Internal carotid artery aneurysm mimicking normal-tension glaucoma / Aneurisma de carótida interna simulando glaucoma de pressão normal

ABSTRACT Differentiating glaucomatous from nonglaucomatous optic disc cupping remains challenging. We present a case of a 48-year-old woman with an internal carotid aneurysm of approximately 3.5 mm × 6.5 mm that mimicked normal-tension glaucoma. The patient had a 2-year history of low vision acuity in her left eye and frontal oppressive headache. Owing to the carotid aneurysm, she developed an asymmetric vertical cup-to-disc ratio above 0.2, and marked inferotemporal neuronal rim loss and pallor of the residual rim were noted in the left disc. She also developed a visual field defect with an arcuate scotoma in the left eye. The patient was referred to a neurosurgeon and underwent endovascular aneurysm occlusion. This case highlights the diagnostic importance of recognizing that many neurological defects remain underdiagnosed.

RESUMO diferenciação de escavações glaucomatosas e não glaucomatosas ainda permanece um desafio ainda nos dias de hoje. Nos descrevemos um caso de aneurisma de carótida interna medindo 3.5mm x 6.5mm que simulava um glaucoma de pressão normal. O caso é sobre uma paciente feminino de 48 anos com história de 2 anos de baixa acuidade visual no olho esquerdo e cefaléia frontal. Devido ao aneurisma de carótida a paciente desenvolveu uma assimetria de escavação vertical maior que 0.2 no olho esquerdo em relação ao direito com defeito localizado da camada de fibras nervosas temporal inferior. Ela também apresentava um defeito arqueado temporal superior a esquerda, cruzando a linha média vertical consistente. Após o diagnostico confirmado pela ressonância magnética funcional, a paciente foi enviada para o neurocirurgião para realização de uma oclusão endovascular do aneurisma. Esse caso nos alerta da importância de se lembrar que não apenas o glaucoma gera escavações suspeitas no disco óptico e que ainda muitos defeitos por causas neurológicas são subdiagnosticados.

Mismatch between TOF MR Angiography and CT Angiography of the Middle Cerebral Artery may be a Critical Sign in Cerebrovascular Dynamics

PURPOSE: Although time-of-flight (TOF)-magnetic resonance angiography (MRA) can clearly depict intracranial arteries, the arterial flow of middle cerebral artery (MCA) is occasionally not detected. We evaluated this phenomenon with reference to cerebrovascular dynamics. MATERIALS AND METHODS: Seventeen patients with suspected occlusion of MCA or internal carotid artery on TOF-MRA were enrolled. All patients underwent CT angiography (CTA) and quantitative cerebral blood flow (CBF) examination for measurement of resting CBF and cerebrovascular reactivity (CVR). Depending on appearance, patients were categorized into three groups. Group A (n=6) had MCA delineation on both MRA and CTA, while groups B (n=6) and C (n=5) had no signal on MRA, but Group B had a MCA delineation on CTA.

Hemodynamic Significance of Internal Carotid or Middle Cerebral Artery Stenosis Detected on Magnetic Resonance Angiography

PURPOSE: We evaluated hemodynamic significance of stenosis on magnetic resonance angiography (MRA) using acetazolamide perfusion single photon emission computed tomography (SPECT). MATERIALS AND METHODS: Of 171 patients, stenosis in internal carotid artery (ICA) and middle cerebral artery (MCA) (ICA-MCA) on MRA and cerebrovascular reserve (CVR) of MCA territory on SPECT was measured using quantification and a 3-grade system. Stenosis and CVR grades were compared with each other, and their prognostic value for subsequent stroke was evaluated. RESULTS: Of 342 ICA-MCA, 151 (44%) presented stenosis on MRA; grade 1 in 69 (20%) and grade 2 in 82 (24%) cases. Decreased CVR was observed in 9% of grade 0 stenosis, 25% of grade 1, and 35% of grade 2. The average CVR of grade 0 was significantly different from grade 1 (p<0.001) and grade 2 stenosis (p=0.007). In quantitative analysis, average CVR index was -0.56+/-7.91 in grade 0, -1.81+/-6.66 in grade 1 and -1.18+/-5.88 in grade 2 stenosis. Agreement between stenosis and CVR grades was fair in patients with lateralizing and non-lateralizing symptoms (kappa=0.230 and 0.346). Of the factors tested, both MRA and CVR were not significant prognostic factors (p=0.104 and 0.988, respectively), whereas hypertension and renal disease were significant factors (p<0.05, respectively). CONCLUSION: A considerable proportion of ICA-MCA stenosis detected on MRA does not cause CVR impairment despite a fair correlation between them. Thus, hemodynamic state needs to be assessed for evaluating significance of stenosis, particularly in asymptomatic patients.

Aneurisma de carótida interna extracraniano mimetizando tumor glômico / Extracranial internal carotid artery aneurysm presenting as glomus tumor

Aneurismas de carótida interna extracranianos (ACIE) são raros e o diagnóstico pode ser feito com ultrassonografia, tomografia computadorizada com contraste, ressonância nuclear magnética e angiografia. Este último é fundamental para definir a anatomia vascular e a melhor estratégia para o acesso operatório. O objetivo deste trabalho é apresentar e discutir um caso de aneurisma de artéria carótida interna extracraniano cujo diagnóstico definitivo foi realizado no intraoperatório, uma vez que, embora este diagnóstico tenha sido sugerido pela ultrassonografia pré-operatória, a tomografia computadorizada e a ressonância nuclear magnética com reconstrução arterial indicaram tratar-se de um tumor glômico.

Extracranial internal carotid artery aneurysm is rare and the diagnosis is made by ultrasonography, computed tomography scan with contrast, magnetic resonance imaging and carotid angiography. The latter is important to define the vascular anatomy and best surgical approach. The aim of this study is to present and discuss a case of extracranial internal carotid artery aneurysm diagnosed intraoperatively. Ultrasonography suggested a carotid artery aneurysm but CT and angiographic nuclear scanning erroneously indicated a glomus tumor.

Morphological and hemodynamic patterns of carotid stenosis treated by endarterectomy with patch closure versus stenting: a duplex ultrasound study

OBJECTIVES: A duplex ultrasound study was performed to investigate morphological and hemodynamic patterns of carotid stenoses treated by endarterectomy with patch closure versus stenting. MATERIALS AND METHOD: Twenty-nine carotid stenoses were treated with stenting and 65 with patch closure. Duplex ultrasound parameters (luminal diameter, mm; peak systolic velocity and end-diastolic velocity, cm/s) were measured 24 hours after the procedures and also at 12 months post-procedure. Residual stenoses (immediately postprocedure) and restenoses (within 12 months of procedure) were defined as narrowings of >50 percent on duplex ultrasound examination. RESULTS: In stented patients, the luminal diameter of the proximal internal carotid artery increased in the interval between the 24-hour and 12-month post-procedure studies, while in the patch closure patients, the diameter decreased. Carotid hemodynamics normalized immediately after both patching and stenting and remained relatively stable thereafter up to 12 months. No statistically elevated flow velocities (in the absence of residual stenosis or restenosis) were observed in the patched or stented carotid arteries. No significant differences in residual stenosis rates were observed between the stenting group (3 cases, 10.34 percent) and the patch closure group (1 case, 1.53 percent, P = 0.08). At 12 months, 2 stenting patients (6.88 percent) and 2 patch closure patients (3.07 percent) had $50 percent restenosis (P = 0.58). One case of late stroke due to restenosis was observed in the stenting group; the patient died 12 months postoperatively, before receiving new intervention. CONCLUSION: Measurements over time in luminal diameter signalized differences in arterial remodeling mechanisms between patched and stented carotids. Both stenting and patch closure were associated with carotid patency and flow restoration. This study does not support a general approach to new velocity criteria indiscriminately applied to stented or patched carotids.

Agenesis of the internal carotid artery: a case report / Agenesia da artéria carótida interna: relato de caso

Relata-se, aqui, caso de uma adolescente de 14 anos de idade que apresentou episódio isolado de síncope, sem outros sintomas. No exame de ressonância magnética observou-se, nos cortes nos planos axial e coronal ponderados em T2, ausência do flow void da artéria carótida interna direita na sua porção intracavernosa. Realizou-se, então, angiorressonância magnética técnica time-of-flight, que mostrou ausência da artéria carótida interna direita, o que foi comprovado com a angiorressonância magnética de vasos cervicais e com angiotomografia computadorizada, que mostrou, nos cortes axiais, agenesia do canal carotídeo direito. Tal achado é relatado na literatura, em associação com outras anomalias, como encefaloceles transesfenoidais e aneurismas do polígono de Willis. No presente caso, não foram observadas tais associações. A paciente permaneceu assintomática.

The present paper reports a case of a 14-year-old-female adolescent who presented a single episode of syncope, without any other symptom. Axial and coronal T2-weighted magnetic resonance imaging demonstrated an absent right internal carotid artery flow void. A subsequent magnetic resonance angiography utilizing the time-of-flight technique showed absence of the right internal carotid artery. This finding was confirmed by magnetic resonance angiography of the cervical vessels, and axial computed tomography angiography showed agenesis of the right carotid canal. The literature reports such finding in association with other anomalies such as transsphenoidal encephaloceles and circle of Willis aneurysms. These associations were not observed in the present case. The patient remained asymptomatic.

Repair of extra-cranial internal carotid artery aneurysm with application of modified carotid shunt: a case report.

Aneurysms of the extracranial internal carotid artery (ICA) are uncommon. These lesions usually present with symptoms of transient ischemic attacks (TIA) from emboli and cranial nerve dysfunction from compression. The primary objective of treatment is to prevent a permanent neurologic deficit arising as a result of atheroembolism. The resection of an ICA aneurysm with restoration of flow is the preferred method of treatment. The authors present the case of a 32-year-old woman diagnosed with an ICA aneurysm. The patient underwent aneurysmectomy using an autologous saphenous vein graft with ICA blood flow being maintained using a carotid-to-carotid shunt, which was modifiedfrom an intravenous catheter set. This modified carotid shunt is easy to prepare for use and is of low cost. The authors do not expect this shunt to represent the standard commercially available shunt; but in some institutes, where commercial shunts are not available, this shunt may be suitably used.

Massive cerebral infarction as a feature of pituitary apoplexy.

A patient with pituitary apoplexy is reported who, in addition to the clinical features of apoplexy, developed a cerebral infarct secondary to compression of the internal carotid artery. The mechanisms of a cerebral infarct associated with pituitary apoplexy are discussed.

Zumbido por fístula carótido-cavernosa de origem traumática / Post-traumatic caroticocavernous fistula as a cause of tinnitus

Fístula carótido-cavemosa é uma conexäo arteriovenosa entre a artéria carótida interna e o seio cavernoso. É uma entidade rara, principalmente se a queixa única for zumbido. Pode ser classificada de acorcdo com três critérios: traumática ou espontânea, de alto ou baixo fluxo, e diretas ou durais. A sintomatologia é geralmente insidiosa e o diagnóstico por radio-imagem geralmente é feito de um a oito meses após o ocorrido, com média de cinco meses. É relatado um caso de zumbido provocado por uma fístula carótido-cavernosa

Tratamiento médico en un caso de disección espontánea de la carótida interna / Medical treatment in a case of spontaneous dissecting aneurysm of internal carotid artery

El accidente vascular encefálico originado de la disección espontánea de la arteria carótida interna es poco frecuente en nuestras estadísticas.Presentamos un caso que se inicia con un infarto cápsulo putaminal anterior, diagnosticado mediante un examen angiográfico. A propósito del caso, se revisa la literatura nacional e internacional. Se discute la etiología hormonal, traumática, degenerativa y la influencia de las variantes anatómicas (tortuosidades) del vaso. Se hace especial énfasis en el diagnóstico radiológico y se analiza el tratamiento médico o quirúrgico

Aneurismas cerebrovasculares extracraneanos / Extracraneal cerebrovascular aneurysms

El compromiso aneurismático del árbol vascular extracraneano es infrecuente y ocurre sólo en un 0,3% de los aneurismas arteriales según datos reportados. Durante los últimos 10 años hemos tratado 4 pacientes con aneurisma de la arteria carótida extracraneana. Angiográficamente se demuestra aneurisma sacular de la carótida interna cervical en 2 y dilatación aneurismática difusa en 2. Los pacientes con aneurisma sacular se intervienen quirúrgicamente sin complicaciones. En los 2 casos con aneurisma difuso se prefiere tratamiento antiplaquetario por la ubicación y extensión del aneurisma. En el seguimiento alejado, promedio de 21 meses, todos los pacientes están asintomáticos. Creemos que, al igual que los aneurismas arteriales en otra ubicaciones, el aneurisma carotídeo extracraneano debería ser resecado quirúrgicamente si las condiciones locales lo permiten. La conducta expectante con antiplaquetarios evita parcialmente el riesgo de embolización distal pero no previene la complicación habitual del aneurisma, cual es su ruptura