Crisis focal motora sin alteración de conciencia secundaria a accidente cerebrovascular. Reporte de un caso y diagnóstico diferencial con Limb Shaking

Introducción: Si bien la primera causa de crisis epilépticas en la población adulta mayor es el accidente cerebrovascular, un importante diagnóstico diferencial corresponde al limb shaking syndrome, una manifestación clínica particular de un accidente isquémico transitorio. Caso clínico: Se describe entonces el caso de un hombre chileno de 62 años de edad que sufre una crisis focal motora sin alteración de conciencia con evidencia imagenológica de injuria isquémica de unos 10 días de antigüedad y de estenosis carotídea significativa, la cual es manejada quirúrgicamente. Discusión: Existen diferentes elementos que pueden distinguir una crisis epiléptica de un limb shaking sryndrome. La fisiopatología de la primera corresponde un fenómeno irritativo post isquémico con una clara manifestación electroencefalográfica, mientras que la segunda es producida por hipoperfusión relativa gatillada por ortostatismo en el contexto de una enfermedad carotídea oclusiva. El cuadro clínico del paciente se consideró más compatible con una crisis epiléptica que con un limb shaking syndrome.

Introduction: Although the leading cause of seizures in the older adult population is cerebrovascular accident, limb shaking syndrome is an important differential diagnosis, being a particular clinical manifestation of a transient ischemic attack. Clinical case: We thus describe a clinical case of a 62-year-old Chilean man who suffers a simple focal motor epileptic seizure, with imaging evidence of ischemic injury about 10 days old and significant carotid stenosis which is managed surgically. Discussion: There are different elements that can distinguish an epileptic seizure from a limb shaking syndrome. The pathophysiology of the first corresponds to a post-ischemic irritative phenomenon with a clear electroencephalographic manifestation, while the second is produced by relative hypoperfusion triggered by orthostatism in the context of carotid occlusive disease. The patient's clinical picture was considered more compatible with an epileptic seizure than with a limb shaking syndrome syndrome.

Anxiolytic-like and proneurogenic effects of Trichilia catigua ethyl-acetate fraction in mice with cerebral ischemia

Abstract Trichilia catigua A. Juss., Meliaceae, known as "catuaba" in Brazil, has been popularly used as a tonic for fatigue, impotence and memory deficits. Previously, we have demonstrated that T. catigua ethyl-acetate fraction exerted antidepressive-like effects in mice. Affective-like symptoms are also well recognized outcome of cerebral ischemia in clinical and preclinical settings. Therefore, here we evaluated the effects of ethyl-acetate fraction on the emotional outcomes and its relation with hippocampal neurogenesis in ischemic mice. Male Swiss mice were subject to the bilateral common carotid occlusion during 20 min. The animals received ethyl-acetate fraction (400 mg/kg, orally) 30 min before and once per day during 7 days after reperfusion. Emotional outcomes were assessed using the open field test, elevated zero maze, and the tail suspension test. After the behavioral testing, the animals were sacrificed and their brains were processed to immunohistochemistry and Nissl staining. Ischemic mice exhibited anxiogenic-like behaviors in the elevated zero maze, hippocampal neurodegeneration and decreased hippocampal neurogenesis. The anxiogenic-like effect was counteracted by ethyl-acetate fraction administration. Furthermore, ethyl-acetate fraction restored the number of newborn neurons in the dentate gyrus of hippocampus of ischemic mice. In conclusion, T. catigua ethyl-acetate fraction promoted functional recovery and restored hippocampal neurogenesis in ischemic mice.

Endarterectomía satisfactoria en paciente con oclusión y rama anómala de la carótida interna / Satisfactory endarterectomy in patient with occlusion and anomalous branch of the internal carotid

La oclusión de la arteria carotidea interna no es infrecuente, típicamente su evolución impide la endarterectomía debido a que el trombo se extiende hasta el origen de la arteria oftálmica y hace inadecuada su reconstrucción. La carótida interna solo emite ramas intracraneales, pero extraordinariamente, existe una rama extracraneal de la carótida interna que mantiene el flujo distal a la oclusión y hace viable la revascularización como en el caso que se describe a continuación. Se trata de un paciente masculino, blanco, de 67 años de edad, fumador inveterado con antecedentes de dislipidemia. Acude por presentar disminución de la visión del ojo izquierdo acompañado de cuadros vertiginosos. Con el ultrasonido vascular y la angiotomografía computarizada se comprobó la oclusión de la emergencia de la carótida interna izquierda, con recanalización distal y presencia de vaso colateral anómalo. Se realizó endarterectomía carotidea y restitución del flujo a la carótida interna con preservación del vaso anómalo. El paciente evolucionó de forma satisfactoria. El conocimiento de las variantes anatómicas y una técnica cuidadosa permiten alcanzar buenos resultados en la cirugía de la oclusión carotidea(AU)

Occlusion of internal carotid artery is not uncommon; its progression frequently hinders endarterectomy because the thrombus extends into the origin of the ophthalmic artery, making the carotid artery inadequate for reconstruction. The internal carotid only emits intracranial branches, but exceptionally, there is an extracranial branch of the internal carotid that keeps the distal flow to the occlusion and makes the revascularization viable as it occurs in the case described here. This is a 67 years old Caucasian male patient, heavy smoker with a history of dyslipidemia. He went to the doctors because of decreased vision in his left eye and dizzy changes. Vascular US and angiotomography showed occlusion of left internal carotid artery, with distal recanalization and presence of collateral anomalous vessel. The treatment consisted of carotid endarterectomy and reestablishment of the flow to the left internal carotid with preservation of the anomalous collateral vessel with satisfactory recovery. The knowledge of the anatomical variations and a careful surgical technique allow reaching good results in carotid occlusion surgery(AU)

Emergent Recanalization with Stenting for Acute Stroke due to Athero-Thrombotic Occlusion of the Cervical Internal Carotid Artery : A Single Center Experience

OBJECTIVE: The purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting (CAS) for acute stroke due to athero-thrombotic occlusion of the cervical internal carotid artery (ICA). METHODS: Review of medical records identified 17 patients who underwent emergent CAS for treatment of athero-thrombotic occlusion of the cervical ICA with acute stroke between 2009 and 2013. Eleven patients (64.7%) presented with concomitant intracranial artery occlusion, which was treated primarily by mechanical thrombectomy after CAS. RESULTS: Successful revascularization of the cervical ICA with emergent CAS was achieved in all patients. After CAS, intracranial recanalization with Thrombolysis in Cerebral Infarction > or =2b flow was achieved in four of the 11 patients (36.4%). The overall recanalization rate (cervical ICA and intracranial artery) was 10 of 17 patients (58.8%). Symptomatic intracranial hemorrhage occurred in two patients (11.8%), resulting in death. Ten patients (58.8%) showed improvement (decrease in NIHSS score of > or =4 points) at seven days after recanalization. Nine patients (52.9%) showed a favorable outcome (mRS < or =2) at the last follow-up. A favorable outcome (mRS < or =2) was obtained in four of the six patients with isolated cervical ICA occlusion (4/6, 66.7%) and five of 11 patients with intracranial tandem occlusion (5/11, 45.5%). CONCLUSION: Emergent CAS for acute stroke due to athero-thrombotic occusion of the cervical ICA showed a good technical feasibility and favorable clinical outcome.

Spontaneous Internal Carotid Artery Occlusion and Rapid Cerebral Aneurysm Progression: Case Series and Literature Review / 신경중재치료의학

PURPOSE: An accurate determination of the natural history of a cerebral aneurysm has implications on management. Few risk factors other than female gender and cigarette smoking have been identified to be associated with cerebral aneurysm progression, particularly rapid progression. MATERIALS AND METHODS: This case series and literature review serves to illustrate a relationship between spontaneous carotid occlusion and rapid enlargement of cerebral aneurysms. RESULTS: In our case series, we demonstrated that increased hemodynamic stress on collateral vessels caused by a spontaneous carotid occlusion may contribute to unusually rapid aneurysm growth and/or rupture. CONCLUSION: Spontaneous carotid occlusive disease may be considered a risk factor for rapid cerebral aneurysm progression and/or rupture that may warrant more aggressive management options, including more frequent surveillance imaging in previously treated aneurysms.

Endovascular treatment of traumatic carotid cavernous fistula with trapping technique.

Conventional endovascular treatment for carotid cavernous fistula (CCF) involves a direct delivery of either coils, detachable balloon or both to the fistula with end point of CCF resolution and carotid artery preservation. But in few cases with severe laceration of carotid artery, the feasible endovascular technique applicable is by blocking the filling of fistula from cerebral circulation. This method known as trapping technique which implicates carotid artery occlusion, was performed in our present case with good result.

Development of 'De novo' Aneurysm after Therapeutic Carotid Occlusion

Carotid occlusion is an inevitable therapeutic modality for the treatment of complex aneurysms such as giant, traumatic, and intracavernous aneurysms. Late complications of carotid occlusion include 'de novo' aneurysm formation at a distant site because of hemodynamic changes in the circle of Willis. We report a case of de novo aneurysm in a vessel that appeared to be normal on initial angiography. The patient developed an anterior communicating artery aneurysm and marked growth of a basilar bifurcation aneurysm 9 years after trapping of the left internal carotid artery for the treatment of a ruptured large saccular aneurysm involving ophthalmic and cavernous segments. We propose that patients who undergo therapeutic carotid occlusion should be periodically followed by magnetic resonance angiography or computed tomographic angiography to evaluate the possibility of de novo aneurysm formation; this advice is in line with previous reports.

Cerebral Vasoreactivity in Carotid Stenosis or Occlusion Cases: A Transcranial Doppler Study with Acetazolamide (Diamox) Test

BACKGROUND: The aim of this trial was to evaluate the acetazolamide induced vasoreactivity of the cerebral vasculature in patients with carotid stenosis/occlusion, relative changes of blood flow velocity within the middle cerebral artery were measured by transcranial doppler ultrasonography during acetazolamide challenge. To evaluate the effectiveness of extracranial-intracranial bypass surgery in patients with ICA stenosis/occlusion with decreased vasoreactivity, we studied whether the vasoreactivity could show a significant difference between the territorial infarction and borderzone infarction cases. METHODS: To test vasoreactivity in 21 patients with unilateral carotid stenosis or occlusion, we measured blood flow velocity in the middle cerebral artery by transcranial doppler sonography both at rest and after injection of acetazolamide. Among 21 patients, 13 patients are MCA territorial and 8 patients are borderzone infarction which are angiographically confirmed symptomatic cases. RESULTS: The increase in blood flow velocity (%Vm) after acetazolamide stimulation was significantly different between the both hemisphere (affected side: 24.01+/-24.44%, contralateral side: 49.39+/-19.38%, p<0.05). In patients with carotid stenosis/occlusion, vasoreactivity of the borderzone infarction cases was lower than territorial infarction cases(mean+/-SD: 12.25+/-11.20% and 29.92+/-26.42%, p=0.13), but it is not significant statistically. CONCLUSION: We concluded that TCD with acetazolamide challenge is a useful method for assessment of the adequacy of hemodynamic reserve in patients with severe stenosis or occlusive cerebrovascular disease but it is very difficult problem apply to EC-IC bypass surgery directly.