tandem occlusions Methods: Individual data were pulled from the prospective TITAN and ETIS registries. Patients with anterior circulation tandem occlusion treated with EVT with and without cervical internal carotid artery ( c-ICA) stenting were included. Patents were divided into two groups (IVT+/IVT-) based on IVT treatment. Inverse Probability Treatment Weighting (IPTW) analysis were used to compare the outcomes between the two groups. Results: A total of 602 patients were included of whom 380 (62%) patients received IVT prior to EVT (IVT+). Mean age was 64 and 62 years in IVT+ and IVT - groups, respectively. Median NIHSS was 16 in both groups. Onset to imaging time was shorter in IVT+ group (median 103 vs. 140 minutes). In contrast, imaging to puncture time was longer in IVT+ group (median, 107 vs. 91 minutes). In IPTW analysis, IVT was associated with higher odds of favorable outcome (90-day modified Rankin Scale [mRS] 0-2), excellent outcome (mRS 0-1) and successful reperfusion (modified Treatment in Cerebral Ischemia [mTICI] 2b-3). IVT was also associated with lower odds of any intracranial hemorrhage but not with symptomatic hemorrhage or parenchymal hemorrhage. In secondary analysis of patients treated with cervical internal carotid artery stenting, IVT was associated with higher odds of favorable outcome, and lower odds of mortality. Conclusion: Up to our knowledge, this is the first study comparing EVT alone to EVT+IVT in anterior circulation tandem occlusion patients. IVT prior to EVT was associated with better functional outcome and higher odds of successful reperfusion.

Utility of Pipeline embolization device for emergency recanalization of a dissecting carotid tonsillar loop: illustrative cases

BACKGROUNDCervical arterial tortuosity is not uncommon in patients with spontaneous carotid artery dissections (CADs), but the tortuosity often precludes endovascular stent reconstruction. The authors report 2 cases of emergency recanalization of a carotid tonsillar loop dissection using a Pipeline embolization device (PED).OBSERVATIONSTwo patients presented with symptomatic CAD involving tonsillar looping of the cervical internal carotid artery (ICA). Although the tonsillar loop prevented navigation of the carotid and peripheral stent delivery system, a PED was easily navigated and successfully deployed, resulting in successful recanalization of a looped ICA.LESSONSEmergency recanalization of a cervical CAD using a PED is a feasible alternative for treating a cervical CAD associated with tonsillar loops.

Excision and End-to-End Anastomosis of a Giant Partially Thrombosed Cervical Internal Carotid Artery Aneurysm Mimicking a Neck Tumor: 2-Dimensional Operative Video

Aneurysms of the cervical internal carotid artery (ICA) are a rare entity1,2 accounting for less than 0.2% to 0.5% of all carotid surgeries3 and less than 1% of all arterial aneurysms.4 There are several types of aneurysms, which include dissecting aneurysms, pseudoaneurysms, mycotic aneurysms, and fusiform and saccular aneurysms.5 The causes can include atherosclerosis, trauma, infection, and dysplasia. We present the case of a 70-yr-old otherwise healthy female found to have a neck mass. She was referred from a peripheral vascular surgeon to a head and neck surgeon for potential biopsy. The head and neck surgeon obtained vascular imaging and referred the patient to neurosurgery for definitive management. The patient gave informed consent for the procedure. An excision of the cervical ICA aneurysm and reanastomosis of the cervical ICA was performed. The patient remained neurologically intact postoperatively and imaging demonstrated complete aneurysm occlusion and a patent cervical ICA anastomosis. The patient gave verbal consent for this case to be published.